Sever's Disease (Calcaneal Apophysitis)

Also known as: Sever's disease, Sever disease, Calcaneal apophysitis, Calcaneal apophysitis of childhood, Heel growth plate inflammation

Last updated: December 18, 2024

Sever’s disease (calcaneal apophysitis) is an overuse-related inflammatory condition of the growth plate at the back of the heel bone in growing children. Repetitive pulling from the Achilles tendon and plantar fascia can cause micro-irritation, often during rapid growth. It typically causes activity-related posterior heel pain and tenderness that can limit sports, and is usually self-limited with growth.

Key Facts

•Sever's disease, also called calcaneal apophysitis, describe an overuse-related inflammatory condition involving the growth plate (apophysis) at the back of the heel bone (calcaneus) in growing children
•Posterior heel pain that worsens with running, jumping, or prolonged walking and improve with relative rest
•Diagnosed through history, physical exam, and imaging
•First-line treatment includes exercise, weight management, and activity modification

What It Is

Sever's disease, also called calcaneal apophysitis, may describe an overuse-related inflammatory condition involving the growth plate (apophysis) at the back of the heel bone (calcaneus) in growing children. It can occur when repetitive traction from the Achilles tendon and plantar fascia contributes to micro-irritation at the calcaneal apophysis, particularly during periods of rapid growth. Symptoms often present as activity-related heel pain and tenderness that can limit sports participation. The condition typically represents a self-limited process associated with skeletal growth rather than an infection or a fracture, although other causes of heel pain may need consideration.

Affected Anatomy

This condition affects several structures in and around the joint:

•Calcaneal apophysis (posterior calcaneal growth plate)
•Calcaneus (heel bone), especially the posterior tuberosity
•Achilles tendon (calcaneal tendon) insertion region
•Gastrocnemius muscle–soleus muscle complex (triceps surae)
•Plantar fascia origin at the calcaneal tubercle
•Retrocalcaneal bursa (adjacent to the Achilles insertion)
•Subcutaneous calcaneal bursa (superficial to the Achilles tendon)
•Calcaneal fat pad (heel pad) and surrounding soft tissues

Common Symptoms

Symptoms can vary in intensity and may change over time. Common experiences include:

•Posterior heel pain that may worsen with running, jumping, or prolonged walking and can improve with relative rest
•Heel tenderness that can be more noticeable with squeezing the sides of the heel near the calcaneal apophysis
•Pain that may occur at the onset of activity and can intensify as activity continues, sometimes persisting afterward
•Limping or altered gait that may reflect pain avoidance, often more apparent after sports
•Stiffness or tightness in the calf/Achilles region that can limit ankle dorsiflexion and contribute to discomfort
•Pain that may be unilateral or bilateral, with bilateral symptoms often reported in active children
•Discomfort that can increase with wearing cleats or rigid shoes and may lessen with cushioned footwear
•Localized swelling or warmth at the back of the heel that can occur but is typically mild

Causes and Risk Factors

Multiple factors can contribute to the development of this condition:

Causes

•Repetitive traction and loading at the calcaneal apophysis from the Achilles tendon during running and jumping activities
•Rapid growth periods in which bone growth can outpace muscle-tendon length adaptation, increasing tension across the heel growth plate
•Biomechanical stress related to foot alignment (such as overpronation) that can increase strain on the heel and plantar fascia
•Training load changes, including sudden increases in intensity, frequency, or duration of sports participation
•External mechanical irritation from footwear (for example, cleats or stiff heel counters) that can increase local pressure and friction

Risk Factors

•Age associated with an open calcaneal apophysis, typically in school-aged children and early adolescents
•Participation in high-impact sports that often involve running and jumping (such as soccer, basketball, gymnastics, or track)
•Recent growth spurt that can increase relative tightness of the gastrocnemius-soleus complex
•Limited ankle dorsiflexion or calf tightness that may increase traction on the calcaneal apophysis
•Foot biomechanics such as overpronation, pes planus, or pes cavus that can alter heel loading patterns
•Higher body mass or rapid weight changes that can increase repetitive load through the heel during activity
•Training on hard surfaces that can increase impact forces transmitted to the calcaneus
•Footwear with limited cushioning or rigid cleats that can concentrate pressure at the heel

How It's Diagnosed

Diagnosis typically involves a combination of clinical assessment and imaging studies:

