Podopaediatrics: Sever’s Disease

Sever’s Disease, more rightly called “calcaneal apophysitis”, is a common cause of heel pain in active children ages 8-14. It is not technically a disease, but was named as such when it was described in 1912 by James Warren Sever, an American orthopaedic doctor.

This condition involves inflammation of the calcaneal growth plate (seen in the image above), which is a weak area at the back of the heel where new bone is forming, as a result of too much repetitive stress on that tissue.

Sever’s Disease presents with heel pain at the posterior end of the calcaneus which is usually worse during or after activity, especially running and jumping sports. The heel is painful when striking the ground, but may also be painful when standing in tip-toes due to the pull of the insertion of Achilles tendon on the affected area of the calcaneus. Half of cases present with pain on one side (unilateral). The other half will be bilateral (both sides).

Repeated impacts to the heel bone, such as when running, and jumping, can lead to repetitive microtrauma of the calcaneal apophysis, causing inflammation and pain. Both the Achilles tendon insertion and the plantarfascia are attached to the apophysis, so tension in or overuse of these tissues can lead to Sever’s Disease. Excessive subtalar or whole foot pronation (flat feet) also put tension on the plantarfascia and can contribute to the development of this condition.

Diagnosis is usually made through taking a history of the condition and a medical history, as well as by palpation. Radiographs will appear normal.

This condition is self-recovering, which means that once the calcaneus (heel bone) has stopped growing, the condition will resolve by itself, even without treatment. It does not lead to any long-lasting disability. Treatment is aimed at reducing symptoms while the condition is present and can involve any of the following:

  • Reduction in activity to a level that is tolerable.
  • Rest, Ice, Compression, Elevation (RICE) during acute flare-ups.
  • Non-steroidal Anti-inflammatory drugs (NSAIDs), such as ibuprofen, if required.
  • Changing from weightbearing sports to non-weightbearing, such as cycling or swimming.
  • Using temporary shoe inserts, such as rubber heel cushions, to reduce the force of impact on heel strike.
  • Custom foot orthoses (medical grade insoles) to address any biomechanical issues of the foot that may be contributing to increased stress on the Achilles tendon or plantarfascia.
  • Stretches and strengthening exercises to address soft-tissue imbalances (e.g. tight gastrocnemius muscles).
  • Acupuncture for pain relief, if tolerated.
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