Summary

  • Sever’s disease is a common cause of heel pain, particularly in the young and physically active.
  • Just before puberty the calf bones typically grow faster than the surrounding soft tissue, which means the Achilles tendon is pulled uncomfortably tight. This can lead to an injured heel.
  • Treatment includes relative rest, modifying activities and teaching the young person how to manage the condition when a flare-up happens.
  • Sever’s disease is self-limiting and rarely causes long-term problems.

Sever’s disease (sometimes called Sever disease, or just ‘Severs’) is a common cause of heel pain, particularly in the young and physically active. Another, more accurate, name for Sever’s disease is calcaneal apophysitis.

It usually develops just before puberty. Boys are slightly more prone to this condition than girls. It is considered an overuse injury.

Physiotherapy can help manage the symptoms of Sever’s disease so that the young person can continue to take part in physical activity. 

Cause of Sever’s disease

A big tendon called the Achilles tendon joins the calf muscle at the back of the leg to the heel. Sever’s disease is thought to occur because the growth area where the Achilles muscle tendon attaches to the bone (the apophysis) is ‘active’, which means it is beginning to transition from cartilage to bone. 

During this phase, active pre-teens can get pain at the attachment area, and in the tendon and the heel bone itself. This is known as apophysitis.

Sever’s disease most commonly affects boys aged ten to 12 years and girls aged nine to 11 years, when growth spurts are beginning. 

Symptoms of Sever’s disease

A few signs and symptoms point to Sever’s disease, which may affect one or both heels. These include: 

  • pain and stiffness at the heel or around the Achilles tendon, often after a non-weight-bearing period (such as sleeping, or working at a desk for a period of time)
  • heel pain during physical exercise, especially activities that require running or jumping
  • worsening of pain after exercise
  • a tender swelling or bulge on the heel that is sore to touch
  • limping – often in the morning, or during or after sport
  • a tendency to tiptoe.

 

Factors that contribute to Sever’s disease

Sever’s disease is age and activity related – it usually starts in pre-teens who are physically active. It occurs when the calcaneal (heel) apophysis is open and active, and when there has been a change in sport or a change in the volume, frequency or intensity of physical activity being done. 

A change in shoes can also bring it on – particularly in running sports that have shoes or boots with a lower heel, such as football boots and some running shoes. The lower heel adds extra load to the apophysis, because it places the Achilles tendon on increased stretch.

Physical activity factors that, together with growth, may contribute to developing Sever’s disease include: 

  • type of physical activity – most commonly sports and activities that are weight bearing, such as sports that involve running or jumping or both, such as football, netball, running and gymnastics
  • change in type of physical activity – a change in the type of physical activity done, such as starting a different activity, or returning to a physical activity after a break
  • change in amount of physical activity – this may be an increase in volume, intensity or frequency of activity. This commonly occurs:
    • as one sports season ends and another starts
    • where there is crossover in sport
    • when a child starts to train and play for a team (the volume of activity increases with multiple weekly training sessions and a game)
    • when they are involved in a sports carnival which involves playing multiple games in one day or over a number of days
  • equipment or external factors – such as changing to shoes with a low heel (such as football boots or some types of running shoes), doing a sport in bare feet, or even walking at the beach in thongs/flip flops
  • foot posture – active children who have a flat foot posture and weak foot muscles may be slightly more predisposed to Sever’s disease.

 

Diagnosis of Sever’s disease

A doctor or other health professional such as a physiotherapist can diagnose Sever’s disease by asking the young person to describe their symptoms and by conducting a physical examination. In some instances, an x-ray may be necessary to rule out other causes of heel pain, such as heel fractures. 

When an apophysis is active, there is a transition from cartilage to bone. During this phase, the normal x-ray appearance will vary from no bony tissue to small deposits of bone to a fully united bony tendon attachment.

However, there is usually no difference in what can be seen in a heel x-ray of a child experiencing Sever’s disease-related pain, and that of another child of the same age who is pain free. For this reason, x-rays are generally not used to diagnose Sever’s disease.

 

Treatment of Sever’s disease

Treatment depends on the severity of the condition, but may include: 

  • education on how to self-manage the symptoms and flare-ups of Sever’s disease (this is an essential part of the treatment)
  • load management – this may initially include a period of decreased or modified load. However, load is important for the tendon, heel bone and apophysis, so after the initial flare, load needs to managed to ensure these remain healthy 
  • avoiding stretches and eccentric exercises (such as lowering your heel over a step or jumping or hopping) in the initial phase 
  • calf massage or use of a foam roller or trigger ball to maintain calf length and flexibility
  • temporary use of a heel raise (one to two weeks), often just in the football boots or running shoes causing the problem, to take the pressure off the apophysis and tendon. Orthotics are usually not needed. (Note: The use of a heel raise is temporary, as prolonged use will shorten the calf muscle and further exacerbate the pain.)
  • correction of any biomechanical issues, particularly around the foot, but may also include the knee, hip and trunk – a physiotherapist can identify and discuss any biomechanical issues that may cause or worsen the condition. Foot taping and/or doing exercises to improve neuromuscular control around the foot, knee hip and trunk can be helpful 
  • cold packs – when a flare up occurs, apply ice or cold packs to the back of the heels for around 15 minutes after the physical activity
  • medication – pain-relieving medication such as ibuprofen may help in some cases (such as for tendon pain), but should always be combined with other treatment following consultation with a doctor
  • time – generally the pain will ease in one to two weeks if the person seeks help from a physiotherapist early on, although it can take longer. As the apophysis takes two years to mature (sometimes longer), there may be flare-ups from time to time over this period, triggered by growth spurts, changes in sporting activities or intensity, changes in footwear or changes in surface.

Self-monitoring of symptoms (such as heel pain and stiffness in the morning), how much sport and what type of sport is being played, and any overall growth or growth of the feet, is very useful. Such records inform the individual and the treating physiotherapist, and help them to modify the treatment program. They can also help to predict likely flare ups and thus prevent them, and help you to be better prepared to manage unavoidable flare ups.

Other causes of heel pain

Causes of heel pain in pre-teens, other than Sever’s disease, include: 

  • bursitis – bursae are small sacs that contain fluid to lubricate moving parts such as joints and muscles. Common causes of bursitis at the back of the heel include injury, overuse and tight shoes
  • posterior ankle impingement (not common in this age group) – can occur after an ankle sprain and in activities such as dance, gymnastics and football where participants spend a lot of time on their toes 
  • stress fracture (not common in this age group) – can result when loading on the bone leads to weakening of the bone 
  • heel fracture – can occur with a fall from a height directly onto the heel
  • juvenile rheumatoid arthritis – causes persistent joint pain, swelling and stiffness
  • tumour – this is a less common cause of heel pain, but is important to consider and rule out.

Where to get help

References

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This page has been produced in consultation with and approved by: Australian Physiotherapy Association

Last updated: May 2017

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