Sever’s disease, also known as calcaneal apophysitis, is one of the most common causes of heel pain in growing children and adolescents. It occurs when the growth plate (apophysis) at the back of the heel bone becomes irritated and painful due to repetitive stress and traction forces. This growth plate is where new bone forms during childhood and is weaker than mature bone, making it more vulnerable to overload.
Sever’s disease most commonly affects physically active children between the ages of 8 and 15, particularly those involved in sports that include running, jumping, and rapid changes of direction such as football, netball, basketball, athletics, and soccer. Despite the name, Sever’s disease is not an infection or long-term disease. It is a temporary, growth-related condition that settles once the heel growth plate matures.
Physiotherapy for Sever’s disease focuses on reducing pain, managing load through the heel, addressing muscle tightness and strength deficits, and guiding a safe return to sport. With appropriate management, most children can remain active and return to full sport without long-term problems.
Key Facts
- Sever’s disease is considered the most common cause of heel pain in children and adolescents, particularly during periods of rapid growth. 🔗
- The condition most commonly affects children aged 8 to 15 years and is strongly associated with participation in running and jumping sports. 🔗
- Sever’s disease is self-limiting and resolves once the calcaneal growth plate closes, with no long-term damage when managed appropriately. 🔗
Risk Factors
- Rapid growth spurts during late childhood and early adolescence.
- Participation in high-impact sports involving running and jumping.
- Tight calf muscles and Achilles tendon.
- Flat feet or high arches altering load distribution through the heel.
- Unsupportive or worn-out footwear with poor shock absorption.
- Higher body weight increasing repetitive heel load.
Symptoms
- Pain and tenderness at the back or underside of the heel, especially during or after activity.
- Pain that worsens with running, jumping, or prolonged standing.
- Stiffness in the heel, particularly first thing in the morning.
- Swelling or redness around the heel.
- Pain when squeezing the sides of the heel (positive squeeze test).
- Limping or walking on tiptoes to avoid loading the heel.
Aggravating Factors
- Running and jumping activities, especially during sport training or games.
- Prolonged standing or walking, particularly on hard surfaces.
- Barefoot walking on hard floors.
- Poorly cushioned or worn-out footwear.
Causes
Sever’s disease occurs due to repetitive stress and traction at the heel growth plate. During growth spurts, the heel bone often grows faster than the muscles and tendons of the lower leg. This can lead to tightness in the calf muscles and Achilles tendon, which increases pulling forces on the calcaneal apophysis.
When this traction is combined with repetitive impact from running and jumping, the growth plate becomes irritated and painful. This explains why Sever’s disease is common in active children and often flares during periods of increased training or competition.
Foot biomechanics can further influence loading through the heel. Children with flat feet, high arches, or altered walking and running patterns may place uneven stress through the growth plate. Excess body weight can also increase the load passing through the heel with each step.
A physiotherapist will assess these contributing factors to identify why the heel is overloaded and to guide appropriate management rather than relying on rest alone.
How Is It Diagnosed?
Sever’s disease is usually diagnosed clinically based on history and physical examination. A physiotherapist or doctor will ask about the child’s age, growth stage, sport participation, recent increases in activity, and the pattern of pain. The classic presentation includes activity-related heel pain that improves with rest.
On examination, tenderness is typically present at the back of the heel, and pain is often reproduced with squeezing the sides of the calcaneus. Gait assessment may show limping or toe walking, and calf tightness is commonly identified.
Imaging is not routinely required because Sever’s disease is a clinical diagnosis. X-rays may appear normal or show growth plate changes that are also seen in pain-free children. Imaging is generally reserved for atypical cases, severe pain, or when other diagnoses such as fracture or infection need to be ruled out.
Investigations & Imaging
- X-ray
- Usually not required for diagnosis but may be used to exclude fractures or other causes of heel pain if symptoms are atypical.
- MRI
- Rarely needed; may be used if symptoms are severe, persistent, or if alternative diagnoses are suspected.
Physiotherapy Management
Physiotherapy for Sever’s disease aims to reduce heel pain while allowing the child to remain as active as possible. Treatment focuses on managing load through the growth plate, addressing muscle tightness and strength deficits, and modifying activities so symptoms do not escalate. Because Sever’s disease is self-limiting, physiotherapy does not aim to ‘fix’ the growth plate, but rather to control symptoms and prevent recurrence during growth.
A physiotherapist will work closely with the child and parents to balance sport participation with recovery, rather than recommending prolonged rest unless symptoms are severe.
