Sever's disease is a musculoskeletal condition that affects children and adolescents as they grow. Also called calcaneal apohysitis, it is a painful inflammation of the growth plate or epiphyseal plate, in the heel bone.
The term ‘disease’ is deceptive, simply put, it is a condition of the heel caused by overuse which affects adolescents during growth spurts in puberty. This is typically between eight and 13 for girls and 10 and 15 for boys. After this time, growth at the heel finishes, the bones at the heel fuse together and the inflammation subsides.
Inflammation can occur when the soft tissues connected to the heel mature more quickly than the bone itself, putting pressure on the bone. Pain is often experienced during adolescent and pre-pubescent growth spurts.
It is more common in active, athletic children and adolescents that play a lot of sport in school and outside, perhaps for a local or county team. Some sports are worse than others for exacerbating symptoms, for example, gymnastics in bare feet is typically bad. Running on tarmac or concrete at length is also likely to worsen the condition, as the heel bone is sensitive to repeated pounding into the pavement. Heel pain can be experienced in one or both feet.
Strenuous exercise, particularly sprinting, can often aggravate already over-stretched tendons and result in the onset of Sever’s.
In many cases of Sever's the biomechanics of the foot type may increase the chances of developing the disease. These are common foot types that can be causal:
- a pronated foot type will cause tightness of the Achilles tendon, which increases the stress over the heel bone
- a high arched foot can also cause tightness over the Achilles tendon
- leg length discrepancy will cause uneven stress on the heel of the shorter leg
- Anecdotally, we also see a lot of hypermobile children suffering from Sever’s
The external appearance of the heel is almost always normal and the primary symptom is sharp pain which goes up one or both heels, usually at the back. Swelling, tenderness, or a tight heel are also painful symptoms that a child may experience. At times the pain can be so debilitating that patients enter the clinic limping or walking on their tip-toes. Sudden knocks to the foot can also be very painful.
Other symptoms may include swelling or redness at the heel, difficulty walking, stiffness upon waking, and discomfort when the heel is squeezed at both sides.
Heel pain that gets worse during and after exercise, particularly jumping or running, can be an indication of Sever’s. There are no long-term consequences of getting the condition at any age.
A diagnosis is made based on the symptoms. A ‘positive squeeze test’ is used by a GP or clinician as a diagnostic test, by squeezing the heel to bring on pain. X-rays and imaging do not diagnose Sever's but they may be used to rule out other injuries such as fractures.
Sever's disease is commonly treated by rest, anti-inflammatory pain relief, ice and elevation. Sometimes the pain will disappear within a few weeks or after a period of rest, but there is the potential for it to recur until the growth plate is fully developed.
When parents come in to the clinic, one of the first things we often ask them to do, if their child is particularly active, is fill out an activity timetable over a period of weeks to determine how much exercise they are doing and whether it could be considered too much whilst their muscles and skeleton matures.
The long-term prognosis is positive, as the condition is self-limiting i.e. a child will eventually grow out of it during puberty. However the break from sport can be hard for children who enjoy playing regularly for a team at a competitive level. For cases like this, bespoke orthotic insoles can offer a good solution.
Foot orthotics can help all foot types with a predisposition to Sever’s, by normalising the foot posture, particularly the hind foot and reducing stress at the heel caused by a tightened Achilles heel.
Heel lift orthotics raise the heel inside the shoe and can prevent the Achilles pulling hard on the growth plate. For other patients, more padding or shock absorbing material may be appropriate and added to their insoles. As they are bespoke, they will vary from patient to patient.