Sever's Disease: Understanding Heel Pain in Active Children and Adolescents

What is Sever's heel?

Sever's disease, medically known as calcaneal apophysitis, is a common cause of heel pain in physically active children and adolescents, characterized by inflammation of the growth plate in the heel bone (calcaneus) due to repetitive stress.

Understanding Sever's Disease

Sever's disease is not truly a "disease" in the pathological sense, but rather an overuse injury or an osteochondrosis. It specifically affects the calcaneal apophysis, which is the growth plate located at the back of the heel bone (calcaneus). This growth plate is a cartilaginous area in a child's bone where new bone is formed, allowing the bone to grow in length.

During childhood and adolescence, particularly during periods of rapid growth, these growth plates are softer and more vulnerable to injury than mature bone. The powerful Achilles tendon, which connects the calf muscles to the heel bone, inserts very close to this growth plate. Repetitive pulling and stress on the Achilles tendon, combined with the impact of weight-bearing activities, can lead to microtrauma and inflammation of the growth plate.

Unlike adult heel pain often associated with heel spurs or plantar fasciitis, Sever's disease is unique to the skeletally immature individual because it directly involves the active growth plate.

Causes and Risk Factors

Sever's disease primarily results from repetitive stress and microtrauma to the vulnerable heel growth plate. Several factors contribute to its development:

• Overuse and Repetitive Stress: This is the primary driver. Activities involving repeated running, jumping, and forceful push-offs – common in sports like soccer, basketball, gymnastics, track and field, and dance – place significant strain on the Achilles tendon and, consequently, the heel's growth plate.
• Rapid Growth Spurts: During periods of accelerated growth, bones can grow faster than the surrounding muscles and tendons. This disparity can lead to increased tension in the Achilles tendon, pulling more forcefully on its attachment point at the calcaneal apophysis.
• Biomechanical Factors:
  • Tight Achilles Tendon/Calf Muscles: Reduced flexibility in these muscles increases the strain on the heel.
  • Foot Mechanics: Conditions like excessive pronation (flat feet) or high arches can alter the distribution of forces through the foot and heel, leading to increased stress on the growth plate.
• Improper Footwear: Shoes that lack adequate cushioning, arch support, or heel stability can exacerbate the impact forces and contribute to the condition. Training in worn-out athletic shoes is also a common culprit.
• Hard Surfaces: Regularly training or playing on unforgiving surfaces (e.g., concrete, artificial turf) increases the impact transmitted through the heel.
• Age and Gender: Sever's disease most commonly affects children between 8 and 14 years old, which aligns with peak growth spurts. While it can affect both boys and girls, it is observed more frequently in boys, possibly due to higher participation rates in high-impact sports.

Common Symptoms

The symptoms of Sever's disease typically manifest gradually and are often activity-related. Key indicators include:

• Heel Pain: The most prominent symptom. The pain is usually felt at the back or bottom of the heel, often worse during or immediately after physical activity. It may be bilateral (affecting both heels) in 50-60% of cases, though one heel might be more painful than the other.
• Tenderness to Touch: The heel, particularly when squeezed from the sides (medial-lateral compression) or when the Achilles tendon insertion is palpated, will be notably tender.
• Limping: Children may limp, especially after activity, or in the morning after waking up, as pain tends to be worse after periods of rest.
• Stiffness: Some children may report stiffness in the ankle or heel, particularly after inactivity.
• Pain Relief with Rest: A hallmark of Sever's disease is that the pain typically subsides with rest and returns with resumed activity. This helps differentiate it from more serious conditions.
• Difficulty with Activities: Pain may interfere with running, jumping, walking long distances, or participating in sports.

Diagnosis

Diagnosing Sever's disease is primarily clinical, based on a thorough medical history and physical examination.

