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Sever's disease

Sever’s disease is a common cause of heel pain, particularly in the young and physically active. It usually develops just before puberty. Boys are slightly more prone to this condition than girls. Physiotherapy can help manage the symptoms of Sever’s disease so that the young person can continue to engage in physical activity.

Another name for Sever’s disease is calcaneal apophysitis. ‘Calcaneus’ is your heel bone, ‘apophysis’ is where the tendon joins the heel and ‘itis’ means inflammation. ‘Sever’ is the person who first identified this condition.

The structure of the heel
A big tendon called the ‘Achilles’ tendon joins the calf muscle at the back of the leg to the heel. Sever’s disease is thought to occur because of a mismatch in growth of the calf bones to the calf muscle and Achilles tendon. It is thought that the bones grow faster than the muscles, so the muscles and the Achilles tendon that attach the muscle to the heel get tight. At the same time, the heel bone is soft and weak around its growth centre. The tight calf muscle and Achilles tendon cause a traction injury on the soft heel. The traction causes tiny bits of bone to pull away, causing inflammation.

Sever’s disease most commonly affects boys aged ten to 12 years and girls aged nine to 11 years, when growth spurts are beginning.

Sever’s disease heals itself with time. This is known as ‘self limiting’. There is no evidence to suggest that Sever’s disease causes any long-term problems or complications.

There are a few signs and symptoms that indicate Sever’s disease, which may affect one or both heels. These include:

  • Pain at the heel or around the Achilles tendon
  • Heel pain during physical exercise, especially activities that require running or jumping
  • Worsening of pain after exercise
  • A tender swelling or bulge on the heel that is sore to touch
  • Calf muscle stiffness first thing in the morning.
  • Limping
  • A tendency to tiptoe.
Contributing factors
Apart from age, other factors that may contribute to developing Sever’s disease include:
  • Physical activity – any form of exercise that is weight bearing through the legs or stresses the soft tissue, can exacerbate the pain of the disease.
  • External factors – for example, running on hard surfaces or wearing inappropriate shoes during sport.
  • Overuse injury – very active children may repeatedly but subtly injure the bones, muscles and tendons of their feet and ankles. In time, the accumulated injuries cause symptoms.
A physiotherapist can diagnose Sever’s disease by asking the young person to describe their symptoms and through a physical examination. In some instances an x-ray may be necessary to exclude other causes of heel pain, such as heel fractures.

Treatment depends on the severity of the condition but may include:
  • Relative rest and modified activity – a physiotherapist can help work out what, and how much, activity to undertake.
  • Cold packs – apply ice or cold packs to the back of the heels for around 15 minutes after any physical activity, including walking.
  • Shoe inserts – small heel inserts worn inside the shoes can take some of the traction pressure off the Achilles tendons. This will only be required in the short term.
  • Medication – pain-killing medication may help in extreme cases but should always be combined with other treatment.
  • Splinting or casting – in severe cases, it may be necessary to immobilise the lower leg using a splint or cast, but this is rare.
  • Time – generally it will take one to two weeks for the pain to ease, although there may be flare-ups from time to time.
  • Correction of any biomechanical issues – a physiotherapist can identify and discuss any biomechanical issues that may cause or worsen the condition.
Education on how to self-manage the symptoms and flare-ups of Sever’s disease is an essential part of the treatment provided by physiotherapists.

Other possible causes of heel pain
Other causes of heel pain include:
  • Plantar fasciitis – inflammation of the ligament that runs from the heel bone along the sole of the foot. Causes include flat feet and stiff shoes.
  • Bursitis – bursae are small sacs that contain fluid to lubricate moving parts such as joints and muscles. Common causes of bursitis at the back of the heel include injury, overuse and tight shoes.
  • Achilles tendonitis – the Achilles tendon joins the calf muscle to the heel. Inflammation of this tendon can be caused by stiff calf muscles and running on hard surfaces like concrete or bitumen.
  • Stress fracture – a hard impact or awkward landing may fracture (break) the heel bone.
Where to get help Things to remember
  • Sever’s disease is a common cause of heel pain, particularly in the young and physically active.
  • Just before puberty, the bone typically grows faster than the surrounding soft tissue, which means the Achilles tendon is pulled uncomfortably tight. This can lead to an injured heel.
  • Treatment includes relative rest, modifying activities and teaching the young person how to manage the condition when a flare-up happens.
  • Sever’s disease is ‘self limiting’ and rarely causes long-term problems.

    Related articles:

Feet - relief for pain and injury.
Foot problems - heel pain.

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Australian Physiotherapy Association

Article publication date: 11/04/2003
Last reviewed: 31/10/2009

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