Calcaneal Apophysitis

Sever disease (Calcaneal apophysitis)

Sever disease is painful irritation and inflammation of the apophysis (growth plate) at the back of the calcaneus (heel bone), where the Achilles tendon inserts. In a child, the bones grow from areas call growth plates. The growth plate is made up of cartilage, which is softer and more vulnerable to injury than mature bone. The condition is most often seen in physically active boys and girls between the ages of 8 and 13 years and is the most common cause of heel pain in this age group. It is most commonly seen in soccer, basketball and gymnastics. Approximately 60% of Sever disease is bilateral.

How it occurs

Sever disease is caused by repetitive tension and/or pressure on the growth center. Running and jumping generate a large amount of pressure on the heels. Tight calf muscles are a risk factor because they increase the tension on the growth center. The condition can also result from wearing shoes with poor heel padding or poor arch support.

Signs and symptoms

The most common complaint is pain in the heel. The pain usually occurs during or after activity (typically running or jumping) and is usually relieved by rest. The pain may be worse with wearing cleats. The pain may limit your child’s activities and when severe, may cause a limp.


Sever disease is diagnosed based on your doctor’s physical examination of the lower leg, ankle and foot and review of your child’s symptoms. If the diagnosis is in question, the doctor may order x-rays to evaluate for other injuries that may be causing the heel pain. In Sever disease, x-rays are normal.


Your child needs a short period of rest from painful activities in order to take pressure off the growth center and allow inflammation to resolve. Ice is very helpful in reducing pain and inflammation. Apply ice for 10-15 minutes as often as every hour when sore. Do not use ice immediately before activity. It is very important to stretch tight calf muscles in order to relieve tension on the growth center. Shoes with padded heel surfaces and good arch support can decrease pain. Your doctor may also recommend gel heel cups or supportive shoe inserts. In some cases, the doctor may
prescribe an anti-inflammatory medication.

Returning to activity and sports

The goal is to return your child to his sport or activity as quickly and safely as possible. If he returns to activities too soon or plays with pain, the injury may worsen. This could lead to chronic pain and difficulty with sports. Everyone recovers from injury at a different rate. Your child’s return to sport or activity will be determined by how soon his injury resolves, not by how many days or weeks it has been since the injury occurred. In general, the longer he has had symptoms before starting treatment, the longer it will take for the injury to heal. He may return safely to his sport or activity when each of the following is true:

  • Your child has full range of motion of the ankle without pain.
  • He has no pain at rest.
  • He is able to walk without pain.
  • He is able to jog without pain.
  • He is able to sprint without pain.
  • He is able to jump and hop on the affected foot without pain.

If he needs heel cups to do all of these maneuvers without pain, that is acceptable, and he should wear the heel cups during sports and activities. If the heel pain recurs when your child returns to sports, he should rest, ice and stretch until the pain is gone before trying to return again.

Preventing Sever disease (Calcaneal Apophysitis)

Perform a proper warm-up before starting any activity. Ten minutes of light jogging, cycling, or calisthenics before practice will increase circulation to cold muscles, making them more pliable so that they put less stress and tension on their attachment sites (apophyses). Studies have shown that an active warm-up is associated with better athletic performance than a warm-up that consists only of static stretching. Have your child wear shoes that fit properly. The heel portion of the shoe should not be too tight and there should be good padding in the heel. Stretch tight calf muscles several times a day. It is better to stretch after exercise than before exercise. Hold each stretch for 30 seconds. Don’t bounce.
Do not play through pain. Pain is a sign of injury, stress, or overuse. Rest is required to allow time for the injured area to heal. If pain does not resolve after a couple days of rest, consult your physician. The sooner an injury is identified, the sooner proper treatment can begin. The result is shorter healing time and faster return to sport.

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