Sever’s Disease | Most Common Cause of Heel Pain in Children

Is your child suffering from heel pain? Our latest blog post discusses one of the most common causes of heel pain in children – Sever’s disease.

Sever’s disease (also known as Calcaneal Apophysitis) is a common reason parents seek help from their children’s podiatrist. Despite its name, Sever’s disease isn’t really a disease; rather it is best understood as a self-limiting, overuse injury. This is great news for worried parents for two main reasons:

  1. Sever’s disease isn’t lifelong and will eventually resolve on its own (usually around the age of 13-16 when the bones involved fuse together); and
  2. Your podiatrist can offer different treatment strategies to relieve pain in the meantime.

Causes of Heel Pain in Children 

When it comes to heel pain in kids, Sever’s disease is widely regarded as being the most common culprit. Although it is most commonly attributed to overuse or excessive stress to the growth plate region of the heel, a conclusive explanation as to how and why this condition occurs is yet to be agreed upon. However, a number of different factors have been suggested as possibly contributing to the development of Sever’s including the following.

1. Rapid Growth

Rapid growth is thought to be a contributing factor for Sever’s disease. It has been suggested that when bones grow too quickly during a growth spurt, the muscles and tendons can struggle to keep up. As a result, the muscles and tendons are pulled tight, resulting in tugging and irritation where they attach to bones. This is why it is often suggested that a tight calf muscle and/or Achilles tendon may contribute to heel pain in children. The Achilles is a robust tendon that attaches to the heel area and can tug and pull on the bone it attaches to (in Sever’s this is the calcaneal apophysis) causing irritation, inflammation and pain.

2. Biomechanics

Biomechanical malalignment is another potential reason for heel pain in kids and has been suggested as a potential factor in Sever’s disease. Feet are designed be be able to roll in and roll out with walking and running. However, if these movements are excessive or occur at the wrong time then excessive stress is put on the structures in and around the foot. With excessive rolling in of the foot (e.g. with flat feet or collapsed arches) a curve in the Achilles’ tendon can sometimes be seen when looking at the back of the heel. When combined with running and jumping, the Achilles is abnormally stressed and may pull on the bone it attaches to leading to irritation and pain. Similarly, feet that roll out too much or at the wrong time (e.g with high arches) can also cause a traction (pulling) injury where it attaches to the bone. Of course heel pain in the context of poor biomechanics may also cause stress to other areas like the attachment of the Achilles’ tendon causing Achilles insertional tendinopathy and even the bottom of the heel causing plantar fasciitis.

3. Trauma

High impact forces can potentially contribute to Sever’s disease by causing severe stress to the calcaneal apophysis where it ends under the back part of the bottom of the heel, leading to irritation and pain. In some cases, there is an obvious single instance of direct trauma to the heel such as contact with a sliding tackle in soccer or jumping from a height. However, there can also  be more subtle, repetitive micro-trauma that can occur when the bottom of the heel is subjected to regular impact. This may be because the activity itself requires a lot of running or jumping. It may also be due to things such as wearing poorly cushioned football boots on hard dry fields where the studs are unable to sink into the ground. Other sources of trauma or stress can stem from rapidly increasing the amount or intensity of exercise which can be the case for representative squads with intensive block training.

4. Obesity

Obesity is thought to contribute to the development heel pain by increasing the amount of force directed into the feet. With this in mind, obesity is somewhat related to trauma in that it can subject the heel to greater levels of impact, increasing stress on the heel and other parts of the foot and lower limbs, potentially increasing the chances of other heel pain conditions such as a bruised heel, Achilles insertional tendinopathy and Plantar Fasciitis.

5. Infection

Although relatively uncommon, infection is a potentially serious reason for heel pain in children. Importantly, heel pain due to infection is entirely different to Sever’s disease and requires medical attention from a doctor rather than a podiatrist. The growth plate at the heel is quite vascular which means there is strong blood flow through the area. Systemic infections that travel through the bloodstream can find their way to different parts of the body (e.g. joints, growth plates and even muscles). If your child experiences heel pain and is also generally unwell (e.g. lethargy, high temperatures etc) you should seek medical attention as soon as possible from your doctor or local emergency department if after hours.

Sever’s Disease Symptoms

Sever’s disease symptoms can vary between children. However, the main symptom is usually pain at the back of the heel anywhere from where the Achilles tendon attaches to the calcaneus (heel bone) down to the bottom of the heel. Some of the other symptoms associated with Sever’s disease include:

  1. Tenderness at the back and lower regions of one or both heels;
  2. Heel pain that is aggravated by activity but seems to improve with rest from activities;
  3. Heel pain that may return on walking after ‘cooling down’;
  4. Limping, walking on the outside of the heel or on tip-toes;
  5. Heel pain that may increase when barefoot but is relieved with supportive and/or cushioned shoes.

