Sever’s disease, or calcaneal apophysitis, is a temporary orthopedic condition that commonly affects physically active children and adolescents. It is a frequent source of heel pain, particularly in young athletes between the ages of 8 and 15 who are undergoing a growth spurt. The condition results from repetitive stress on the back of the heel, an area where the growth plate is still developing.
The Mechanism of Sever’s Disease
Sever’s disease is the clinical term for inflammation of the calcaneal apophysis, which is the growth plate located at the back of the heel bone. This growth plate is composed of cartilage and is structurally weaker than the surrounding bone and tendons in a growing child. The condition is caused by repetitive microtrauma from the Achilles tendon pulling on this vulnerable site.
During a rapid growth spurt, bones often lengthen faster than the surrounding muscles and tendons. This difference in growth rate causes the calf muscles and Achilles tendon to become relatively tight, increasing the traction force applied to the heel bone’s growth plate. Repetitive high-impact activities like running and jumping intensify this stress, leading to irritation, inflammation, and pain. Since the pain is directly related to activity and impact, it typically subsides with rest but flares up with renewed physical exertion.
Guidelines for Continuing Sports Activity
Sports participation is often possible with Sever’s disease, provided that activity is modified and managed based on the athlete’s pain level. Continuing activity without modification risks exacerbating the inflammation and prolonging the condition. The guiding principle for participation is the athlete’s personal pain threshold, aiming for relative rest rather than complete cessation of activity.
A common strategy involves monitoring symptoms using a “traffic light” system to determine the appropriate level of training load. Green light indicates minor pain that resolves quickly after activity, allowing for continued participation with minor adjustments. Yellow light signifies moderate pain during or after activity that may cause a slight limp, requiring reduction in training intensity, frequency, or duration. Red light means the athlete is limping, experiencing severe pain, or feeling pain even during simple walking, which mandates immediate cessation of high-impact activities and evaluation.
Training load adjustments should focus on reducing impact and strain on the heel. This might involve substituting high-impact running drills with low-impact activities like swimming or cycling to maintain cardiovascular fitness and strength. Activity should not stop completely to prevent deconditioning, but any activity causing a noticeable limp must be stopped immediately. Open communication between the athlete, parents, and coaches is necessary to ensure symptoms are honestly reported and training limits are respected.
Acute Pain Management Techniques
Immediate, short-term strategies control inflammation and enable the athlete to continue activity. The RICE protocol—Rest, Ice, Compression, and Elevation—is effective, particularly the application of ice. Applying ice to the painful heel for 15 to 20 minutes after activity helps to reduce localized inflammation and pain by constricting blood vessels.
Supportive footwear and orthotic devices reduce tension on the growth plate during movement. Heel cups or heel lifts, placed inside athletic shoes, cushion the heel strike and slightly elevate the heel, which decreases the pull of the Achilles tendon on the irritated apophysis. Athletes must ensure their athletic shoes are well-cushioned and supportive, avoiding worn-out or flat shoes, and especially avoiding sports cleats without proper heel padding.
Targeted stretching of the calf musculature reduces strain before activity. Consistent stretching of the gastrocnemius and soleus muscles helps to lengthen the muscle-tendon unit, thereby relieving the excessive traction force on the heel. These stretches should be performed gently, without causing pain, both before and after participation.
Protocols for Full Recovery and Prevention
Sever’s disease is a self-limiting condition, meaning it will resolve completely when the calcaneal growth plate naturally fuses and hardens, typically around late adolescence. The objective of the long-term protocol is to manage symptoms until this natural maturation occurs. Full recovery involves a comprehensive rehabilitation plan that moves beyond acute pain relief to address underlying biomechanical issues.
Strengthening exercises should focus on the lower kinetic chain, including the core, hips, and lower leg muscles, to improve overall shock absorption and movement efficiency. Improved strength and control help to distribute forces more effectively during athletic movements, reducing repetitive stress on the heel. Maintaining flexibility through consistent stretching is important for long-term prevention of recurrence.
Once the athlete is pain-free during normal daily activities, a gradual return to full sport intensity is implemented to prevent immediate symptom relapse. This progression should increase the training load incrementally, such as by 25% each week, allowing the body time to adapt to the renewed stress. Adherence to this structured, progressive return and continued use of supportive footwear and stretching routines prevent future episodes.