Severs Disease Calcaneal Apophysitis: Symptoms, Types, Causes and Treatment

Severs Disease, also known as calcaneal apophysitis, is the leading cause of heel pain in children and young adolescents, particularly those involved in sports or high-impact activities. While it can be distressing for both children and parents, understanding its symptoms, forms, causes, and effective treatment options can make a significant difference in recovery and return to activity. This article offers a comprehensive, evidence-based overview of Severs Disease, drawing on the latest research and clinical findings.

Symptoms of Severs Disease Calcaneal Apophysitis

Severs Disease rarely goes unnoticed by active children or their caregivers. The symptoms are quite specific and tend to arise in the context of increased physical activity, making early recognition essential for effective management.

Symptom	Description	Frequency/Significance	Source(s)
Heel Pain	Aching or sharp pain at back/bottom of heel	Most common, often activity-related	1 2 4 5
Unilateral/Bilateral	Affects one or both heels	Unilateral in majority, bilateral possible	1 4 6
Worsens with Activity	Pain increases during and after exercise	Typical pattern in young athletes	1 4 6
Squeeze Test	Pain with medial-lateral heel compression	Diagnostic indicator	4

Table 1: Key Symptoms

Heel Pain: The Defining Feature

The hallmark of Severs Disease is pain located at the back or bottom of the heel. Children often describe it as a dull ache or a sharp, stabbing sensation that is aggravated by physical activity. Sports involving running and jumping, such as soccer or gymnastics, tend to bring on or worsen the pain 1 4 6. The discomfort is usually at its peak at the end of exercise or later in the day.

Laterality: One or Both Heels

While most cases are unilateral (affecting one heel), a significant number of children may experience pain in both heels simultaneously 1 4 6. Bilateral involvement is more common in children with higher activity levels.

Activity-Related Pattern

A classic feature is the relationship between pain and physical activity. Children often report that the pain intensifies during sports or play and lingers after the activity has stopped. Rest typically brings relief 1 4 6.

Diagnostic Tests and Physical Exam

A simple clinical test known as the "squeeze test"—where the examiner compresses the sides of the heel—can provoke pain in affected individuals and supports the diagnosis 4.

Types of Severs Disease Calcaneal Apophysitis

Although Severs Disease is generally described as a single condition, clinical presentations can vary, particularly in terms of laterality and severity.

Type	Distinction	Prevalence	Source(s)
Unilateral	One heel affected	~85% of cases	1 6
Bilateral	Both heels affected	~15–61% of cases	4 6
Acute	Sudden onset with clear activity link	Frequent	1 4
Chronic/Recurrent	Symptoms persist or return after rest	Up to 28% recurrence	1 6

Table 2: Types of Severs Disease

Unilateral versus Bilateral Presentation

Most children experience symptoms in one heel, but bilateral cases are not uncommon, especially in very active children or those with certain biomechanical predispositions 1 4 6. Bilateral pain may be more challenging to manage due to its impact on overall mobility.

Acute Onset

Acute cases are typically seen after a sudden increase in physical activity or the start of a new sport season. The pain comes on quickly and is closely linked to recent exertion 1 4.

Chronic or Recurrent Cases

Some children may experience chronic discomfort, with symptoms persisting for months, or they may have recurrences even after a symptom-free interval. Recurrence rates of up to 28% have been reported, especially if the child returns to high-impact activities too soon 1 6.

Causes of Severs Disease Calcaneal Apophysitis

Understanding the underlying causes of Severs Disease is essential for prevention and targeted treatment. Although multiple risk factors have been proposed, only some are strongly supported by research.

Cause/Factor	Mechanism/Role	Evidence Strength	Source(s)
Overuse/Impact	Repeated stress on growth plate	Strong	1 2 4 6
Age (8–15 years)	Open growth plate during puberty	Strong	1 4 5
High-impact Sports	Running/jumping sports increase risk	Strong	1 4 6
Biomechanical Malalignment	Pronation, foot posture, dorsiflexion limits	Moderate, under review	3 6
Obesity	Increased load on heel	Mixed	4
Rapid Growth	Tension at heel growth plate	Theoretical	1 4

Table 3: Causes and Risk Factors

Overuse and Mechanical Stress

The most significant cause is repetitive microtrauma from running, jumping, or high-impact sports. The heel’s growth plate (apophysis) is especially vulnerable during periods of rapid growth, making active children between 8 and 15 years old most at risk 1 2 4 6.

