Sever’s Disease

Sever’s Disease

What is Sever’s disease?

Sever’s disease, also known as calcaneal apophysitis, is a common cause of heel pain in growing children and young people.

It affects the growth area (apophysis) at the back of the heel bone (calcaneus), where the Achilles tendon attaches. During childhood and adolescence, this area is still developing and is more vulnerable to repetitive loading.

Sever’s disease is not a disease in the traditional sense. It is a growth-related overuse condition that is commonly associated with running, jumping and other high-impact activities.

Symptoms usually settle as the heel matures and the growth plate closes, although pain can come and go during periods of growth.

What causes Sever’s disease?

Sever’s disease is thought to develop when repeated loading through the heel exceeds the capacity of the developing growth area to cope.

It is particularly common during periods of rapid growth. The bones can grow faster than the surrounding muscles and tendons, which may increase tension through the Achilles tendon and the heel.

Activities involving repeated running and jumping can place additional stress through the area.

Factors that may contribute include:

• A rapid growth spurt

• Frequent running, jumping or other high-impact activities

• A sudden increase in training or activity

• Tight calf muscles or reduced ankle flexibility

• Changes in training, such as starting a new sport or a new season

• Footwear that provides limited cushioning or support

• Changes in foot posture or lower-limb movement

• A high overall training load without enough opportunity for recovery

Sever’s disease is not necessarily caused by one single factor. Often, it is the combination of growth, activity and the body's current capacity to tolerate load that contributes to symptoms.

When does Sever’s disease usually occur?

Sever’s disease most commonly affects physically active children and adolescents during periods of growth.

It is generally seen in children around 8–15 years old, although the exact age varies between individuals depending on their stage of growth.

It can affect one or both heels.

Symptoms can return during another growth spurt, even after a period when the heel has been feeling better.

What are the symptoms of Sever’s disease?

Common symptoms include:

• Pain at the back or bottom of the heel

• Pain that becomes worse during or after running, jumping or other physical activity

• Tenderness around the heel

• Pain when the sides of the heel are gently squeezed

• Pain that improves with rest

• Possible swelling around the heel

• Limping or changing the way they walk because of pain

• Walking on their toes to avoid putting weight through the heel

• Tightness through the calf or Achilles tendon

Symptoms can fluctuate, with some days being better than others.

How can Sever’s disease affect activity and participation?

Because Sever’s disease is closely linked to physical activity, heel pain can have a significant impact on a child's participation in sport and everyday activities.

Pain may affect:

• PE at school

• Football, gymnastics, athletics and other sports

• Running and jumping

• Training sessions and competitions

• Walking and general mobility

• Confidence in taking part in activities

• Motivation to exercise

A child may also change the way they walk or run to avoid putting pressure on the painful heel. For example, they may walk on their toes or limp.

Continuing to repeatedly push through significant pain can make symptoms more difficult to settle. However, complete rest is not always necessary. The aim is usually to find an appropriate level of activity that allows the child to remain active while symptoms settle.

Growth spurts and training load

Growth spurts can be a particularly important time to pay attention to training load.

A child may be able to tolerate a certain amount of running, jumping and training before a growth spurt, but find that the same amount of activity suddenly becomes more difficult.

This is why heel pain and other overuse injuries can sometimes appear at the beginning of a new sports season, school term or following a sudden increase in training.

Rather than simply stopping all activity, we focus on helping children and families understand:

• How much activity the child is currently doing

• How their symptoms respond during and after activity

• Whether training has recently increased

• Whether they are getting enough recovery between sessions

• How growth may be affecting their ability to tolerate their usual workload

Signs that a child may be struggling with their current training load

Heel pain is not always the only sign that a child's overall activity load may be too much for them at that point in time.

Other signs can include:

• Unusual or persistent tiredness

• Frequent aches and pains

• Reduced motivation to train

• Taking longer to recover between sessions

• A noticeable drop in sporting performance

• Poor sleep

• Changes in mood

• Repeated minor injuries

Growth, school demands, stress, sleep and nutrition can all influence how well a young person copes with their activity levels.

The aim is not to discourage children from being active, but to help them find a healthy balance between training, recovery and growth.

Can physiotherapy help with Sever’s disease?

Yes. Physiotherapy can help children manage the symptoms of Sever’s disease and safely maintain or return to their usual activities.

Sever’s disease is self-limiting, meaning it generally settles as the heel matures. Physiotherapy does not need to “correct” the growth plate itself.

Instead, physiotherapy can help identify factors contributing to symptoms, manage pain and loading, maintain strength and flexibility, and support a gradual return to sport.

At Positive Steps, treatment is tailored to the child rather than simply the diagnosis.

Depending on their symptoms and goals, physiotherapy may include:

Stretching and flexibility

We may use appropriate calf and ankle mobility exercises to improve flexibility and reduce excessive tension through the Achilles tendon.

Exercises are selected carefully so that they do not aggravate the heel.

Strength and conditioning

Once symptoms allow, strengthening the foot, ankle and lower leg can help develop the capacity needed for sport and everyday activities.

For older children and teenagers, strength and conditioning can also form part of their wider sporting rehabilitation.