Exercise
Exercise therapy for Sever’s disease focuses on reducing excessive traction through the heel while maintaining lower limb strength. Gentle calf stretching is commonly prescribed to reduce tension from a tight Achilles tendon pulling on the growth plate. These stretches are performed within pain-free limits and progressed gradually.
Strengthening exercises target the foot, ankle, and lower limb to improve shock absorption and stability during walking and running. This may include calf strengthening, foot intrinsic exercises, and general lower limb control work. Exercises are chosen carefully so they do not significantly aggravate heel pain.
Your physiotherapist will adjust exercises based on symptom response and growth stage, ensuring that strengthening supports long-term participation in sport.
Activity Modification
Activity modification is a cornerstone of Sever’s disease management. This does not necessarily mean stopping all sport. Instead, your physiotherapist will help identify which activities and volumes trigger symptoms and adjust these accordingly.
High-impact activities such as running and jumping may need to be reduced temporarily during painful periods. Low-impact alternatives such as swimming or cycling can be used to maintain fitness. Walking barefoot on hard surfaces is often discouraged, as this increases heel loading.
As pain settles, activities are gradually reintroduced with monitoring to ensure symptoms do not flare.
Manual Therapy
Manual therapy may be used as part of physiotherapy management to address calf muscle tightness and joint stiffness in the ankle or foot. Soft tissue techniques can help reduce muscle tension, while joint mobilisation may improve ankle movement patterns that influence heel loading.
Manual therapy is used to support exercise and activity modification, rather than as a stand-alone treatment.
Postural Retraining
Postural and movement retraining focuses on improving how the child walks and runs. Some children adopt compensatory strategies such as toe walking or altered foot placement to avoid heel pain. A physiotherapist can help correct these patterns once pain is better controlled.
This reduces the risk of secondary issues developing elsewhere in the lower limb.
Bracing & Taping
Heel cups, heel pads, or orthotics may be recommended to reduce load on the growth plate. These devices provide cushioning and slightly elevate the heel, reducing tension from the Achilles tendon.
Footwear advice is also important. Supportive shoes with good shock absorption are encouraged, particularly during sport and school hours. A physiotherapist will help determine whether orthotics are appropriate for the individual child.
Heat & Ice
Ice is commonly used to manage pain and inflammation after activity. Applying ice to the heel for 10 to 15 minutes after sport can help reduce symptoms. Heat is generally not recommended over the growth plate.
Education
Education is essential in managing Sever’s disease. Physiotherapists explain the growth-related nature of the condition, reassure families that it is temporary, and provide guidance on load management. Education helps reduce fear and encourages sensible activity modification rather than complete avoidance of sport.
Parents and children are taught how to recognise flare-ups, adjust activity levels, and maintain consistency with exercises and footwear strategies.
Other
Other management strategies may include coordinating return-to-sport plans with coaches, providing advice on warm-up and cool-down routines, and addressing whole-body conditioning so overall fitness is maintained during growth-related flare-ups.
Other Treatments
Other treatments may include short-term use of pain relief or anti-inflammatory medication, but only under medical advice. These medications do not address the underlying cause and should be used cautiously in children.
Supportive strategies such as icing, footwear modification, and orthotics are usually more appropriate alongside physiotherapy.
Surgery
Surgery is not indicated for Sever’s disease. Because the condition resolves naturally once the growth plate closes, surgical intervention is unnecessary and inappropriate.
Prognosis & Return to Activity
The prognosis for Sever’s disease is excellent. It is a self-limiting condition that resolves once the heel growth plate matures, usually by the mid-teens. Symptoms often last a few months but can recur intermittently during growth spurts or periods of increased activity.
With appropriate physiotherapy management, most children can continue participating in sport with modified load and return to full activity as symptoms allow. Importantly, Sever’s disease does not cause long-term damage or arthritis when managed appropriately.
Complications
- Persistent pain during growth spurts if activity is not modified.
- Reduced participation in sport due to pain-related avoidance.
- Temporary altered gait patterns leading to calf or knee discomfort.
Preventing Recurrence
- Increase training loads gradually during growth spurts to avoid sudden spikes in heel stress.
- Maintain calf flexibility and lower limb strength with regular exercises prescribed by a physiotherapist.
- Ensure children wear supportive, well-cushioned footwear for sport and daily activities.
- Avoid prolonged barefoot walking on hard surfaces during symptomatic periods.
When to See a Physio
- If heel pain is affecting your child’s ability to walk, run, or participate in sport.
- If pain persists despite rest and simple measures.
- If your child is limping or walking on tiptoes for prolonged periods.
- If you would like guidance on activity modification and safe return to sport.