•Clinical history focusing on activity-related posterior heel pain, recent growth changes, sport participation patterns, and symptom timing (during vs after activity)
•Physical examination that can include inspection for swelling, palpation of the posterior calcaneus, and a heel squeeze maneuver to reproduce localized tenderness
•Assessment of ankle range of motion, particularly dorsiflexion, and evaluation of calf/Achilles tightness that may contribute to traction forces
•Gait assessment to identify limping, toe-walking, or compensatory patterns that can reflect pain avoidance
•Evaluation of foot alignment and biomechanics (such as pronation/supination patterns) that can influence heel stress distribution
•Imaging when needed to evaluate alternative diagnoses; plain radiographs can help assess for fracture or other bony conditions, although apophyseal appearance can vary with normal growth
•Consideration of other causes of heel pain (for example, stress fracture, plantar fasciitis, Achilles tendinopathy, bursitis, infection, or inflammatory arthritis) based on red flags, systemic symptoms, or atypical presentation

Treatment Options

Treatment approaches range from conservative measures to surgical interventions, often starting with the least invasive options:

Self-Care and Activity Modification

•Activity modification and relative rest, which can reduce repetitive loading of the calcaneal apophysis while symptoms are prominent
•Ice application after activity, which may help reduce pain and local inflammation-related discomfort
•Heel cups, heel lifts, or cushioned inserts that can reduce impact and decreases Achilles traction on the heel
•Supportive footwear with cushioning and an appropriate heel counter, which can reduce local irritation from pressure and friction
•Short-term immobilization (such as a walking boot) in more symptomatic cases, which can reduce mechanical stress during ambulation
•Gradual return to sport with load management strategies that can include limiting high-impact drills initially and monitoring symptom response
•Specialist referral (such as pediatric orthopedics or sports medicine) when symptoms are persistent, atypical, or associated with concerning features; operative treatment generally is not typical for calcaneal apophysitis and may prompt reassessment for alternative diagnoses

Physical Therapy and Exercise

•Stretching programs that often focus on the gastrocnemius-soleus complex and Achilles tendon to address tightness contributing to traction forces
•Physical therapy approaches that can include flexibility work, strengthening of lower-extremity stabilizers, and gradual return-to-sport conditioning

Medications

•Analgesic/anti-inflammatory medications that may be used in some cases for symptom relief, with selection and suitability typically depending on clinical context and clinician guidance

Prognosis and Recovery

The course of this condition varies between individuals:

•Symptoms often improve with conservative measures and load reduction, although the time span can vary based on activity level and growth phase
•Recurrence can occur, particularly during growth spurts or with rapid increases in sports intensity, and may fluctuate with training demands
•Long-term outcomes are generally favorable, with symptoms typically resolving as the calcaneal apophysis matures and closes, although the timing can differ among individuals
•Persistent or worsening pain may suggest an alternative or additional diagnosis, particularly if pain occurs at rest, at night, or with systemic symptoms
•Functional limitations often relate to pain with impact activities, and gradual reconditioning can help restore participation as symptoms lessen

Osgood-Schlatter Disease (tibial tubercle apophysitis)(Condition)
Achilles Tendinitis (Achilles Tendinopathy)(Condition)
Physical Therapy (Physiotherapy)(Procedure)

Frequently Asked Questions

Common symptoms include: Posterior heel pain that may worsen with running, jumping, or prolonged walking and can improve with relative rest; Heel tenderness that can be more noticeable with squeezing the sides of the heel near the calcaneal apophysis; Pain that may occur at the onset of activity and can intensify as activity continues, sometimes persisting afterward; Limping or altered gait that may reflect pain avoidance, often more apparent after sports; Stiffness or tightness in the calf/Achilles region that can limit ankle dorsiflexion and contribute to discomfort.

Diagnosis typically involves: Clinical history focusing on activity-related posterior heel pain, recent growth changes, sport participation patterns, and symptom timing (during vs after activity); Physical examination that can include inspection for swelling, palpation of the posterior calcaneus, and a heel squeeze maneuver to reproduce localized tenderness; Assessment of ankle range of motion, particularly dorsiflexion, and evaluation of calf/Achilles tightness that may contribute to traction forces; Gait assessment to identify limping, toe-walking, or compensatory patterns that can reflect pain avoidance.

Treatment options range from conservative measures to surgical interventions, including: Activity modification and relative rest, which can reduce repetitive loading of the calcaneal apophysis while symptoms are prominent; Ice application after activity, which may help reduce pain and local inflammation-related discomfort; Heel cups, heel lifts, or cushioned inserts that can reduce impact and decrease Achilles traction on the heel; Supportive footwear with cushioning and an appropriate heel counter, which can reduce local irritation from pressure and friction; Stretching programs that often focus on the gastrocnemius-soleus complex and Achilles tendon to address tightness contributing to traction forces.