Activity and training load

One of the most important parts of managing Sever’s disease is finding the right balance between activity and recovery.

We can help children, parents and coaches understand:

• Which activities are currently aggravating symptoms

• How activity can be modified

• When lower-impact alternatives may be useful

• How to build activity back up gradually

• How to respond if symptoms increase

Swimming, cycling and other lower-impact activities may allow a child to remain active when running and jumping are aggravating their heel.

Supporting recovery

Recovery is an important part of helping a growing body adapt to training.

We encourage families to consider four simple areas:

Recover – allow enough time between demanding activities for the body to adapt.

Rehydrate – encourage regular fluid intake, particularly around exercise.

Recharge – support good-quality sleep appropriate for the child's age.

Refuel – make sure the child is eating enough to support growth, everyday activity and sport.

Rather than focusing on one specific number of hours of sleep or a single nutritional target, we consider the child's age, activity levels and individual circumstances.

Supporting a gradual return to sport

If a child has had to reduce or pause their usual sport because of heel pain, we can help them plan a gradual return.

This may involve gradually increasing:

• Duration

• Frequency

• Intensity

• Running

• Jumping

• Sport-specific movements

We avoid increasing everything at once.

The child's symptoms and response to activity help guide how quickly they progress.

As they return to sport, we may also use functional activities such as hopping, running, jumping, changing direction and sport-specific drills to build confidence and assess how the heel is coping.

Footwear and heel cushioning

Supportive, well-fitting footwear can improve comfort for some children.

Where appropriate, we may discuss options such as heel cups or cushioned insoles to reduce discomfort during activity.

Any recommendation for orthotics or insoles would be based on the individual child rather than assuming that everyone with Sever’s disease needs them.

Gait and movement assessment

Pain can cause children to change the way they walk or run.

We can assess movement patterns and look for compensations such as:

• Toe walking

• Limping

• Reduced heel contact

• Changes in running technique

• Reduced ankle movement

• Changes in lower-limb control

This can help us understand what may be contributing to symptoms and what strategies could make movement more comfortable.

What does physiotherapy look like at Positive Steps?

There is no one-size-fits-all approach to Sever’s disease.

Every child has different activity levels, sports, symptoms and goals.

Our sessions are planned around what matters to the child and family. This could mean:

• Getting back to football

• Returning to gymnastics

• Managing symptoms through a sports season

• Continuing to take part in PE

• Understanding why the heel hurts

• Building strength and confidence

• Returning to activity safely after a period of reduced training

We combine exercise, functional movement, education and practical advice that can fit into the child's everyday routine.

For younger children, this may be incorporated into fun, play-based activities. For older children and teenagers, sessions can become more sport-specific and include strength and conditioning.

Working with the wider team

Managing Sever’s disease can involve more than just the child and physiotherapist.

At Positive Steps, we are happy to work alongside:

• Parents and carers

• Schools

• PE teachers

• Sports coaches

• Strength and conditioning coaches

• Other healthcare professionals

Where appropriate, we can help families and coaches understand how training may need to be modified while symptoms settle and how activity can gradually increase again.

Personal training and strength & conditioning

For older children and teenagers involved in regular sport, our strength and conditioning support can complement physiotherapy.

The focus can be on developing strength, movement quality, control and physical capacity so that the young person feels prepared to return to their sport.

This is particularly useful when a child is returning from a period of reduced activity and needs to gradually rebuild their training capacity.

When should your child be assessed?

Heel pain in a growing child is not always caused by Sever’s disease.

A healthcare professional should assess persistent, severe or unusual heel pain, particularly if there is:

• Significant pain at rest

• Night pain

• Fever or feeling generally unwell

• Significant swelling or redness

• Pain following a significant injury

• Inability to put weight through the foot

• Symptoms that are not improving with appropriate activity modification

• Pain that is progressively getting worse

These symptoms can indicate that another condition needs to be considered.

What are the goals of physiotherapy for Sever’s disease?

Goals will depend on the individual child, but may include:

• Reducing pain and improving comfort

• Helping the child stay active within their current tolerance

• Identifying and managing contributing factors

• Maintaining strength and flexibility

• Supporting healthy training and recovery habits

• Reducing unnecessary changes to walking and running

• Building confidence in movement

• Supporting a gradual return to sport

• Helping parents and coaches understand activity modification

• Reducing the likelihood of repeated flare-ups during future growth spurts

How can Positive Steps help?

Sever’s disease usually improves with time as the heel matures, but the right support can make a difference to a child's comfort, confidence and ability to stay involved in the activities they love.

At Positive Steps, we work with active children and young people to understand their symptoms, manage activity levels and build towards a safe return to the things that matter to them.

Our approach is focused on finding the right balance between protecting the heel and keeping the child moving.

Always finding what can be done.

If your child is experiencing heel pain and you would like to find out whether physiotherapy could help, get in touch with the Positive Steps team to arrange an assessment.

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Find out more

For further information about Sever’s disease and heel pain in children, speak to your GP, physiotherapist or other healthcare professional.

Useful sources include:

• NHS physiotherapy information on calcaneal apophysitis (Sever’s disease)

• Association of Paediatric Chartered Physiotherapists (APCP)

• Your child's GP or healthcare team