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Sever's Disease
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Sever's disease is heel pain in growing children and teenagers. It is described as the most common cause of heel pain in young people, at about 3.7 per 1000 patients. The Achilles tendon (the thick cord at the back of the ankle) pulls on the growth plate of the heel bone, especially with running and jumping. The usual sign is heel pain with activity that eases with rest. It is not a true disease, and it is expected to settle as growth finishes. Treatment aims to ease the pain in the meantime.
What is it?
Sever's disease (also called calcaneal apophysitis) is heel pain in growing children and teenagers. The heel bone has a growth plate, an area of softer cartilage where the bone is still growing. The calf muscles pull on this area through the Achilles tendon, and with repeated pulling it becomes sore.
Despite the name, many people describe it as a side-effect of growth rather than a true disease. It is a common cause of heel pain in children, and it is not a sign that anything is wrong with your child's health overall.
Who does it affect?
It affects children and teenagers who are still growing. It is most common in girls aged 7 to 12 and in boys aged 8 to 15. In both, it peaks between 10 and 12. Younger children can get it too. It is especially common in children who do a lot of high-impact activity, such as running and jumping sports like soccer, and it can be worse during growth spurts.
Signs and symptoms
The main symptom is heel pain that comes on during or after activity and eases with rest. The pain is usually at the back or underside of the heel, or where the Achilles tendon meets the heel bone. Your child may limp or walk on their toes to take the pressure off.
Other things you might notice:
- the heel is tender when squeezed
- some swelling at the back of the heel
- tight calf muscles
- trouble joining in sport
Your child is usually otherwise well. Heel pain that behaves differently from this, or comes with other symptoms, is covered in the section on when to see a podiatrist.
What causes it?
The cause is thought to be repeated pulling of the calf muscles and Achilles tendon on the growth plate. Cartilage handles this kind of pulling and bending poorly. During a growth spurt, bones grow faster than muscles and tendons, so the calf muscles get tight and pull harder on the heel. Repeated impact from running and jumping adds to the strain.
The exact way it happens isn't known. It also isn't clear which factors, such as foot shape, weight, ankle movement or how active a child is, really raise the risk. Some children are very active and never get it, so please don't blame yourself or your child.
How is it diagnosed?
It is mainly diagnosed from your child's story and an examination. Your podiatrist will ask when the pain happens, where it is, what makes it better or worse, and whether there is a limp. It helps to jot these down before the visit.
They will press on and squeeze the heel, check how tight the calf muscles are, check how far the ankle lifts upwards, and watch your child walk. They will also look for signs that point to something other than Sever's disease. Other causes of heel pain in children include a stress fracture (a small crack in the bone from overuse), tendon problems, joint inflammation and, rarely, infection.
Treatment
Treatment is aimed at easing the pain while your child grows. All the treatments used are non-surgical. There is only limited proof about which work best, so the choice can reasonably be shared between you, your child and your practitioner.
Looking after it at home
Common steps include cutting back the activities that bring on the pain, such as running and jumping, and resting when it flares. Calf stretches, ice and taping are also often used. It isn't yet clear how much each of these helps on its own. No best amount of rest or stretching has been shown. If the pain isn't settling, see the section on when to see a podiatrist.
Treatment from your podiatrist
Your podiatrist can check your child's calf tightness and ankle movement, and suggest a plan that suits your child's sport and school routine. They may suggest heel lifts (small raisers worn inside the shoe under the heel) or orthoses (shoe inserts).
Heel lifts and orthoses are both used. It isn't yet clear which is better. Some results show little difference in pain between them in the short term, and others favour custom orthoses (made to fit your child's feet) after about 12 weeks. Your podiatrist can talk through the options with you.
Other options
If simple steps aren't enough, custom orthoses are one option. Beyond that, no other add-on treatment has been shown to help reliably. If the pain hasn't settled, your practitioner can recheck the diagnosis and consider other causes.
Recovery
Sever's disease is expected to settle by itself, either as growth finishes or sooner. How long this takes varies. It can last up to three years while your child is still growing. There are no known long-term effects.
The pain can come and go during that time, especially after busy periods of sport. If it isn't settling, or it gets worse, see the section on when to see a podiatrist.
Preventing it
No measure has been shown to stop it from starting or coming back, so there is no proven way to prevent it. Because tight calf muscles and a lot of impact are thought to play a part, your podiatrist can check your child's calf flexibility and ankle movement and talk about balancing sport with rest.
When to see a podiatrist
When to book
Book an appointment with your podiatrist if:
- your child has heel pain that comes on with running, jumping or sport
When to get help sooner
Get urgent medical assessment (see your GP today, or go to an urgent care clinic or the nearest emergency department) if:
- your child has heel pain with a fever, and the heel is red, hot or swollen, or they seem very unwell: go straight away, without waiting for an appointment
- your child can't put weight on their foot after a fall or injury
See your GP soon if:
- your child has heel pain at night or at rest that comes regularly or doesn't stop
- your child has a limp that hasn't improved after a week, limps without pain, or doesn't want to put weight on their foot
- your child has heel or ankle pain together with hip or knee pain, morning stiffness that lasts more than 20 minutes, or a foot that has started to turn outwards
See your podiatrist or GP soon if:
- your child's heel pain came on suddenly without an injury, or is in one heel only and comes at night or without any activity to set it off
- your child's heel pain is getting worse, or doesn't settle with rest, less activity or pain relief
Frequently asked questions
Can my child keep playing sport?
The pain tends to come on with running and jumping and ease with rest, so many children cut back on those activities until it settles. Your podiatrist can help you work out how much is right for your child. It isn't yet known how much activity is best, so the plan is adjusted to how the heel feels.
Can it affect both heels?
Yes. Sever's disease can affect one heel or both. Pain in both heels is common and doesn't on its own mean something more serious is going on.
Does my child need an X-ray?
Not always. Sever's disease is mainly diagnosed from your child's symptoms and an examination. An X-ray can help confirm it or check for other causes of heel pain. Your podiatrist or doctor will decide whether your child needs one.