This was a question from a patient’s father. He wasn’t the nicest guy and had very little empathy for his son who did have a lot pain in his heels. His son, however, was a really nice kid. He was a 12 year old boy who had very tight heel cords. He was in the middle of a growth spurt and had recently begun playing soccer for a club team. He had all the signs and symptoms of Sever’s disease. Sever’s disease (which is not an actual disease) is also known as calcaneal apophysitis. It is a common cause of heel pain in adolescence.
What is Sever’s disease?
Sever’s disease is caused by repetitive stress on the heel bone or calcaneous. There is a growth plate at the back of the heel called an apophysis. An apophysis is the area of growth of a boney protuberance on a larger bone. The protuberance of bone is attached to the heel through the calcaneal apophysis. It is not associated with a joint. A boney protuberance is usually the site of a tendon or ligament attachment. The Achilles tendon attaches the calf muscle to the heel at the area of the bone growth. The apophysis is the weakest area of this bone, tendon, muscle group. As the achilles tendon pulls on the back of the heel over and over, the apophysis becomes irritated.
The calf is made up of the gastrocnemius and soleus muscles. These muscles point the foot and are very important in pushing off the ground in walking, running, and jumping. In sports that require a lot of running or jumping, the Achilles tendon is constantly pulling on the back of the calcaneous which will lead to irritation at the apophysis.
Sever’s disease most commonly presents during a period of rapid growth during adolescence. During growth spurts the bone grows faster than the muscle can stretch. This increases the tension on apophysis. However, this is a self-limiting condition. The apophysis will close or completely ossify around the ages of 15-16.
What ages does Sever’s disease affect?
Sever’s disease occurs in adolescence as the apophysis on the heel is still open and is hardening. This is different for males and females.
- For females, the median age is 11
- For males, the median age is 12
What sports can lead to Sever’s disease?
Any sport that requires a lot of running and jumping can lead to Sever disease. Unfortunately that is a lot of sports. Here is a list of common sports that might lead to Sever’s disease.
- Basketball
- Football
- Gymnastics
- Volleyball
- Track and field
- Soccer
- Cross country
What are risk factors for Sever’s disease?
There are several risk factors that could increase the chances of developing Sever’s disease. These include:
- Playing a sport with repetitive jumping and running
- Tight heel cord or Achilles tendon
- Weakness in the ankle
- Old shoes or shoes with very little support
- Running on hard surfaces
- Abnormal foot mechanics
- Obesity
What are the symptoms of Sever’s disease?
There are several symptoms that are characteristic of Sever’s disease. These include:
- No pain when getting up in the morning.
- Pain with running and jumping – This can be one or both feet. Sever’s disease is present in both feet in 60% of cases. Pain is in the back or bottom of the heel.
- Mild swelling at the back of the heel.
- Pain is reproduced when squeezing the sides of the heel.
- Pain with walking on toes.
- Limping
How long will this last?
As previously mentioned this is a self-limiting condition. It will end when the apophysis is closed and the back part of the heel fuses. This occurs around ages 15-16. If properly treated, the pain and inflammation can be controlled until this time.
What can we do to?
There are many things that can be done to help decrease the pain and swelling.
- Take a break – The first and best thing to do is to stop doing whatever it is that is causing the pain. This is most likely a sport. I am not saying that the child has to give up the sport but taking a break is a good idea. This might be for a week or two or, maybe, a month or two. This gives the heels some time to heal, and also time to stretch the calf muscle to decrease it’s pull on the heel.
- Taking a break may not be necessary if the pain is very mild. This means that the pain during and after play is very mild and goes away an hour or two after play. It also means that the pain does not cause a limp or change the way the child runs or walks. Keep in mind that mild pain can get worse if not treated so don’t ignore pain just because it is not interfering with play. Take the steps outlined to help decrease the mild pain and prevent it from becoming worse.
- Relative rest – Relative rest is participating in an activity or sport that does not bother an injury. Switching to a sport that is not so irritable to the heels is also an option. You can always return to your previous sport at a later date if desired. Also it is not advisable to have kids specialize in a sport at this age so getting them involved in a different sport that is less irritating to their feet is a good way to practice relative rest. Swimming is very good for Sever’s because it is less stressful for the feet but very strengthening for the body.
- Ice – Ice is a natural anti-inflammatory and works great at decreasing pain and swelling. Ice with an ice pack immediately after activity. This includes after practice, games, or maybe running around outside. Ice for about 15 to 20 minutes. Ice several times a day if the pain is more constant and is occurring with walking or going up and down steps.
- Stretching – Stretching the calf muscle can decrease the pull on the heel and help decrease the pain and inflammation. Also strengthening ankle dorsiflexion can improve calf mobility and foot/ankle strength. The ankle dorsiflexors are muscles on the front of the leg. These muscles work to bring your foot toward your shin. Below are videos on stretching the calf muscles and strengthening the ankle dorsiflexors. Using resistance bands can increase the difficulty of the exercises.
- Heel cup – Using a gel sock or heel cup might help take the some pull off of the Achilles and cushion the heel during activity.
- Shoe wear – Invest in quality shoes. Most running stores have a good selection of kids athletic shoes and could help you find one appropriate for your child’s foot.
- Physical therapy – Physical therapy is a good option to help decrease the pain and inflammation and also teach exercises to help lengthen and strengthen muscles.
In review
- Sever’s disease is an inflammation of a growth plate or apophysis at the back of the heel.
- Symptoms include pain and swelling at the back or bottom of the heel.
- It typically occurs during a growth spurt.
- It is caused by repetitive running and jumping.
- It is self limiting and will stop when the apophysis calcifies in later adolescence.
- There are many things that can be done to control the pain and swelling.
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.