Sever's disease

What is Sever's disease?

Sever's disease (calcaneal apophysitis) is heel pain in growing children and teenagers¹. The Achilles tendon (the thick cord at the back of the ankle) pulls repeatedly on the heel bone at its growth plate (the area where the bone is still growing). This causes pain and swelling, especially with running and jumping².

Among children and young people, it is the most frequent cause of heel pain, mostly affecting those aged about 8 to 15, with the peak falling at 10 to 12¹. Despite the name, it's better thought of as a side-effect of growth than a disease in the usual sense³.

What causes it, and who gets it?

The cause is thought to be the calf muscles and Achilles tendon repeatedly pulling on the heel's growth plate, which is made of cartilage¹. During a growth spurt, bones grow faster than muscles and tendons, so the calf muscles become tight². Repeated running and jumping adds stress and strain to the growth plate, which can then become inflamed and painful⁴. It's especially common in children who do a lot of high-impact activity, and it can be worse during growth spurts⁴. The exact mechanism isn't known⁵.

No single factor, such as foot shape, body weight, ankle movement or activity level, is a proven cause¹. Limited ankle movement is the one looked at most often, so a health professional may check calf flexibility and ankle movement¹. Most reported cases are boys, though that may reflect who is seen rather than who is truly at risk⁶.

What does it feel like, and how is it diagnosed?

In Sever's disease, the heel usually hurts more during activity and improves when the child is at rest⁷. The pain typically sits at the rear or base of the heel, or at the spot where the Achilles tendon joins it¹. Your child may limp or walk on their toes, and the heel may be tender when squeezed, with some swelling at the back of the heel⁸. The calf muscles may feel tight⁹.

Diagnosis is mainly based on your child's symptoms and an examination. An X-ray can help confirm it or look for other causes¹. An assessment matters because other problems can also cause heel pain in children¹⁰.

What helps first?

Simple, non-surgical care comes first: rest, exercises and taping, and shoe inserts are the treatments used⁶. Easing back on the running and jumping that bring the pain on is a sensible first step, because rest often eases it⁹.

A podiatrist or physiotherapist can talk through other options, including heel lifts (a raised pad inside the shoe) and orthoses (shoe inserts). In the short term, heel lifts and orthoses seem to make little difference to pain or function compared with each other¹¹. How well activity changes, stretching or footwear advice work on their own isn't clear yet.

Because the choice isn't clear-cut, it can reasonably be shared between you, your child and the practitioner.

What helps if that isn't enough?

Custom orthotics (made for your child's feet) may ease pain more than heel lifts by 12 weeks, so they're worth asking about¹². It isn't clear yet which other add-on treatments help.

A GP, podiatrist or physiotherapist can recheck the diagnosis and consider other causes⁸.

How long does it last, and can it come back?

Sever's disease is self-limiting, meaning it settles by itself, by the time growth finishes or earlier⁷. It can last for up to three years while a child is still growing⁸, so the time it takes varies. It isn't known to cause long-term problems¹³.

In rare cases, untreated Sever's disease has been reported to cause a small break (an avulsion fracture) at the heel's growth plate¹⁴.

It isn't clear yet what speeds recovery or stops it coming back, so there's no particular step to promise.

What can make it serious?

• 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.
• 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.
• Your child has heel pain with a fever, and the heel is red, hot or swollen, or they seem very unwell.
• Your child can't put weight on their foot after a fall or injury.