Sever’s disease is a heel injury that occurs in physically active children. It is a common complaint that causes temporary pain but no long-term damage.
Sever’s disease is named after James Warren Sever, the American doctor who first described the condition in 1912. It is also known as calcaneal apophysitis.
This article addresses the causes and symptoms of Sever’s disease and outlines the treatment options available.
Sever’s disease is caused by inflammation due to overuse or excessive force on the growth plate of the heel.
The growth plate, also called a physis or an epiphyseal plate, is an area located at the end of the bones of children and adolescents. It produces new tissue in order to grow and shape the developing bone.
Sever’s disease occurs during a growth spurt in children, which usually begins between the ages of 8 and 10 in girls, and 10 and 12 in boys. The condition is often seen at the beginning of a new sporting season, as children put additional pressure on their heels during this time.
Once children have reached the age of 15, they are highly unlikely to experience Sever’s disease. This is because bone growth is usually complete and the growth plate of the heel has hardened.
Sever’s disease is caused by excessive use or force on the growth plate of the heel.
In the growth spurt of adolescence, the heel bone may grow at a faster rate than the muscles and tendons in the leg, causing overstretching of these soft tissues. As a result, the heel becomes less flexible and places additional pressure on the growth plate.
When the tightened muscles and tendons are subjected to extra stress and strain associated with sports and physical activities, the growth plate experiences more trauma, leading to swelling and pain.
Activities that increase the risk of Sever’s disease include:
- standing for long periods
Basketball, soccer, and gymnastics are among the physical activities that lead to the development of this painful heel condition. Running track or jumping rope also increase the risk.
In one study of injuries among children aged 9 to 19 who played soccer, it was found that Sever’s disease accounted for 2 percent of soccer injuries, with those under 11 years old the most likely to be affected.
Though previously thought to be more common in boys, the increase in sports participation of girls has shown that Sever’s disease affects both sexes equally.
Other factors associated with Sever’s disease include:
- ill-fitting shoes
- activity on hard surfaces
- flat or high arches
- pronated foot, where the foot rolls inwards when walking
- having one leg shorter than the other
- being overweight or obese
The defining symptom of Sever’s disease is pain or tenderness in the heel. The pain is usually located at the back of the heel, but may also affect the sides and bottom of the heel.
Pain tends to get worse during or following physical activity. Symptoms usually improve with rest.
Other symptoms include:
- swelling of the heel
- redness of the skin
- stiffness of the foot upon waking
- tenderness that worsens if the heel or foot is squeezed
- trouble walking
Children with Sever’s disease who try to avoid putting weight on their heels may be observed walking on tiptoes or with a limp.
Doctors usually diagnose Sever’s disease based on a child’s medical history and the symptoms they have.
The doctor may also examine the heel and perform a “squeeze test.” In this test, the doctor squeezes the back of the heel to check if it hurts.
The child may also be asked to stand on their tiptoes, to see if other symptoms occur.
Imaging tests, including X-rays, are not typically used to diagnose Sever’s disease, as results usually show up as normal. However, a doctor may order an X-ray to rule out other foot conditions and injuries, such as fractures.
Due to the limited research available, it is not possible to recommend one form of treatment over another for children with heel pain. Therefore, doctors usually favor a combination of treatments.
Relieving the pain and tenderness in the foot is the first goal of treatment. Reducing the swelling and pressure on the growth plate is also a priority.
As a result, the first step in treating Sever’s disease is rest. Avoiding the physical activities that cause symptoms reduces pressure on the heel bone, leading to a reduction in pain and inflammation.
Once the injury has healed, it is best to return to activities gradually to prevent recurrence.
Other treatment options include:
- Ice therapy. In addition to resting the foot, doctors may recommend using ice packs to reduce swelling. These should not be placed directly on the skin as that can cause an ice burn. Apply ice packs wrapped in a cloth or towel to the heel for 20 minutes at a time, up to 3 times a day.
- Compression. Wearing a specially designed compression wrap or stocking can help decrease pain and swelling.
- Elevation. Lying down and raising the foot can help reduce swelling and pain.
- Exercises. Foot and leg exercises may help stretch and strengthen the muscles and tendons. However, it is important to check with a doctor or physical therapist before attempting any exercises.
- Supportive shoes and shoe inserts. Doctors may recommend special shoes or insoles to reduce stress on the heel bone. These can be particularly helpful if another condition, such as high or low arches, is aggravating Sever’s disease.
- Medication. Over-the-counter medications can relieve pain and inflammation. A person should ask the pharmacist which medicines are suitable for children, as some are not. For example, aspirin has been linked to Reye’s syndrome in children, a rare but life-threatening condition.
- Immobilization. Severe cases of Sever’s disease may require the child to wear a cast for up to 3 months to allow the foot time to heal.
Recovery from Sever’s disease usually happens without any long-term complications. Children can return to physical activity once the pain and other symptoms have gone.
Even with conservative treatment approaches, such as rest, ice, compression, and stretches, the condition takes 2 to 8 weeks to improve. However, early intervention usually means a quicker recovery time.
Recurrence of Sever’s disease is possible, particularly if steps are not taken to address the cause of the condition.
Preventing recurrence of Sever’s disease
Wearing good quality shoes with adequate heel support and shock-absorbing properties is an important factor in preventing the occurrence or recurrence of Sever’s disease.
Children should avoid wearing heavy or high-heeled shoes. Shoes with open backs may be recommended for some children, as these do not rub the back of the heel.
Other preventive measures include:
- stretching the calves, heel, and hamstrings regularly
- choosing low-impact activities, such as swimming or biking, at least some of the time
- running or jumping on suitable surfaces, for example, grass or purpose-built running tracks instead of concrete
- putting ice on the heel after physical activity
- taking adequate rest periods and avoiding over-training, especially if pain is felt in the heel
- maintaining a healthy weight and losing excess weight if necessary
- addressing conditions that increase the risk of Sever’s disease, such as pronated feet, flat feet, or high arches
Once the foot is fully formed, which happens around the age of 15, there is no longer a risk of Sever’s disease recurring.