The heel is the portion of the human body that lies at the bottom rear part of each foot. Its exterior shape is formed by the calcaneus, also known as the heel bone. The heel bone is the largest bone in the foot. The heel bone also contains the starting point of the Achilles tendon, which attaches the calf and its muscles to the heel.
The placement of the ankle and heel helps shape the area of the foot known as the arch. The arch and heel together allow the foot to evenly distribute any forces exerted on it, especially on the ground that is not completely flat.
Sever’s disease, also known as calcaneal apophysitis, is a painful inflammation located in the heel that results from a dramatic growth spurt in younger pre-teen patients. The inflammation comes about due to an abrupt growth when the heel bone grows at a faster rate than surrounding muscles and tendons which become overstretched and tight.
In addition, Sever’s disease occurs either acute or chronic. Almost every young athlete will most likely experience some heel pain from acute Sever’s disease, but you generally do not need to seek medical care for acute cases. If the patient’s heel pain doesn’t resolve on its own and is constant, it is most likely chronic. Chronic Sever’s disease is much more serious, and as the name implies, is an ongoing condition that affects the patient every day even when they are not active. Chronic does not respond to conservative treatments, and a custom orthotic foot specifically is considered one of the best treatment options in cases of a chronic Sever’s disease.
Causes & Symptoms
Sever’s disease is a painful injury that develops in the growth plates in the heel, near the Achilles tendon. Therefore, during a growth spurt, these growth plates tend to grow faster than the ligaments in the leg, which can cause tightness and leave the individual’s heel vulnerable to injury. Active adolescents who spend more time running, jumping, and playing sports are at especially high risk due to the repetitive stress these activities can put on the heel. It can be especially painful for student-athletes who train and compete on hard surfaces, such as track, basketball, and gymnastics. Ill-fitting shoes can also contribute to the condition by not providing enough support or padding for the feet by rubbing against the back of the heel.
Additionally, this bone injury is similar to another underlying condition known as Osgood-Schlatter disease, a type of condition that affects the growth plates in the knees of young athletes and active adolescents. Both injuries are caused by repetitive stress on the growth plates. However, while Osgood-Schlatter disease affects the growth plates in the knee, Sever’s disease typically creates pain in the heel.
The most common symptom of Sever’s disease is pain or tenderness in the back of one or both of the heels. The pain normally occurs at the back of the heels, however, it can also extend to the sides and bottom of the heel.
If your child has Sever’s disease, these symptoms may include:
- Heel pain, especially after running
- Swelling and redness around the affected heel
- A feeling of discomfort
- Stiffness after sleeping
Who Gets Sever's Disease?
Sever’s disease is age-related and activity-related. It typically begins in pre-teens and may be more common in pre-teens who are physically active. This condition occurs when the calcaneal apophysis is open and active.
Different risk factors that may contribute to Sever’s disease in younger patients include changes in height and weight, and how much physical activity they are performing; this may be an increase in volume, intensity, or frequency of activity. This often occurs:
- As one sports season ends and another one begins.
- Where there’s crossover in between other sports.
- When a child starts to train and play for a team (meaning the volume of activity will increase within multiple weekly training sessions).
- When they are involved in a sports carnival which involves participating in multiple games in one single day or over a number of days.
Other risk factors linked to Sever’s disease include:
- Frequency of physical activity
- The type of physical activity – such as starting a different activity or returning to physical activity after a break. Sever’s disease is commonly accompanied by sports and activities that are weight-bearing, such as sports that involve constant running or jumping or both (football, running, basketball, and gymnastics).
- Equipment – such as changing to shoes with a low heel (for instance, football boots or certain types of running shoes; the lower heel adds extra load to the back of the heel because it places the Achilles tendon on increased stress), performing a sport in bare feet, or walking at the beach in flip flops.
- Foot posture – active children who have a flat foot posture may be slightly more prone to Sever’s disease.
- Increased body weight.
How Does It Affect You? How Serious Is It?
Currently, there are thought to be no serious complications associated with this condition. Although Sever’s disease may come and go as your child is growing, it does not cause long-term health problems. Children grow out of the condition as they age and their growth plates harden into solid bone. However, side effects from NSAIDs (non-steroidal anti-inflammatory drugs) can occur if taken due to Sever’s disease. They are rare and normally affect people who have taken a medication for a long period of time. Side effects of NSAIDs include:
- Stomach pain, heartburn, and stomach ulcers
- High blood pressure
Recommended Treatment & Rehabilitation
Doctors diagnose Sever’s disease with a physical examination. Your child’s doctor will apply gentle pressure to the affected heel and foot to determine which specific areas are causing the pain. An X-Ray or MRI (magnetic resonance imaging) can help your doctor confirm a diagnosis and rule out other conditions, such as a fracture.
