Sever’s disease is caused by the growth plate in the heel becoming inflamed, and it is the most common cause of heel pain in adolescents.

This condition is especially prevalent in children who play sports. Treatment includes ice, rest, and pain relievers to manage pain and discomfort.

Any underlying foot conditions may also need to be assessed and managed. Sever’s disease does not cause any permanent damage, and will resolve when the growth of the heel is complete.

What is Sever’s Disease?

Sever’s disease (also called calcaneal apophysitis) is a condition that occurs in the growth plate of the heel bone (the calcaneus) in children and adolescents. When the muscles and tendons in the leg and heel exert too much pressure on this growth plate, swelling and pain can result.

What are the Symptoms of Sever’s Disease?  

The symptoms of Sever’s disease occur in the heel and the foot, and may worsen with activity. Pain and stiffness can occur in one or both heels. Symptoms can include:

• Swelling in the heel
• Redness in the heel
• Antalgic gait (such as limping)
• Foot pain or stiffness first thing in the morning or while walking
• Pain that is worsened by squeezing the heel

Who Gets Sever’s Disease?

Sever’s disease is common, and typically occurs during a child’s growth spurt, which can occur between the ages of 10 and 15 in boys and between the ages of 8 and 13 in girls. Feet tend to grow more quickly than other parts of the body, and in most kids the heel has finished growing by the age of 15.

Being active in sports or participating in an activity that requires standing for long periods can increase the risk of developing Sever’s disease.

In some cases, Sever’s disease first becomes apparent after a child begins a new sport, or when a new sports season starts. Sports that are commonly associated with Sever’s disease include track, basketball, soccer, and gymnastics.

Children who are overweight or obese are also at a greater risk of developing this condition. Certain foot problems can also increase the risk, including:

• Over pronating: Kids who over pronate (roll the foot inward) when walking may develop Sever’s disease.
• Flat foot or high arch: An arch that is too high or too low can put more stress on the foot and the heel, and increase the risk of Sever’s disease.
• Short leg: Children who have one leg that is shorter than the other may experience Sever’s disease in the foot of the shorter leg because that foot is under more stress when walking.

What Causes Sever’s Disease?

Growth plates, also called epiphyseal plates, occur at the end of long bones in children who are still growing. These plates are at either end of growing bones, and are the place where cartilage turns into bone. As children grow, these plates eventually become bone (a process called ossification).

During a growth spurt, the bone in the heel may outpace the growth of the muscles and tendons that are attached to the heel, such as the Achilles tendon.

During weight bearing, the muscles and tendons begin to tighten, which in turn puts stress on the growth plate in the heel. The heel is not very flexible, and the constant pressure on it begins to cause the symptoms of Sever’s disease.

Sever’s disease is common, and it does not predispose a child to develop any other diseases or conditions in the leg, foot, or heel. It typically resolves on its own.

How is Sever’s Disease Diagnosed?

Children or adolescents who are experiencing pain and discomfort in their feet should be evaluated by a physician. In some cases, no imaging tests are needed to diagnose Sever’s disease.

A podiatrist or other healthcare professional may choose to order an x-ray or imaging study, however, to ensure that there is no other cause for the pain, such as a fracture. Sever’s disease will not show any findings on an x-ray because it affects cartilage.

Most often, a healthcare professional can diagnose Sever’s disease by taking a careful history and administering a few simple tests during the physical exam.

A practitioner may squeeze the heel on either side; when this move produces pain, it may be a sign of Sever’s disease. The practitioner may also ask the child to stand on their tiptoes, because pain that occurs when standing in this position can also be an indication of Sever’s disease.

How is Sever’s Disease Treated?

Treatment for Sever’s disease is mainly supportive, to stop inflammation and reduce pain. The condition will resolve on its own when the growth in the growth plate is complete, but until then, measures can be taken to resolve pain and discomfort.

• Icing: Applying ice to the painful or swollen areas on the foot may provide some short-term relief from pain and prevent further inflammation. Ice can be applied for about 20 minutes two or three times a day.

• Supportive footwear: Footwear that is too big, too small, or does not provide proper support can exacerbate the symptoms of Sever’s disease. Supportive footwear is important to prevent discomfort, especially in children who participate in sports and activities that take place on a hard surface (such as pavement or a basketball court). Shoes should also have adequate padding and not rub against the heel. In some cases, shoes that do not have heels (such as sandals) may be more comfortable to wear while the heel is healing, but care should be taken that the shoe provides proper support to the rest of the foot. Children with Sever’s disease should avoid going barefoot.

• Treating foot conditions: Children with flat feet, high arches, or over-pronation may need treatment to resolve these underlying conditions. In many cases, an orthotic worn inside the shoe can help put the foot into a better alignment and provide relief to the foot or the arch.

• Losing weight: Children who are overweight or obese may be counseled to lose weight. Being overweight can contribute to the development of several conditions, including Sever’s disease.

• Rest: Resting the foot and discontinuing sports and other activities until the pain and stiffness is resolved may be recommended. In extreme cases, a walking boot or a cast might be used to completely immobilize the foot.

• Stretching: A physical therapist may recommend stretching exercises for the muscles in the calf and the Achilles tendon. A stretching routine is usually done several times a day. Stretching these muscles can help improve strength and decrease the stress on the heel plate.

• Anti-inflammatory medications: Some physicians may recommend over-the-counter pain relievers such as ibuprofen or acetaminophen. Care must be taken when administering these medications to children, especially with acetaminophen, as overdoses are possible when using more than one medication containing acetaminophen. Aspirin should never be given to children. The utility of pain relievers in children must be weighed against their possible side effects.

• Correcting unequal leg length: For small variations—less than an inch or so—shoe lifts can help equalize the length of the legs. In cases with more variation between legs, surgical solutions may be considered.

• Physical Therapy: Research indicates that targeted manual therapy techniques performed by a licensed physical therapist can help to reduce pain from Sever’s Disease and to improve muscle function. When the larger calf muscles and the smaller ankle and foot muscles become tight, this tightness can affect the mechanics of the ankle joint. Manual therapy includes both joint and muscle release techniques to restore optimal function to the calf, ankle, and foot muscles, and results can generally be achieved within a few months.

What is the Prognosis for Sever’s Disease?

Having Sever’s disease does not predispose children or teens to any other condition, nor is it a permanent problem. It is self-limiting, and when treated, the pain and other symptoms will abate within a few weeks.

Once the growth plate has finished growing, Sever’s disease will resolve and won’t recur. It is important to continue to treat any underlying foot conditions and to avoid any long periods of inactivity.