• Medical History: The healthcare professional will inquire about the child's age, activity level, recent growth spurts, onset and pattern of pain (when it started, what makes it better/worse), and any previous injuries.
• Physical Examination:
  • Palpation: The clinician will gently press on the heel to identify the exact location of tenderness, which is typically at the back or sides of the calcaneus, specifically over the growth plate.
  • Squeeze Test: Squeezing the heel from side to side often reproduces the characteristic pain.
  • Range of Motion: Assessing the flexibility of the ankle and calf muscles, looking for tightness in the Achilles tendon.
  • Gait Analysis: Observing the child's walking pattern for any limping or compensatory movements.
• Imaging (X-rays): X-rays are generally not required to diagnose Sever's disease, as the growth plate itself appears normal on X-ray. However, X-rays may be ordered to rule out other, more serious conditions that could cause heel pain, such as fractures, infections, or tumors. The diagnosis of Sever's disease is made when the clinical presentation is consistent and other pathologies have been excluded.

Treatment Strategies

The primary goal of treating Sever's disease is to reduce pain and inflammation and allow the growth plate to heal. Treatment is largely conservative and focuses on activity modification and supportive measures.

• Rest and Activity Modification: Reducing or temporarily stopping activities that aggravate the pain is crucial. This doesn't always mean complete immobilization but rather a reduction in intensity, duration, or frequency of high-impact activities.
• Ice Application: Applying ice packs to the affected heel for 15-20 minutes, several times a day, especially after activity, helps reduce inflammation and pain.
• Stretching: Gentle and consistent stretching of the calf muscles (gastrocnemius and soleus) and the Achilles tendon helps improve flexibility and reduce tension on the heel growth plate.
• Footwear Adjustments:
  • Supportive Shoes: Wearing well-cushioned athletic shoes with good arch support is essential.
  • Heel Cups/Pads: Silicone or gel heel cups inserted into shoes can provide extra cushioning and elevate the heel slightly, reducing Achilles tendon tension.
• Pain Management: Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen may be used for short-term pain relief, but always under the guidance of a healthcare professional, especially for children.
• Physical Therapy: A physical therapist can provide a tailored program that includes:
  • Specific stretching and strengthening exercises for the foot, ankle, and calf.
  • Manual therapy techniques to improve joint mobility.
  • Gait analysis and correction of biomechanical imbalances.
  • Guidance on proper warm-up and cool-down routines.
• Orthotics: Custom or over-the-counter arch supports may be recommended to correct foot mechanics (e.g., excessive pronation) and reduce stress on the heel.
• Gradual Return to Activity: Once pain subsides, a progressive return to sports and activities is vital to prevent recurrence. This involves slowly increasing the duration, intensity, and frequency of training.

Prevention and Management Tips

While Sever's disease often resolves as the growth plate matures (typically by age 15-16), proactive measures can help prevent its onset and manage symptoms if it occurs:

• Ensure Proper Footwear: Children should wear athletic shoes that provide adequate cushioning, arch support, and heel stability for their specific activities. Replace shoes regularly as cushioning degrades.
• Prioritize Stretching and Flexibility: Regular stretching of the calf muscles and Achilles tendon should be part of any active child's routine, especially before and after sports.
• Gradual Activity Progression: Avoid sudden increases in training volume or intensity. Gradually build up activity levels to allow the body to adapt.
• Cross-Training: Encourage participation in a variety of sports and activities to avoid repetitive stress on the same body parts.
• Listen to the Body: Teach children to communicate pain early. Ignoring pain can lead to more severe or prolonged issues.
• Proper Technique: Ensure children are taught and use proper form and technique in their sports to optimize biomechanics and reduce undue stress.
• Adequate Rest: Ensure sufficient rest periods, especially during growth spurts and intense training seasons.

When to See a Doctor

While many cases of Sever's disease can be managed with rest and home care, it's important to consult a healthcare professional, such as a pediatrician, sports medicine physician, orthopedist, or physical therapist, if:

• The heel pain is persistent and does not improve with rest and basic home remedies.
• The pain is severe, constant, or significantly interferes with daily activities or walking.
• There are signs of infection, such as redness, warmth, swelling, or fever accompanying the heel pain.
• The child is limping significantly or has difficulty bearing weight on the affected heel.
• You have any concerns about the child's growth, development, or overall health.

A proper diagnosis is crucial to rule out other potential causes of heel pain and to ensure an appropriate management plan is put in place.