Sever’s Disease Treatment 

Knowing that Sever’s will eventually resolve on its own is often welcome news for concerned parents. Unfortunately, depending on the child’s age, it may take months or years for the bones to fuse and for symptoms to disappear completely. During that time, children can suffer from varying levels of pain and disability. This can affect activity levels and participation in favourite sporting activities, potentially hampered by pain, causing them to miss out on some or all of a given sporting season. Furthermore, limping and other types of compensatory gait can cause pain and injury in other areas of the feet and lower limbs. In extreme cases, left untreated, Sever’s may lead to fractures of the bone where the Achilles tendon attaches. Understandably, finding out what to do about symptoms in the meantime becomes priority for many parents.

Given that there are a number of potential causes and treatments, your kid’s podiatrist will be best placed to discuss specific treatment strategies they feel are suitable for your child based on their specific needs. Generally speaking, Sever’s disease treatment, exercises and strategies vary and will usually reflect the most likely causes. Some of the treatments that might be discussed with you and your child could include:

  • Encouraging your child to wearing supportive cushioned shoes as much as possible rather than going barefoot. Heel raises or heel cushions might be something your child’s podiatrist can recommend or provide.
  • Changing sporting activities (e.g. swapping from running to swimming), avoiding activities that make the pain worse and if necessary, cutting back on sporting activities to a manageable level can sometimes help. In more severe cases rest and/or immobilisation may be recommended but only when absolutely necessary;
  • In addition to activity modification, ice, elevation and anti-inflammatory medication (if allowed by your child’s doctor) may help when pain occurs;
  • Addressing any biomechanical factors that seem to be contributing to the problem (e.g. feet that roll in or out excessively). Early on, application of sports tape and introducing padding to temporarily improve foot function and protect the heel can trialled to reduce symptoms and importantly try and keep the young patient playing sport whilst reducing symptoms in the short-term. Longer term, orthotics (premoulded or custom) may help to continue protecting the heel from excessive stress from poor biomechanics.
  • Calf stretches performed under the supervision of a podiatrist or physiotherapist, and/or professional massage therapy may help to reduce the tension of the tight muscle on the calcaneal apophysis where this is thought to be a likely contributing factor.
  • Feet that roll in or roll out too much, can have weak muscles that struggle to control the foot and the strain caused can increase symptoms. Your child’s podiatrist can assess leg muscle strength and offer some suggestions regarding strengthening exercises to help control the abnormal movement and reduce stress on the foot if they think it’s necessary
  • Gait retraining to encourage children who have developed a limp or toe-walking to return to their normal walking pattern once symptoms start to improve.

Sometimes a single treatment strategy such as avoiding going barefoot may be all that’s needed. In other instances, a trial of a combination of different strategies may be required.

Additional Info

Even though Calcaneal apophysitis or Sever’s disease is benign and will resolve eventually, it can be very painful and even debilitating. Children who enjoy being active can find it particularly frustrating when pain prevents them from participating in their favourite sports, especially if it means missing that important grand final.

Sever’s disease is a benign condition that will resolve completely when the heel bones fuse. Until then, some children may experience symptom free periods (e.g. during the off season or when they are in shoes all day at school). In other cases, as the heel only becomes solid around 14 years of age or after, symptoms can be present year after year.

The only ‘cure’ for Sever’s is the fusing of the bones in the heel as your child’s foot matures. However, there are a number of different things our podiatrists can do to help your child if they are experiencing heel pain.

For Your Child’s Safety

Remember, a person’s health and circumstances are unique. This information is general in nature and is not intended to replace individual professional advice or the opinion of your medical practitioner. We endeavour to keep only up to date information on this site however, its accuracy is not guaranteed. Always seek the advice of a qualified health professional before making any decisions about your health.

References

  1. Becerro-de-Bengoa-Vallejo, M., Losa-Iglesias, M.E, & David Rodriguez-Sanz, D. (2014).; Static and Dynamic Plantar Pressures in Children With and Without Sever Disease: A Case-Control Study, Physical Therapy, 94(6), 818-826. Retrieved from  https://doi.org/10.2522/ptj.20120164.
  2. Marchick, M., Young, H. & Ryan, M.F. (2015) Sever’s Disease: An Underdiagnosed Foot Injury in the Pediatric Emergency Department. Open Journal of Emergency Medicine, 3, 38-40. http://dx.doi.org/10.4236/ojem.2015.34007
  3. Scharfbillig, R. W., Jones, S., & Scutter, S. D. (2008). Sever’s disease: what does the literature really tell us?. Journal of the American Podiatric Medical Association, 98(3), 212-223.

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