Sever's disease

Sever's disease
Synonyms	Calcaneal apophysitis
Pronounce
Field	Pediatrics, Orthopedics, Sports medicine
Symptoms	Heel pain, limping, pain with physical activity, tenderness over calcaneus
Complications	Chronic heel pain (rare)
Onset	Ages 8–14
Duration	Weeks to months; resolves with growth plate closure
Types
Causes	Repetitive stress or microtrauma to the growth plate of the heel
Risks	Running sports, jumping activities, rapid growth, tight calf muscles
Diagnosis	Clinical exam; squeeze test; X-ray to rule out other causes
Differential diagnosis	Achilles tendinitis, plantar fasciitis, calcaneal stress fracture, bursitis
Prevention	Proper footwear, stretching, limiting high-impact activity
Treatment	Rest, ice, stretching, heel lifts, physical therapy
Medication	NSAIDs for pain management
Prognosis	Excellent with rest and growth plate closure
Frequency	Common in athletic children; peak onset 9–11 years
Deaths	None

Sever's disease, also known as calcaneal apophysitis, is a common cause of heel pain in growing children and adolescents. It is an overuse injury that results from repetitive stress and microtrauma to the calcaneal apophysis, the growth plate at the back of the heel. The condition is most frequently observed in physically active children between the ages of 8 and 14, especially during periods of rapid growth.

Illustration of the developing bones of the foot, including the calcaneal apophysis

Presentation

Children with Sever's disease typically complain of:

• Pain at the back or bottom of the heel, particularly during or after physical activity
• Limping or walking on tiptoe
• Pain with medial-lateral compression of the heel (positive squeeze test)
• Discomfort when the heel is palpated or stretched

Notably, there is no visible swelling or redness, and radiographic findings (e.g., fragmentation or sclerosis of the apophysis) are not diagnostic, as they can be seen in asymptomatic children.

Cause

The condition results from repetitive traction of the Achilles tendon on the vulnerable growth plate of the calcaneus during activities like running, jumping, and playing sports. Risk factors include:

• Participation in high-impact sports (e.g., soccer, basketball, gymnastics)
• Rapid growth spurts during puberty
• Tight gastrocnemius and soleus muscles (calf muscles)
• Flat feet or overpronation
• Inappropriate footwear lacking adequate heel support

Sever’s disease is considered the pediatric equivalent of Osgood–Schlatter disease, which affects the knee.

Diagnosis

Diagnosis is clinical and based on characteristic signs and symptoms. A positive calcaneal squeeze test, where compression of the heel elicits pain, is a key diagnostic sign. Imaging studies such as X-rays are not typically required but may be used to exclude other conditions like:

• Calcaneal stress fracture
• Bone tumors
• Infections
• Osteomyelitis

Prevention

Preventive strategies include:

• Wearing well-cushioned, supportive shoes
• Stretching exercises to improve calf flexibility
• Avoiding excessive physical activity or impact during growth spurts
• Using heel lifts or cushioned insoles to reduce strain on the heel

Treatment

Treatment may consist of one or more of the following:

• Elevating the heel
• Stretching hamstring and calf muscles 2–3 times daily
• Using R.I.C.E. (Rest, Ice, Compression, Elevation)
• Foot orthotics
• Medication
• Physical therapy
• Icing daily (morning)
• Heating therapy
• Avoiding high-heeled shoes

Recovery

Sever's disease is self-recovering, meaning that it will go away on its own when the foot is used less or when the bone is through growing. The condition is not expected to create any long-term disability, and expected to subside in 2 or more weeks. Some orthopedic surgeons will put the affected foot in a cast to immobilize it.

While symptoms can resolve quickly, they can recur. Sever's disease is more common in boys than girls; the average age of symptom onset is nine to eleven years.

Eponym

It is named for James Warren Sever (1878–1964), an American orthopedic doctor, who described it in 1912. Sever had "The Principles of Orthopaedic Surgery" published in 1940 through the Macmillan Company.

See also

• List of childhood diseases