Sever disease, also known as calcaneal apophysitis, is a common cause of heel pain in growing children and adolescents, particularly among children and teens who are athletes. It occurs when repetitive stress and tension from the Achilles tendon cause inflammation at the growth plate in the heel bone. Main symptoms include pain and tenderness at the back or sides of the heel, which often worsens with running, jumping, or other sports activities. These symptoms may be accompanied by mild swelling, and some children may limp or walk on the toes to avoid putting weight on the heel.

Sever disease most often affects children between the ages of 8 and 15, with boys being affected more frequently than girls. It is one of the most common causes of heel pain in this age group, accounting for 2% to 16% of all musculoskeletal complaints in children, and has an incidence of about 4 cases per 1,000 children in general practice. The condition is often seen in children who participate in sports such as soccer, basketball, track, and gymnastics, but can also occur in less active children, especially during periods of rapid growth.

Sever disease typically gets better on its own, and can be managed effectively with rest, activity modification, supportive footwear, and stretching exercises. Most children make a full recovery from Sever disease and can return to their usual activities without any long-term problems.

Children have a growth plate at the back of the heel bone (calcaneus), where the Achilles tendon attaches to the heel. The growth plate is a region made of cartilage that allows the bone to lengthen as the child grows. While the growth plate is open, the tissue is softer and more vulnerable to injury than the surrounding bone, tendons, or ligaments. When the child is done growing, the growth plate closes and becomes solid bone.

Sever disease is an inflammation of this growth plate. The growth plate becomes irritated and inflamed, causing pain and tenderness at the back or sides of the heel. This pain often worsens with physical activity, especially those involving running or jumping. The condition can affect one or both heels and is most common during periods of rapid growth, when the heel bone is still developing and the growth plate is open.

Sever disease does not cause permanent damage to the heel bone or growth plate, and symptoms resolve once the growth plate matures and closes.

Sever disease is caused by repetitive stress and small injuries to the growth plate at the back of the heel bone, where the Achilles tendon attaches. This stress most often results from activities that involve running, jumping, or other high-impact movements, which place repeated tension and pressure on the growth plate. During periods of rapid growth, the heel bone can grow faster than the muscles and tendons, leading to increased tightness in the Achilles tendon and greater pulling force on the growth plate.

Sever disease is most commonly caused by overuse and repetitive stress, not by a single injury. In rare cases, a direct injury to the heel can cause a different injury—such as a small piece of bone being pulled away from the main bone (called an avulsion fracture)—but this is uncommon.

Risk factors for Sever disease include:

• Ages 8 to 15 years
• Periods of rapid growth
• Participation in sports involving running and jumping (such as soccer, basketball, track, cross-country, gymnastics, dance, and tennis)
• Having obesity
• Limited ankle flexibility
• Wearing worn-out shoes, or shoes with little cushioning
• Running or playing on hard surfaces
• Flat feet (pes planus) or high arches (pes cavus)
• Overpronation or abnormal foot alignment
• Male sex
• Increased height and weight for age

To diagnose Sever disease, your doctor will review your medical history, conduct a physical exam, and, less commonly, order one or more diagnostic tests.

Your doctor may ask about your child’s symptoms, such as heel pain, when the pain occurs, recent changes in activity level, participation in sports, and any recent growth spurts. During the physical exam, your doctor will check for tenderness at the back or sides of the heel, pain with squeezing the heel (the “squeeze test”), swelling, and changes in walking, such as limping or walking on the toes to avoid heel pain.

Additional tests are usually not necessary to make the diagnosis, as Sever disease is typically diagnosed based on history and physical exam. However, if symptoms are severe, unusual, or do not improve after four to eight weeks of treatment, your doctor may order tests to rule out other causes of heel pain, including:

• X-rays: Used to rule out bone fractures, bone cysts, or other bone conditions. X-rays may show changes in the growth plate, but these findings can also be seen in healthy children.
• Magnetic resonance imaging (MRI): Used if symptoms are severe or persistent, to help distinguish Sever disease from infections, tumors, or stress fractures.
• Laboratory tests: Rarely, blood tests may be ordered to rule out infection or other conditions.

Sever disease resolves on its own (without surgical intervention) once the growth plate in the heel closes. The main goal of treatment is to relieve pain and allow a gradual return to normal activities. Treatment focuses on reducing stress and inflammation at the heel and supporting healing. The main treatments include:

• Activity modification or rest: Reducing or stopping activities that cause heel pain, especially running and jumping, until symptoms improve. Gradual return to activity is recommended once pain subsides.
• Ice application: Applying ice to the painful area for about 20 minutes daily (do not directly apply ice to bare skin) to reduce inflammation and relieve pain.
• Heel cups, heel lifts, heel pads, or custom orthotics: Placing these in shoes to cushion the heel, absorb impact, and reduce tension on the growth plate.
• Supportive footwear: Wearing shoes with good heel cushioning and support to help protect the heel and prevent recurrence.
• Stretching and strengthening exercises: Performing calf muscle stretches and exercises to improve flexibility and strength, which can reduce tension on the Achilles tendon and heel.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Taking medications such as ibuprofen or naproxen as needed to reduce pain and swelling. These should not be used to allow more activity than is comfortable.
• Physical therapy: Working with a physical therapist for guided stretching, strengthening, and other therapies if symptoms do not improve with home exercises.
• Immobilization: In severe cases or when pain interferes with walking, using a walking boot or cast for a short period to rest the heel and allow healing.
• Braces: Some individuals—especially children with irregular foot alignment or those who participate in barefoot sports such as gymnastics or dance (when orthotics cannot be worn)—may use braces for additional support and pain relief.

Most children recover fully with these treatments and can return to their usual activities once symptoms resolve. Surgery and injection therapy are not used to treat Sever disease.

People with Sever disease may be at increased risk for certain complications, including:

• Recurrence of heel pain, especially during periods of rapid growth or increased physical activity.
• Temporary changes in walking, such as limping or walking on the toes, due to pain.
• In rare cases, if not properly managed, persistent pain may interfere with participation in sports or daily activities until the growth plate closes.

Children and adolescents with Sever disease recover fully once the growth plate in the heel closes, and the condition does not cause permanent damage to the heel bone or growth plate. Symptoms usually improve within a few weeks to a few months with proper treatment. In some cases, however, symptoms may not improve for six months or until the growth plate is closed.

“The Yale Pediatric Orthopedic Surgery provides a multidisciplinary approach for comprehensive care of Sever’s disease,” says pediatric orthopaedic surgeon Marisa Su, MD, an assistant professor at the Yale School of Medicine. “Our approach focuses on accurate diagnosis, patient education, and minimizing risk of recurrence. While surgical intervention is not indicated, our team of non-operative orthopedic providers and physical therapists are specially trained to provide age-specific treatment modalities for growing children and their families.”