Sever's disease is a common cause of heel pain in active, growing children. We explain why it happens, the typical symptoms, how it differs from other causes of heel pain and what helps at home.
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Sever's disease (calcaneal apophysitis) is an overuse irritation of the growth area at the back and bottom of the heel in active, growing children. It most often affects children aged 8 to 14 and causes heel pain that gets worse with running and jumping. Despite the word "disease", it is not expected to cause lasting damage, and it comes to an end once the heel's growth plate has closed; treatment usually involves adjusting activity, stretching and suitable footwear.
With summer football camps, holiday sports clubs and long days of outdoor play, more children are seen with heel pain at this time of year. This article explains what causes Sever's disease, how it shows itself, how it is told apart from other causes of heel pain and what can be done at home.
What is Sever's disease and what causes it?
At the back of the heel bone (calcaneus), children have a growth area (apophysis) that is responsible for bone growth and has not yet fully turned to bone. The Achilles tendon attaches to the back of this area, while the strong band of tissue under the foot (the plantar fascia) pulls from below. Running and jumping put repeated pulling and impact forces through this growth area.
During growth spurts, bones lengthen faster than muscles and tendons. The calf muscles and Achilles tendon become relatively tight, increasing the pull on the heel's growth area. Combined with intensive activity on hard surfaces, this leads to irritation and pain. The heel growth plate usually fuses between mid and late adolescence, after which Sever's disease no longer occurs. A similar mechanism at the knee, where the kneecap tendon attaches to the shin bone's growth area, causes Osgood-Schlatter disease, and the two conditions can affect the same child at different times.
Who is more likely to get Sever's disease?
- children aged 8 to 14, especially during a growth spurt (girls may be affected slightly earlier);
- those who play sports involving running and jumping, such as football, basketball, volleyball, athletics, gymnastics and dance;
- children who train on hard surfaces or artificial grass;
- those wearing shoes or football boots with poor heel cushioning;
- children with tight calf muscles and Achilles tendons;
- those with differences in foot shape, such as flat feet or high arches;
- children whose training load has risen quickly, who play the same sport most days of the week or who play for more than one team.
Symptoms of Sever's disease
Symptoms usually come on gradually and are linked to activity:
- pain at the back or bottom of the heel during or after running and jumping;
- limping or walking on tiptoe after training;
- heel soreness with the first steps in the morning or after sitting for a while;
- pain when the back of the heel is squeezed from both sides (the squeeze test);
- pain when rising onto tiptoe or standing on the heels.
In many children the pain affects both heels and eases noticeably with rest. Marked swelling, redness, night pain or pain that continues at rest is not typical of Sever's disease and calls for other causes to be looked into.
Diagnosis: is an X-ray needed?
Sever's disease is usually diagnosed from the history and a clinical examination. The doctor will look at where the pain is, how it relates to activity, the squeeze test, calf flexibility and foot shape. An X-ray is not needed for every child, because the heel growth area can look fragmented and dense on X-ray in healthy children too. If the pain is on one side only, if there is marked swelling, night pain or fever, or if symptoms persist despite treatment, an X-ray and sometimes further imaging will be arranged.
Heel pain in children has other causes as well. The table summarises the main clues that help tell them apart:
| Condition | Distinguishing clues |
|---|---|
| Sever's disease | Age 8–14; pain that worsens with activity, often in both heels; pain when the heel is squeezed from the sides |
| Heel bone stress fracture | Pain and swelling on one side that keep increasing, typically after a rise in training |
| Achilles tendon problems | Pain higher up, along the tendon |
| Bone cyst, infection or tumour | Pain at night and at rest, swelling, redness, fever |
| Inflammatory arthritis | Morning stiffness, swelling in more than one joint |
For information on fractures and growth plate injuries in childhood, see our article on common fractures in children.
Treatment of Sever's disease
Treatment aims to reduce the load on the growth area and keep the pain under control. Most children improve with the following measures:
Adjusting activity
Stopping sport altogether is not always necessary. Depending on how bad the pain is, training time and intensity are reduced and the running and jumping parts are shortened. If pain is significant, the child can switch for a while to activities that put little load on the heel, such as swimming or cycling. A useful rule of thumb is that activity should not leave the child limping the next day.
Stretching and strengthening
- Wall calf stretch: hands on the wall, the painful leg stretched back with the heel kept on the floor, first with the knee straight and then with the knee slightly bent.
- Towel stretch: sitting with the leg straight, loop a towel around the sole and gently pull the foot towards you.
- Hamstring stretch: flexibility of the muscles at the back of the thigh also affects loading.
