Sever's Disease (Calcaneal Apophysitis)

Sever's disease is a disorder of the growth plate of the calcaneus. Symptoms most often occur at the posterior (back of the heel) aspect of the growth plate but sometimes are experienced at the plantar aspect below the heel. The Achilles tendon attaches to the posterior aspect of the growth plate and the plantar fascia takes part of its origin from the plantar aspect. Sever’s disease occurs more often in boys than girls. The age of onset is usually between 8 to 12 years. Sever’s disease is believed to be caused by overuse.

On x-ray the growth center first appears in girls between the ages of 4 to 6 years and boys aged 7 to 8 years. The centers fuse to the primary ossification center of the calcaneus in girls at approximately ages 12 to 14 on boys at ages 15 to 17.

The x-ray appearance usually shows the apophysis to be divided into multiple parts. Sometimes a series of small fragments is noted.  Asymptomatic heels may also show x-ray findings of resporption, fragmentation and increased density. But they occur much less often in the normal foot.

Pulling or “traction” of the Achilles tendon on the unossified growth plate is a likely contributing factor to Sever’s disease. Excessive pronation and a tight Achilles and limited dorsiflexion may also contribute to the development of this condition.

Pain is usually related to activity levels. In most cases the posterior aspect of the calcaneus will be tender. Checking both the medial and lateral aspects of the posterior portion of the growth plate will often show tenderness. Occasionally, the plantar aspect may be tender or both of these locations may be found to be tender. Frequently the Achilles tendon is tight and there may have been a recent increase in activity. The factors contributing to this disorder are similar to those causing plantar fasciitis, but a tight Achilles tendon appears to be a greater contributor than pronation.

Differential Diagnosis:
Calcaneal stress fracture
Stress fracture of the growth plate
Neoplasm of the calcaneus
Osteomyelitis

Treatment:

...a heel lift is often helpful, and in some cases orthotics can be a great help. A pneumatic walking boot may be required in severe cases.......

In the early stages limit activity and rest. Use a non-compressible heel lift. Ice may be helpful. As symptoms improve gently stretch the Achilles tendon and calf muscles.
Long term use of a heel lift and orthotics may also be helpful to prevent recurrence and aid return to athletic activity.
While this consition is often said to be self-limited, the period of time in which it becomes limited may be a bit longer than many people would wish. To help speed things along, a pneumatic walking boot may be needed, or high voltage galvanic electrical stimulation and additional physical therapy to decrease symptoms and relax the calf muscles. Orthotics are useful to prevent symptoms from returning.

Treatment Summary:

Treatment Summary for Sever's Disease/Injury:

Careful assessment followed by the appropriate treatment:

Acute Care:

  • Rest, Ice, Elevation.

  • Limit motion using:

    • Heel lift
    • Pneumatic Walker

Long Term:

  • Heel lift
  • Calf stretching
  • Tibialis anterior strengthening
  • Orthotics
  • Gradual return to activity

Acute Care

Rest
Ice
Elevation
Heel Lift
Pneumatic walking boot in resistant cases

Long Term Care

Calf stretch
Heel lift - noncompressible
Orthotics

For additional information on heel pain in adults: Plantar Fasciitis and Plantar Heel Pain In Runners

Selected References:

Liberson A, Lieberson S, Mendes DG, Sharjrawi I, Ben Haim Y, Boss JH. Remodeling of the calcaneal apophysis in the growing child. J Pediatr Orthop B 1995; 4(1):74-79.

Sever JW. Apophysis of the os calcis. New York Med 1912; 95:1025-29.