Sever’s disease, aka calcaneal apophysitis to musculoskeletal physiotherapists is the most common cause of heel pain in growing athletes. Sever’s Disease isn’t really a true disease per se and was actually first identified by Patrick Haglund in 1907[1], but it was James Sever’s characterisation of the disease in 1912 that led to it being named after him.[2] Maybe it just had more dramatic ring to it? Sever’s disease is the inflammation of the calcaneal apophysisa, located on the heel close to where it connects into the Achilles tendon. Sever’s Disease most commonly occurs before or during a child’s peak growth spurt and is often seen when they begin a new sport or footy season. It is most common in boys between the ages of 8 and 12 and quite frequently in girls between the ages of 8 and 10 years old who are also active in sports.
How is Sever’s Disease diagnosed?
For your physio to find the cause of your child’s heel pain and rule out more serious conditions, they will ask some thorough questions about their medical history and ask questions about recent activities or injuries. There is rarely the need for any blood tests or x-rays, your physiotherapist will perform what’s called a squeeze test and some other tests to confirm the diagnosis of Sever’s Disease. During the squeeze test (which is exactly what it sounds like) if the child’s medial and lateral sections of the heel are tender and there are no symptoms such as red skin or swelling, almost always indicates a diagnosis of Sever’s disease.
Symptoms include:
- Pain in the back or bottom of the heel
- Limping
- Walking on toes
- Difficulty running, jumping or participating in usual activities or sports
- Pain when the sides of the heel are squeezed
- Tiredness
What causes Sever’s Disease?
When children (especially boys) are going through a growth spurt, the bones will grow first and the muscles and tendons can take a while to catch up. In Sever’s disease, the area around the heel bone can become quite sore and swollen where the Achilles tendon attaches to it. Children who participate in running and jumping sports such as AFL, soccer, Basketball and athletics are more likely to end up with Sever’s disease. Research has also shown that wearing boots with studs or spikes increases the risk of developing Sever’s disease.[3]
Factors contributing to Sever’s Disease in children include changes to:
- Height and weight – high BMI children have higher rates of the disease
- The frequency of physical activity – AFL carnivals over a few consecutive days
- The type of physical activity – Changing sports or starting new ones eg. Netball, gymnastics
- Shoes and equipment – Many football boots have a lower heel that can add pressure to the apophysis by stretching the Achilles tendon slightly. Lots of barefoot running and even walking in thongs on the soft sand at Dee Why can cause the same increased load.
How is Sever’s Disease treated?
As with most soft tissue injuries, in the first stages of recovery your physio will recommend the R.I.C.E method – Rest, Ice, Compression, and Elevation. Unfortunately, no one treatment method has been definitively proven to be better than others in the long-term management of Sever’s disease. During the early phase your child will probably be unable to walk pain-free, so the first aim is to prescribe your child with some active rest activities and keep away from pain-provoking activities for the time being. Your physio will use and teach your child a range of pain relieving techniques including joint mobilisations for stiff ankles and give the area a good massage in order to restore full Range of Motion, reduce pain and regain full foot biomechanics. A good musculoskeletal physiotherapist will also want to see your child’s biomechanics and technique in action and if they have injured themselves playing AFL or another sport, getting your physio to check it out will help reduce flare ups in the future.
How does Sever’s Disease affect my child’s sport?
Sever’s disease is a self-limiting condition and will fully heal with the right treatment. The first important step is to seek treatment when early signs of Sever’s become apparent. Sub-optimally treated Sever’s disease can cause a permanent bone deformity at the rear of the heel bone which can be painful and annoying. For the time being, seeing a physio will be be helpful to learn ways to stretch the Achilles tendon and keep pain under control. Limit your child’s sport load during the initial period and monitor their return to sport closely afterwards.
If your child is between the ages of 8 to 12 and is complaining of heel pain with no exterior causes, you should suspect Sever’s disease until proven otherwise. Sever’s Disease is a common issue seen by your local Dee Why physio due to the high number of active kids on the Northern Beaches (a positive and a negative there) and they are the best people to speak to if your child is complaining of a sore ankle.
[1] HAGLUND P: Ueber fractur des epiphysenkerns des calcaneus, nebst allgemeinen bemerkungen ueber einige
aehnliche juvenile knochenkernverletzungen. Archiv fur
klinische Chirurgie 82: 922, 1907
[2] SEVER JW: Apophysitis of the os calcis. N Y Med J 95:1025, 1912
[3] Sever’s Disease: What Does the Literature Really Tell Us? Rolf W. Scharfbillig, PhD* Sara Jones, PhD† Sheila D. Scutter, PhD May/June 2008 • Vol 98 • No 3 • Journal of the American Podiatric Medical
