Sever’s Disease: Treating Heel Pain in Children

Sever’s Disease is a common cause of heel pain in children who live an active lifestyle. The experts at Foot Centre Group share their knowledge on best treatments.

What Is Sever’s Disease?

Sever’s disease, formally and medically known as calcaneal apophysitis is the most common cause of heel pain in children. The calcaneus referring to the heel bone and apophysitis referring to the irritation of the growth plate at the back of the heel bone.

Common Symptoms of Sever’s Disease

  • Pain after sport typically football, soccer, basketball, gymnastics and tennis.
  • Increase in pain as activity continues to increase.
  • Pain associated with running and high impact movements like jumping.
  • One of the first signs and symptoms of sever’s could be limping, this can happen in the morning when getting out of bed, during sport or after sport has finished and the body starts to cool down.
  • Favouring the forefoot when walking creating a toe walking or tip toe gait/walking style

What Causes Sever’s Disease?

The causes of Sever’s or calcaneal apophysitis are multifactorial. Many environmental, genetic and physical elements come into play and these should be considered within the treatment plans.

The exact cause is unknown, however the most common theory based on ongoing evidence and research is that it is a growth plate disorder.

The three calf muscles in your child’s body come down and insert into the Achilles tendon. The tendon attaches to the back of the heel where a growth plate or an apophysis is located. The pulling from the calf muscles and Achilles tendon creates irritation and inflammation of the growth plate as it is changing formation as your child grows.

Some risk factors that may help identify the causes of sever’s disease are:

  • Changing height and weight
  • Cross over from one sport season finishing and another one starting, especially if one is more increase in running or jumping
  • Changing sport shoes and footwear. For example soccer and footy boots have a lower heel counter and low drop in heel to forefoot height, compared to barefoot activity such as gymnastics or even really structured shoes like basketball shoes: these all play a role in how the foot structure is impacted
  • A higher BMI (body mass index) as it requires the growth plate to function under more load
  • A foot type that is more pronated or appears to be a flat foot may act as a risk factor for Sever’s due to the bend at the back of the heel and torsion through the Achilles tendon
  • For more information on how your child’s foot type may be a risk factor for Sever’s click here.

Who is most at risk?

  • Kids between the ages of 8-14 years old (it just affects children and adolescents)
  • High activity and sport levels
  • More common in boys than girls
  • Growth spurts
  • Start of sport seasons is more common

Best Treatments for Sever’s Disease?

There is not one superior treatment than another in the management for calcaneal apophysitis.

As mentioned above the treatment should be targeted towards your child’s activities and pain levels.

  • Apply ice if the heel is really sore, especially after sport for 10-15 minutes. This should only be done in the first 3 weeks of the onset of pain. Heat may be more beneficial for low and stable pain or prolonged weeks of experiencing painful symptoms.
  • Activity modification – depending on each case a reduction in duration, intensity, frequency and type of exercise may need to be altered. A podiatrist will be able to determine how much activity is too much for the growth plate currently and modify accordingly.
  • Heel lifts that can be applied to footwear as guided by a health professional can take the pressure off the heel and Achilles tendon
  • NSAIDS topical (such as voltaren gel) or oral (such as nurofen) – the use of anti-inflammatory management as guided by a GP or pharmacist can be very effective with pain management and flare ups
  • Strength and conditioning program will be essential in building back up the load your foot is capable of. This needs to be individualised and functional to your child’s needs and day to day tasks. It needs to be specific to the muscles and tendons that are surrounding the stress on the heel. Whilst stretching may feel nice for the body and help with cool down, relaxation and increase range of motion, strength is more effective in reducing pain levels and prevention of reoccurring pain.
  • If pronation was a contributing factor and conservative treatment has failed an insole, inserts or orthotic device may aid in correcting the excessive force on the heel. This will also allow more cushioning for when hard surfaces are an aggressing factor
  • Education and tips on self management when the same pain of the heel bone flare’s up as they coincide with growth spurts and physical activity changes
  • If a very severe case of Sever’s arises a cast, moon boot, or a surgical opinion may be warranted

How can I help my child suffering from Sever’s Disease?

Monitoring the symptoms of sever’s disease over time will be a big help. As the growth plate develops and changes, your child’s pain could be triggered by growing at a rapid rate, change of sport, increased exercise and more.

Listen out for your child reporting anything different or changes to the normal heel pain they have experienced or if it occurs in a different area of the foot.

There are many other causes of heel pain in children such as bursitis, fractures, juvenile arthritis, infection and tumors. It is important to take note of anything out of the ordinary in order to rule out the more sincere conditions.

An assessment may be neccessary to diagnose sever’s disease. The assessment should include identifying range of motion, motions that cause pain, palpation and looking at your child’s bones and physical strength. Although x rays generally do not give us the information to diagnose it may be an opportunity to rule out the more sincere causes of heel pain as listed above.

Can my child still play sport with Sever’s Disease?

Generally calcaneal (heel bone) apophysitis (sever’s) will resolve on its own with out long term problems. Treatments and interventions will help to speed up the progress.

It is very rare that this condition will cause long term side effects. It is a self limiting condition whereby your child may be guided by their own pain. Yes, they can continue to play sport, however if their activity levels are not modified and the muscles and tendons are not addressed it may delay how long they are in pain for, particularly when running and jumping are a big focus of their sports.

In extreme cases, total rest may be advised by a professional or doctor. However, the ultimate goal is to manage symptoms accordingly so that sport can be participated in.

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