- Foot strengthening: scrunching up a towel with the toes or picking up small objects.
Stretches can be held for about 20–30 seconds in each position, several times a day, without pushing into pain. A physiotherapist or doctor can tailor the programme to the child.
Footwear, heel support and other measures
- Choose shoes with good heel support and a cushioned sole, and avoid running barefoot on hard surfaces.
- Silicone heel cups or small heel raises can ease pain by reducing the pull of the Achilles tendon.
- For differences in foot shape such as flat feet, the doctor may recommend suitable insoles if needed.
- After activity, ice wrapped in a cloth can be applied to the heel for 10–15 minutes.
- Painkillers should only be used on medical advice.
In the small number of children with very severe pain, a walking boot or cast may be needed for a short time. Surgery is not needed for Sever's disease.
Returning to sport and tips for parents
As the pain settles, activity is built back up gradually. Symptoms can come and go over months while the child is still growing; this does not mean that treatment has failed. General advice for parents includes:
- make a warm-up and stretching routine part of every training session;
- plan at least one or two rest days a week, and encourage a variety of activities rather than one sport all year round;
- check the heel support of football boots and trainers, and replace shoes that are worn out or too small;
- talk to the coach and agree how to reduce running and jumping during painful spells;
- take your child's pain seriously; pushing them to play through pain can slow recovery.
Summer camps with more than one session a day, long hours of play on hot, hard ground and thin-soled summer shoes can all increase the load on the heel. Talking to the coach about the programme beforehand, building rest breaks into the day and checking sports shoes can help to prevent flare-ups.
For other musculoskeletal problems during growth, see our guide to paediatric orthopaedic conditions for families.
When should you see a doctor?
It is advisable to have your child assessed by an orthopaedic specialist if there is:
- heel pain that has not settled within a few weeks despite rest and home measures;
- a limp that affects daily life or school;
- pain that wakes the child at night or continues at rest;
- marked swelling, redness or warmth of the heel, or a fever;
- pain on one side that keeps getting worse, or pain that began after a fall or injury;
- pain, swelling or morning stiffness in more than one joint.
Heel pain in growing children is assessed as part of paediatric orthopaedics, and the right approach is decided for each child after examination and, where needed, imaging.
Key points
- Sever's disease is an overuse irritation of the heel's growth area in active, growing children.
- Heel pain that worsens with running and jumping, eases with rest and often affects both sides is typical.
- Diagnosis is usually clinical; atypical features call for X-rays and further assessment.
- Adjusting activity, stretching, suitable footwear and heel support are the mainstays of treatment, and surgery is not needed.
- Night pain, swelling, redness, fever or worsening one-sided pain should be checked for other causes.
Frequently Asked Questions
Painful spells often settle within a few weeks to a few months with adjusted activity and stretching. However, while the heel growth plate remains open, symptoms can return, particularly during intensive sport or growth spurts. Sever's disease ends once the growth plate fuses, usually between mid and late adolescence. Until then, regular stretching, suitable footwear and a balanced training load help to reduce flare-ups.
Most children can carry on playing football with a programme adjusted to their pain. Shorter sessions, less running and jumping, boots with good heel support and silicone heel cups can all ease symptoms. If the child limps noticeably after a match or training, or the pain lasts into the next day, the load should be reduced. When pain is severe, a short break with activities such as swimming can maintain fitness in the meantime.
Sever's disease is a temporary irritation of the growth area and is not generally expected to cause long-term problems. Once the heel growth plate has fused, it no longer causes pain. That said, continuing intensive training through the pain can make symptoms last longer. If the pain does not follow the usual pattern, or there is night pain or swelling, a doctor should be consulted to look for other causes.
Shoes that hold the heel well, with a cushioned sole and a slight heel raise, usually feel more comfortable. Very thin-soled pumps, flat sandals and football boots with poor heel support can make the pain worse. Placing silicone heel cups inside sports shoes may help by reducing the pull of the Achilles tendon. Shoes that are too small or have worn soles should be replaced. If foot shape is very different, the doctor may suggest custom insoles.
Yes, in many children Sever's disease affects both heels, although one side may hurt more than the other. Pain in both heels fits with general overload related to growth and activity. By contrast, pain in one heel only, pain that keeps increasing, swelling or a history of injury should prompt an examination and, if needed, an X-ray to look for other causes such as a stress fracture or bone cyst.
This article is for general information only and does not replace a medical examination, diagnosis or treatment. Treatment options and outcomes vary from person to person.
Related treatment area Paediatric Orthopaedics: Common Bone and Joint Problems in Children
