Calcaneal apophysitis, commonly referred to as Sever’s disease, is one of the most frequent causes of heel pain in children and adolescents, particularly those who are physically active. This condition is characterized by inflammation of the growth plate (apophysis) in the heel and typically affects children aged 8 to 14 years, coinciding with periods of rapid growth. Understanding the etiology, clinical presentation, and evidence-based treatment strategies for calcaneal apophysitis is essential for podiatrists, sports medicine professionals, and healthcare providers involved in pediatric care.
Etiology and Pathophysiology
Calcaneal apophysitis results from repetitive microtrauma to the calcaneal growth plate, which is not yet fully ossified in children. The apophysis is particularly vulnerable to shear and compressive forces generated during running and jumping activities. The condition is often associated with increased physical activity, changes in training intensity, or participation in sports that involve running on hard surfaces. Biomechanical factors, such as tightness in the gastrocnemius-soleus complex, flat feet (pes planus), or high arches (pes cavus), can also contribute to increased stress on the heel.
Clinical Presentation
Patients typically present with the following symptoms:
- Gradual onset of heel pain, often bilateral
- Pain exacerbated by physical activity and relieved by rest
- Localized tenderness at the posterior calcaneus
- Limping or toe-walking to avoid heel contact
Diagnosis is primarily clinical, based on history and physical examination. Imaging is rarely necessary unless atypical features or alternative diagnoses are suspected.
Treatment Principles
The primary goal of treatment is to relieve pain, reduce inflammation, and allow the apophyseal growth plate to heal. Importantly, calcaneal apophysitis is self-limiting and resolves once the growth plate fuses, but appropriate management can significantly improve quality of life and allow safe participation in activities.
1. Activity Modification
The cornerstone of treatment is modifying activities that exacerbate symptoms. This may involve:
- Reducing or temporarily ceasing high-impact sports (e.g., soccer, basketball, athletics)
- Encouraging alternative low-impact activities such as swimming or cycling
- Gradually reintroducing activity as symptoms improve
Complete immobilization is rarely required and may be counterproductive.
2. Footwear Assessment and Modification
Proper footwear is essential in managing calcaneal apophysitis. Recommendations include:
- Supportive shoes with adequate cushioning
- Avoiding barefoot walking, especially on hard surfaces
- Using shoes with a slightly elevated heel to reduce tension on the Achilles tendon
Replacing worn-out shoes and ensuring proper fit can also help minimize symptoms.
3. Orthotic Interventions
Orthotic devices can be highly effective in offloading the heel and correcting biomechanical abnormalities. Options include:
- Heel cups or pads: These provide cushioning and elevate the heel, reducing strain on the apophysis.
- Prefabricated or custom orthotics: For children with significant pronation or supination, orthotics can help correct alignment and distribute pressure more evenly.
Orthotics should be comfortable, easy to use, and regularly reviewed for fit as the child grows.
4. Stretching and Strengthening Exercises
Tightness in the calf muscles is a common contributing factor. A structured home exercise program should focus on:
- Gastrocnemius and soleus stretching: Daily stretches to improve ankle dorsiflexion and reduce tension on the heel.
- Hamstring stretching: Tight hamstrings can alter gait and increase heel pressure.
- Foot intrinsic muscle strengthening: Exercises to support the arch and improve foot mechanics.
A podiatrist or physiotherapist can provide guidance and ensure correct technique.
5. Ice and Anti-inflammatory Measures
Symptomatic relief can be achieved with:
- Ice packs applied to the heel for 10–15 minutes after activity
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, if appropriate and under medical supervision
Topical anti-inflammatory gels may also be considered for localized pain.
6. Patient and Parent Education
Education is critical to ensure understanding of the condition’s benign and self-limiting nature. Key points include:
- Emphasizing that symptoms will resolve with time and growth plate closure
- Encouraging adherence to activity modifications and exercises
- Addressing concerns about long-term impact (there is typically no lasting damage)
Setting realistic expectations can reduce anxiety and improve compliance.
7. Rare and Advanced Interventions
In rare cases where pain is severe or persistent despite conservative measures, further interventions may be considered:
- Short-term immobilization in a walking boot or cast for severe cases
- Referral to a specialist for persistent or atypical symptoms
Surgical intervention is almost never indicated for calcaneal apophysitis.
Prognosis and Return to Activity
The prognosis for calcaneal apophysitis is excellent. Most children experience complete resolution of symptoms within weeks to months. Return to full activity should be gradual, guided by symptom resolution rather than a fixed timeline. Ongoing stretching and strengthening, as well as attention to footwear, can help prevent recurrence.
Calcaneal apophysitis is a common and treatable cause of heel pain in children. Early recognition, patient-centered education, and a multifaceted conservative management plan are key to successful outcomes. By addressing biomechanical factors, modifying activities, and supporting the child and family through the recovery process, healthcare providers can ensure optimal recovery and a safe return to activity.
