Sever's Disease (Calcaneal Apophysitis).
What is Sever's disease?
Sever's disease — more accurately called calcaneal apophysitis — is the most common cause of heel pain in children and adolescents, typically affecting active children between the ages of 8 and 15. Despite the alarming word "disease," it is not a disease in the conventional sense — it is a growth-related overuse condition that is self-limiting and resolves completely once the growth plate closes.
The condition involves irritation and inflammation of the calcaneal apophysis — the growth plate at the back of the heel bone where the Achilles tendon and plantar fascia attach. During the adolescent growth spurt, the heel bone grows faster than the surrounding soft tissues, particularly the calf muscles and Achilles tendon. This relative tightness places increased traction stress on the growth plate during physical activity, producing the characteristic pain at the back of the heel that worsens with sport and improves with rest.
Sever's disease is particularly common in children involved in running and jumping sports — football, basketball, netball, gymnastics and athletics — and typically emerges or worsens during periods of rapid growth or increased training load.
How is it diagnosed?
Sever's disease is usually diagnosed by a healthcare professional based on a combination of the child's medical history, symptoms, and a physical examination. During the exam, the physiotherapist will ask about symptoms including when they started and what activities make them worse or better, perform a physical examination of the affected foot and ankle, palpate the heel bone to check for tenderness, and observe the child's gait.
The squeeze test — applying medial and lateral compression to the posterior heel — reproduces the characteristic pain and is the most useful clinical sign. The diagnosis is clinical and imaging is usually not required. X-ray may be used to exclude other causes of heel pain — stress fracture, bone cyst or infection — in atypical or treatment-resistant presentations.
What are the symptoms?
Heel pain at the back and bottom of the heel that is worse during and after sport, improves with rest, and often causes a limp or toe-walking during acute flares. The pain is typically bilateral — affecting both heels — in approximately 60% of cases, which is an important distinguishing feature from other causes of heel pain that are more commonly unilateral. Morning stiffness in the heel is common. Stiffness in the foot or ankle is a frequent associated complaint.
Will my child need to stop sport entirely?
This is the question parents ask most often, and the answer in most cases is no — or at least not completely. The old approach of enforced complete rest until symptoms resolve is no longer recommended. Research supports a load management approach — reducing the training volume and intensity that is provoking symptoms, while maintaining some activity within a pain-free or low-pain threshold. Stopping all activity often produces significant distress in active children and is unnecessary for most presentations.
The principle is finding the load level at which the child can participate without symptoms flaring significantly, then gradually increasing that load as the condition settles. This requires individual assessment — the right activity level varies considerably between children depending on severity, sport demands and growth rate.
How can physiotherapy help?
Physiotherapy can be an effective treatment for Sever's disease, especially if caught early. A physiotherapist can work with the child to develop a customised exercise program that includes stretching and strengthening exercises for the calf muscles and Achilles tendon to reduce tension on the growth plate and improve flexibility and strength. Manual therapy techniques such as massage and soft tissue release of the calf and Achilles tendon reduce the tensile load on the growth plate.
Calf and Achilles stretching is the most important exercise component — addressing the relative tightness of the gastrocnemius and soleus that is the primary mechanical driver of growth plate stress. Static calf stretches held for 45 seconds and performed consistently throughout the day produce meaningful reductions in traction force at the apophysis.
Heel raises — small wedges worn inside the shoe — reduce the traction force on the calcaneal apophysis by slightly elevating the heel and reducing the effective stretch on the Achilles tendon. They provide immediate symptomatic relief and are a simple, inexpensive and effective adjunct to physiotherapy during the most symptomatic phase.
Footwear assessment is important — children in flimsy shoes with poor heel cushioning are at higher risk of Sever's disease flares. Well-cushioned sports shoes with appropriate heel support significantly reduce impact loading through the growth plate.
Strengthening exercises for the calf, intrinsic foot muscles and hip and gluteal muscles address the broader lower limb weakness that contributes to increased load transmission through the heel during running and jumping. Hip and gluteal strength in particular is often overlooked in Sever's disease management — weakness here increases the shock transmitted to the foot with each stride.
Activity modification during the acute phase — identifying which aspects of training are most provocative (typically high-intensity running, jumping and change of direction) and temporarily reducing these while maintaining lower-impact activities — allows the condition to settle without full withdrawal from sport.
The good news for parents: Sever's disease is always self-limiting. The growth plate closes at skeletal maturity — typically between 14 and 16 in boys and 12 to 14 in girls — after which the apophysis fuses with the calcaneus and Sever's disease cannot recur. The challenge is managing symptoms and maintaining participation until that point.
Our physiotherapists Eliane Machado, Bethany Kippen and Emma Cameron all have experience in paediatric sports conditions and are members of the Australian Physiotherapy Association. For older adolescents with Sever's disease combined with performance goals, Exercise Physiologist Ash O'Regan can contribute to the conditioning program alongside physiotherapy.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Sever's disease — more accurately called calcaneal apophysitis — is the most common cause of heel pain in children and adolescents, typically affecting active children between the ages of 8 and 15. Despite the alarming word "disease," it is not a disease in the conventional sense — it is a growth-related overuse condition that is self-limiting and resolves completely once the growth plate closes.
