Sever's Disease (Calcaneal Apophysitis)
Summary
Sever's Disease is the most common cause of heel pain in children. It is not a "disease" but a mechanical overuse injury: a Traction Apophysitis of the calcaneum. The Achilles tendon pulls repetitively on the open secondary ossification centre (apophysis) of the heel bone, causing micro-avulsion and inflammation. [1,2]
Key Facts
- Mechanism: Bone grows faster than muscle/tendon. During a growth spurt, the tibia lengthens rapidly, stretching the Gastrocnemius-Soleus complex tight "like a bowstring". The point of maximal tension is the insertion at the calcaneal apophysis.
- Demographics: Active children aged 8-14 years. It coincides with the pubertal growth spurt.
- Association: Often seen alongside other osteochondroses like Osgood-Schlatter (Knee) or Iselin's (5th Metatarsal).
Clinical Pearls
The Squeeze Test: The most sensitive clinical sign. Compress the medial and lateral walls of the heel (the calcaneal tuberosity) with the palm of your hand. Pain here is pathognomonic for Sever's. Pain on the plantar surface (bottom) suggests Plantar Fasciitis (rare in kids). Pain on the tendon itself suggests Tendinopathy.
X-Ray Pitfall: The normal calcaneal apophysis looks fragmented, sclerotic (white), and irregular on X-ray. This is often misdiagnosed as an infection or fracture. In Sever's, the X-ray is essentially "normal" (used only to exclude cysts/tumours). Do not treat the X-ray.
Bilateral: Sever's is bilateral in ~60% of cases, though one side may be worse than the other.
Risk Factors
- High Impact Sports: Soccer, Gymnastics, Basketball (running on hard surfaces).
- Footwear: Cleats/Studs (provide poor shock absorption). Flat shoes (increase Achilles tension).
- Biomechanics: Over-pronation (flat feet) or Pes Cavus (high arch).
Apophysis Mechanics
- An apophysis is a growth plate where a tendon attaches.
- Unlike an epiphysis (which takes compressive load), an apophysis takes tensile load.
- In children, the connection between the apophysis and the main bone is cartilaginous and weaker than the tendon.
- Chronic traction -> Inflammation -> Pain.
- Resolves when the apophysis fuses to the main body (Age 15-16).
History
Symptoms
- Squeeze Test: Positive.
- Silfverskiold Test: Check ankle dorsiflexion. Usually restricted (tight calves).
- Inspection: Usually no swelling or redness. (If red/hot -> Suspect Osteomyelitis).
Imaging
- X-Ray (Lateral Heel):
- Purpose: Only to exclude other pathology (Stress fracture, Osteoid Osteoma, Bone cyst).
- Findings: Increased density and fragmentation of the apophysis are normal variants and do not confirm Sever's.
- MRI: Rarely indicated. Shows bone marrow oedema.
Management Algorithm
CHILD WITH HEEL PAIN
↓
POSITIVE SQUEEZE TEST
(Exclude 'Red Flag' night pain)
↓
CLINICAL DIAGNOSIS: SEVER'S
↓
PHASE 1: ACUTE (Painful)
- Activity Modification (Stop running 2-4w)
- Ice (20 mins post-school)
- Analgesia (Ibuprofen)
- **Heel Lifts** (Silicone cups in BOTH shoes)
↓
PHASE 2: REHAB (Pain Settled)
- Calf Stretches (Gastroc + Soleus)
- Correction of footwear
- Gradual return to sport
↓
PHASE 3: RECALCITRANT
- Immobilisation (Walking boot x 4 weeks)
- Podiatry Referral (Orthotics)
1. The "Heel Raise"
- Placing a silicone heel cup (or folded felt) inside the shoe lifts the heel by ~1cm.
- This plantarflexes the foot slightly, bringing the origin and insertion of the gastroc closer together -> Reduces Tension on the apophysis.
- Must be worn in both shoes (to prevent leg length discrepancy).
2. Stretching
- The long-term fix.
- Gastrocnemius stretch (knee straight).
- Soleus stretch (knee bent).
3. Prognosis
- Self-limiting.
- Recurrence is common during future growth spurts until fusion occurs.
- Reduced Participation: Impact on social/sporting life.
- Apophyseal Avulsion: Extremely rare fracture.
- Excellent. No long-term sequelae.
- Unlike Osgood-Schlatter (which can leave a bony bump), Sever's leaves no deformity.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Heel Pain | American College of Foot Surgeons | Heel lifts and stretching are Level A evidence. |
| Paediatric Overuse | AAP | Avoid early specialization in sports to reduce overuse injuries. |
Landmark Evidence
1. James et al (J Foot Ankle Res)
- Review confirmed that "Wait and See" is inferior to active management (Heel raises + Stretching).
Is the heel broken?
No. The heel bone is growing in two parts. The calf muscle pulls on the soft spot between these two parts. Because your child has grown fast recently, the muscle is tight (like a short elastic band), pulling hard and causing soreness.
Do they need to stop sport?
Only while it hurts. "Pain is the guide". If they can run without limping, they can play. If they limp, they must rest. Pushing through the pain just makes the inflammation last longer.
What do the heel pads do?
They lift the heel up slightly. This relaxes the tight calf muscle, taking the tension off the sore bone.
Primary Sources
- James AM, et al. Effectiveness of interventions for non-traumatic heel pain (Sever's disease): a systematic review. J Foot Ankle Res. 2013.
- Wiegerinck JI, et al. Incidence of calcaneal apophysitis (Sever's disease) and return to play in young athletes. J Bone Joint Surg. 2014.
- Scharfbillig RW, et al. Sever's disease: what does the literature really tell us?. J Am Podiatr Med Assoc. 2008.
Common Exam Questions
- Diagnosis: "Squeeze Test?"
- Answer: Medial-Lateral compression of calcaneus.
- Pathology: "Type of injury?"
- Answer: Traction Apophysitis.
- Management: "First line mechanical aid?"
- Answer: Heel lifts/cups.
- Differential: "Unilateral night pain?"
- Answer: Osteoid Osteoma (tumour).
Viva Points
- Osteochondroses Family: Be able to list the others:
- Knee: Osgood-Schlatter (Tibial tuberosity), Sinding-Larsen-Johansson (Inferior patella).
- Foot: Sever's (Calcaneus), Iselin's (5th Metatarsal), Kohler's (Navicular).
- Hip: Perthes (Femoral head).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.