Growth Plate Vulnerability

Severs Disease only occurs while the calcaneal growth plate is still open—typically from childhood until mid-adolescence. After the growth plate closes, the risk disappears 1 4 5.

Sports and Activity Level

Participation in sports like soccer, track, cross-country, gymnastics, and ballet is frequently reported among affected children. However, research suggests that activity level alone may not be the sole risk factor, as not all active children develop the condition 1 3 4 6.

Biomechanical and Anatomical Factors

Certain foot postures—particularly pronation or specific forefoot-to-rearfoot alignment—and limitations in ankle dorsiflexion may contribute to risk, but the evidence for these factors is still evolving 3 6. Physical therapists often consider these aspects during rehabilitation.

Obesity and Rapid Growth

While some sources list obesity and rapid growth as risk factors due to additional heel stress, evidence is mixed; some studies do not support a strong association between weight and the onset of Severs Disease 3 4.

Treatment of Severs Disease Calcaneal Apophysitis

Despite the pain and disruption it causes, Severs Disease is a self-limiting condition. Treatment focuses on symptom relief, maintaining activity when possible, and preventing recurrence.

Treatment	Purpose/Effect	Evidence/Usage	Source(s)
Rest/Activity Modification	Reduce stress on heel	Standard care	1 4 6
Ice Application	Decrease inflammation, relieve pain	Common, effective	4
Stretching/Physical Therapy	Improve flexibility, reduce tension	Widely recommended	6
Heel Cups/Orthoses	Cushion heel, correct biomechanics	Short-term pain relief	6 7 8 9
NSAIDs	Decrease pain/inflammation	Adjunctive	4
Proper Footwear	Support, cushioning	Advised	6 8
Immobilization	Severe/persistent cases	Rare, short-term	4

Table 4: Treatment Strategies

Rest and Activity Modification

The cornerstone of management is reducing activities that cause pain—especially running and jumping. Most children can continue some activity, but with modified intensity or frequency 1 4 6.

Cold Therapy and Anti-inflammatory Medication

Applying ice to the heel for 15–20 minutes after activity can help control inflammation and discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for additional pain relief, though their necessity varies 4.

Stretching and Physical Therapy

A physical therapy program focusing on stretching the Achilles tendon and plantar fascia, as well as strengthening ankle dorsiflexion, can relieve tension on the heel apophysis and promote healing 6.

Heel Cups and Orthotic Devices

Heel cups and soft orthoses, often made from materials like Plastizote, are used to cushion the heel and relieve pressure. Evidence from clinical trials suggests that orthoses may offer greater short-term pain relief than heel lifts, but the overall quality of evidence is limited and more research is needed 6 7 8 9.

Footwear Recommendations

Athletic shoes with proper support, cushioning, and a firm heel counter are recommended. In some cases, replacing worn-out shoes or switching to footwear designed for shock absorption can be beneficial 6 8.

Immobilization

In rare or severe cases—such as when pain persists despite conservative measures—temporary immobilization in a walking boot may be considered 4.

Prognosis and Recurrence

Most children recover fully within weeks to months. Recurrence is possible, particularly if high-impact activities are resumed too early, but there are no known long-term consequences once the growth plate fuses 1 4 6.

Conclusion

Severs Disease, or calcaneal apophysitis, is a temporary but often painful condition for active children and adolescents. Recognizing its symptoms and understanding its causes are crucial for effective treatment and prevention of recurrence.

Key Points:

• Severs Disease is the most common cause of heel pain in children aged 8–15, especially those involved in sports or high-impact activities 1 4 6.
• Typical symptoms include activity-related heel pain, often unilateral, that improves with rest 1 4 6.
• Risk factors include overuse, mechanical stress, open growth plates, and possibly biomechanical factors, rather than weight or activity level alone 3 4.
• Treatment is conservative: rest, ice, stretching, heel cups, proper footwear, and occasional use of NSAIDs. Most cases resolve without long-term effects 4 6 7 8.
• Recurrence can occur if activities are resumed too quickly, but long-term outcomes are excellent once growth is complete 1 4 6.

With proper management, most children are able to return to their favorite activities pain-free, and with a better understanding of how to care for their growing bodies.