Calcaneal apophysitis, commonly known as Sever’s disease, represents one of the most frequent causes of heel pain in physically active children and adolescents. Despite its concerning name, this condition is not actually a disease but rather an inflammatory condition affecting the growth plate in the heel bone. Understanding the etiology, clinical presentation, diagnosis, and management of calcaneal apophysitis is essential for parents, coaches, and healthcare providers who work with young athletes.
The calcaneus, or heel bone, is one of the largest bones in the foot and serves as the attachment point for the Achilles tendon. During childhood and early adolescence, the calcaneus develops through a growth plate called the apophysis, which is located at the posterior aspect of the bone. This growth plate is a cartilaginous area where new bone formation occurs, allowing the calcaneus to grow and mature. The apophysis typically fuses with the rest of the calcaneus between the ages of 13 and 15 years in girls and 15 and 17 years in boys. Before this fusion occurs, the growth plate remains vulnerable to stress and injury.
Calcaneal apophysitis develops when repetitive stress and strain are placed on the heel’s growth plate. The condition occurs most commonly in children between 8 and 14 years of age, coinciding with periods of rapid growth and increased participation in sports activities. During growth spurts, bones often grow faster than the surrounding muscles and tendons, creating tension in the soft tissues. The Achilles tendon, which attaches to the posterior calcaneus, can pull excessively on the growth plate during running, jumping, and other high-impact activities. This repetitive traction, combined with the ground reaction forces transmitted through the heel during weight-bearing activities, leads to inflammation and pain at the apophysis.
Several risk factors predispose children to developing calcaneal apophysitis. Physical activity level is perhaps the most significant factor, with the condition being particularly prevalent among young athletes who participate in sports involving running and jumping, such as soccer, basketball, track and field, and gymnastics. Biomechanical factors also play a crucial role. Children with flat feet or high arches, tight calf muscles, or abnormal gait patterns experience altered stress distribution across the heel, increasing vulnerability to apophysitis. Additionally, inadequate footwear lacking proper cushioning and arch support can exacerbate the problem. Obesity represents another risk factor, as excess body weight increases the load on the developing growth plate.
The clinical presentation of calcaneal apophysitis is typically straightforward. Children complain of pain localized to the back or bottom of the heel, which worsens with physical activity and improves with rest. The pain often becomes more severe during or after sports participation and may cause limping. Many children report that the pain is worst when they first begin walking after prolonged sitting or upon waking in the morning. On physical examination, tenderness is elicited when the sides of the heel are squeezed or when direct pressure is applied to the posterior aspect of the calcaneus. Some children may walk on their toes to avoid placing pressure on the painful heel. Swelling is usually minimal or absent, which helps distinguish calcaneal apophysitis from other conditions.
Diagnosis of calcaneal apophysitis is primarily clinical, based on the patient’s age, symptoms, and physical examination findings. The characteristic squeeze test, performed by applying medial and lateral compression to the heel, typically reproduces the pain and is highly suggestive of the condition. Imaging studies are generally not necessary for diagnosis but may be ordered to rule out other pathology if the presentation is atypical or symptoms persist despite appropriate treatment. X-rays may show fragmentation or sclerosis of the calcaneal apophysis, but these findings can also be present in asymptomatic children and therefore are not diagnostic. More advanced imaging such as MRI or ultrasound is rarely needed unless there is concern for other conditions such as stress fractures, bone infections, or tumors.
Management of calcaneal apophysitis focuses on reducing inflammation, alleviating pain, and modifying activities to prevent recurrence. The cornerstone of treatment is relative rest, which involves reducing or temporarily discontinuing the activities that provoke symptoms. Complete immobilization is rarely necessary, as some level of activity is beneficial for maintaining strength and cardiovascular fitness. Ice application to the affected heel for 15 to 20 minutes after activities can help reduce inflammation and pain. Over-the-counter nonsteroidal anti-inflammatory medications may be used for pain control when needed, though they should be taken according to appropriate dosing guidelines and with parental supervision.
Stretching exercises targeting the calf muscles and Achilles tendon are fundamental to treatment and prevention. These stretches help reduce tension on the growth plate by improving flexibility of the posterior leg muscles. Strengthening exercises for the intrinsic foot muscles and lower leg may also be beneficial. Proper footwear is essential, and children should wear well-cushioned athletic shoes with good arch support and shock absorption. Heel cups or orthotic inserts can provide additional cushioning and may help redistribute forces away from the painful growth plate. In some cases, physical therapy may be recommended to address biomechanical abnormalities, improve flexibility, and guide a safe return to sports.
The prognosis for calcaneal apophysitis is excellent. The condition is self-limiting and resolves completely once the growth plate closes and fuses with the rest of the calcaneus. Most children experience symptom improvement within two weeks to two months of initiating conservative treatment, though some may have intermittent symptoms during growth spurts or periods of increased activity. Prevention strategies include maintaining good flexibility through regular stretching, wearing appropriate footwear, gradually increasing training intensity, and ensuring adequate rest between high-impact activities. Parents and coaches should be educated about the importance of recognizing early symptoms and implementing appropriate activity modifications to prevent prolonged disability and ensure young athletes can continue participating in the sports they enjoy while their bones complete their natural growth and development.