The pain often makes it difficult to maintain normal activity over a longer period, but most people get rid of the problem completely. In this article you will find everything you need to know about the condition and our advice on how to approach the problem.
What is Sever's disease?
Sever's disease is an irritation and inflammation of the apophysis/growth plate at the back of the heel bone. The apophysis acts as an attachment point for the Achilles tendon and the connective tissue under the sole of the foot. During the growth spurt, when the child experiences rapid growth, the apophysis is the weakest link in the muscle, tendon and skeleton complex, and is therefore prone to overload. During activities such as jumping and running, the growth plate is exposed to large forces through the pull from, among other things, the Achilles tendon, and irritation and inflammation can occur. This irritation usually causes pain during and after activity. Often the irritation will settle considerably after a few weeks of activity modification, while complete improvement may not be achieved until the apophysis closes and fully ossifies. This typically happens at the age of 15-17.
Who gets Sever's disease?
Sever's disease develops during the growth spurt in children and adolescents between 8 and 15 years of age, and the onset of pain is most often between 11 and 12 years of age. Both sexes get the condition, but the incidence is 2-3 times higher among boys. Children who are active in sports where running and jumping are central are more susceptible, and the onset of pain can often be linked to starting a new sport, the start of a season, or another sudden increase in training / activity volume. A strong growth spurt is also a risk factor that can make the child particularly susceptible, as it often means that muscles and tendons do not keep up as well and can contribute to a greater pull on the apophysis. High BMI, unsuitable footwear and certain biomechanical factors in the foot are also pointed to as risk factors for developing Sever's disease, but their role is somewhat unknown.
Does my child have Sever's disease?
The typical signs of Sever's disease are pain at the back of the heel where the onset coincides with a sudden change in activity level. The child may limp towards the end of activity because of the problem, but often experiences relief of symptoms in periods when activity is stopped. The pain usually settles overnight after it has been provoked. On clinical examination, it will often be painful to press on the attachment point of the Achilles tendon, and a "squeeze" test, where pressure is applied to both sides of the heel, will be painful. Jumping and running are typically the most provoking activities, but even just stretching the calf muscles can provoke pain in some. Sever's disease is diagnosed clinically, and there is no need for imaging such as X-ray or MRI.
How is the heel pain treated? (what should you do?)
Sever's disease is a self-limiting condition that will resolve on its own in most people, given enough time. By adjusting the activity level, most people experience improvement, but complete improvement may not be achieved until the apophysis is fully closed. Treatment of the condition is therefore precisely about adjusting the activity level to keep the pain to a minimum. This can mean that you have to refrain from, for example, football for a period, and find other ways to be active. As a starting point, you should be careful with running and jumping for as long as the heel is still painful, but complete rest from activity is not necessary. A gradual build-up of previously provoking activity as the pain improves is important. In time, it is also a good idea to introduce exercises to strengthen the area. Heel cups in the shoes can also have a certain effect, and allow more activity at an acceptable level of pain.
Our practitioners all have experience with heel pain in children and adolescents and can help to set up a good treatment plan. It is always a good idea to have someone to discuss with about what kind of measures can be tried.
References:
- Smith JM, Varacallo M. Sever Disease (Calcaneal Apophysitis) [Updated 2024 Jan 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
- Fares MY, Salhab HA, Khachfe HH, Fares J, Haidar R, Musharrafieh U. Sever’s Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clin Med Res. 2021 Sep;19(3):132-137. doi: 10.3121/cmr.2021.1639. PMID: 34531270; PMCID: PMC8445662.
- Hendrix CL. Calcaneal apophysitis (Sever disease). Clin Podiatr Med Surg. 2005 Jan;22(1):55-62, vi. doi: 10.1016/j.cpm.2004.08.011. PMID: 15555843.
- https://synapse.koreamed.org/articles/1096557