The condition involves irritation and inflammation of the calcaneal apophysis — the growth plate at the back of the heel bone where the Achilles tendon and plantar fascia attach. During the adolescent growth spurt, the heel bone grows faster than the surrounding soft tissues, particularly the calf muscles and Achilles tendon. This relative tightness places increased traction stress on the growth plate during physical activity, producing the characteristic pain at the back of the heel that worsens with sport and improves with rest.
Sever's disease is particularly common in children involved in running and jumping sports — football, basketball, netball, gymnastics and athletics — and typically emerges or worsens during periods of rapid growth or increased training load.
How is it diagnosed?
Sever's disease is usually diagnosed by a healthcare professional based on a combination of the child's medical history, symptoms, and a physical examination. During the exam, the physiotherapist will ask about symptoms including when they started and what activities make them worse or better, perform a physical examination of the affected foot and ankle, palpate the heel bone to check for tenderness, and observe the child's gait.
The squeeze test — applying medial and lateral compression to the posterior heel — reproduces the characteristic pain and is the most useful clinical sign. The diagnosis is clinical and imaging is usually not required. X-ray may be used to exclude other causes of heel pain — stress fracture, bone cyst or infection — in atypical or treatment-resistant presentations.
What are the symptoms?
Heel pain at the back and bottom of the heel that is worse during and after sport, improves with rest, and often causes a limp or toe-walking during acute flares. The pain is typically bilateral — affecting both heels — in approximately 60% of cases, which is an important distinguishing feature from other causes of heel pain that are more commonly unilateral. Morning stiffness in the heel is common. Stiffness in the foot or ankle is a frequent associated complaint.
Will my child need to stop sport entirely?
This is the question parents ask most often, and the answer in most cases is no — or at least not completely. The old approach of enforced complete rest until symptoms resolve is no longer recommended. Research supports a load management approach — reducing the training volume and intensity that is provoking symptoms, while maintaining some activity within a pain-free or low-pain threshold. Stopping all activity often produces significant distress in active children and is unnecessary for most presentations.
The principle is finding the load level at which the child can participate without symptoms flaring significantly, then gradually increasing that load as the condition settles. This requires individual assessment — the right activity level varies considerably between children depending on severity, sport demands and growth rate.
How can physiotherapy help?
Physiotherapy can be an effective treatment for Sever's disease, especially if caught early. A physiotherapist can work with the child to develop a customised exercise program that includes stretching and strengthening exercises for the calf muscles and Achilles tendon to reduce tension on the growth plate and improve flexibility and strength. Manual therapy techniques such as massage and soft tissue release of the calf and Achilles tendon reduce the tensile load on the growth plate.
Calf and Achilles stretching is the most important exercise component — addressing the relative tightness of the gastrocnemius and soleus that is the primary mechanical driver of growth plate stress. Static calf stretches held for 45 seconds and performed consistently throughout the day produce meaningful reductions in traction force at the apophysis.
Heel raises — small wedges worn inside the shoe — reduce the traction force on the calcaneal apophysis by slightly elevating the heel and reducing the effective stretch on the Achilles tendon. They provide immediate symptomatic relief and are a simple, inexpensive and effective adjunct to physiotherapy during the most symptomatic phase.
Footwear assessment is important — children in flimsy shoes with poor heel cushioning are at higher risk of Sever's disease flares. Well-cushioned sports shoes with appropriate heel support significantly reduce impact loading through the growth plate.
Strengthening exercises for the calf, intrinsic foot muscles and hip and gluteal muscles address the broader lower limb weakness that contributes to increased load transmission through the heel during running and jumping. Hip and gluteal strength in particular is often overlooked in Sever's disease management — weakness here increases the shock transmitted to the foot with each stride.
Activity modification during the acute phase — identifying which aspects of training are most provocative (typically high-intensity running, jumping and change of direction) and temporarily reducing these while maintaining lower-impact activities — allows the condition to settle without full withdrawal from sport.
The good news for parents: Sever's disease is always self-limiting. The growth plate closes at skeletal maturity — typically between 14 and 16 in boys and 12 to 14 in girls — after which the apophysis fuses with the calcaneus and Sever's disease cannot recur. The challenge is managing symptoms and maintaining participation until that point.
Our physiotherapists Eliane Machado, Bethany Kippen and Emma Cameron all have experience in paediatric sports conditions and are members of the Australian Physiotherapy Association. For older adolescents with Sever's disease combined with performance goals, Exercise Physiologist Ash O'Regan can contribute to the conditioning program alongside physiotherapy.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
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If you are unsure about which appointment type is right for you, please don't hesitate to get in touch with our friendly reception staff by calling 07 3706 3407 or emailing [email protected].