Generally, symptoms of Sever’s disease often improve with treatments like rest and over-the-counter pain relievers. It may take a few months for symptoms to disappear completely. Treatment for Sever’s disease includes:
- Rest – Your child will need to take a break from most weight-bearing activities for several days or weeks. Speak to your doctor about how much time your child should rest.
- Ice application – Apply ice packs to the affected heel a few times for 4-5 days to help reduce further swelling and inflammation.
- Pain relievers – Over-the-counter pain relievers such as ibuprofen or naproxen may help relieve pain and swelling (always seek advice from a doctor in advance).
- Supportive shoes – Ensure that your child wears supportive shoes that support the arches and protect the foot. Cushioned heel cups can absorb shock and decrease the pressure on your child’s heels.
- Stretching exercises – Ask your doctor or physiotherapist for different exercises that will stretch the Achilles tendon and reduce strain on the growth plate. Stretching and strengthening the heels, calves, and hamstrings makes muscles stronger and better able to support the feet and heels.
- Immobilization – If your child still has heel pain after a few weeks of rest, your doctor may recommend a cast to protect the growth plate and give it time to recover.
Physiotherapy can be highly beneficial for the treatment of Sever’s disease. The therapist will plan specific exercises, such as stretching, to help improve symptoms.
Sever’s disease can be prevented by maintaining great flexibility. The most effective way to do so is actively stretching on a regular basis – the extra attention on the muscles near the calf and heel directly improves the conditions caused by Sever’s disease. It is recommended to speed up your child’s recovery process by incorporating well-performed stretches to the Gastrocnemius and Soleus muscles:
The gastrocnemius muscle is attached above the knee and allows the foot, ankle, and knee to flex at their joints. This stretch keeps the heel on the ground while gently pushing and leaning forward. Many physiotherapists and physicians will recommend holding this position for periods up to 45 seconds for better results. For extra support, find a wall to help keep your balance.
The soleus muscle is located at the lower half of the leg behind the calf. This stretch is performed by bringing your toes up against the wall and bending the knee until a stretch is felt. This will exclusively stretch the calf muscle without trying to stretch every muscle at once.
During the early stages of your child’s rehabilitation, active stretching is a great start to get the muscles prepared for treatment. Here are other types of stretches to help reduce symptoms linked to Sever’s disease, including the following:
Calf stretch with assistance
With the knee straight, gently bend the child’s foot up towards the belly, stopping when you feel the muscles start to tighten. Finally, repeat with the opposite foot, then hold each stretch for 30 seconds before repeating 10 times.
Calf stretch against the wall
First, stand facing a wall. Lean towards the wall and place your hands on the wall for support. Bend one knee, then stretch the other leg out behind you. Keep the leg you are stretching straight. Switch leg positions and repeat, stretching the other leg. Lastly, hold each stretch for 30 seconds before repeating 10 times.
Calf stretch with a towel
While seated on the floor, take a towel, sheet, or belt and hold the ends in both hands. Loop the towel around the ball of the foot, then keep the knee straight and pull the towel towards you until you feel a stretch in the calf muscle. Finally, hold each stretch for 30 seconds before repeating 10 times.
Alternative & Homeopathic Treatment
It may not be possible to prevent Sever’s disease, especially in very active children. Therefore, to reduce the risk of developing the condition, you can do the following to reduce Sever’s disease from worsening:
- Balancing a healthy weight – Children who are overweight or obese are more likely to have Sever’s disease. Encouraging your child to eat healthy foods and stay active can keep their weight in the normal range.
- Encourage test – It is necessary to tell your child to take a break from activities if pain or swelling occurs. Children who give their bodies time to heal between activities have a lower risk of developing Sever’s disease.
- Limit certain activities – If your child participates in a lot of high-impact sports that involve running and jumping, limit with low-impact activities such as swimming and bike riding; this will keep your child active whilst also reducing stress on the heel bone.
Overall, with rest, Sever’s disease normally gets better within 2 weeks to 2 months. Most patients can perform most sports and activities that they have done before. Usually, by age 15, the growth plate is finished growing; typically, your child won’t experience Sever’s disease thereafter.