Added to Saved items
This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Sever's Disease article more useful, or one of our other health articles.

Read COVID-19 guidance from NICE

Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Synonyms: calcaneal apophysitis

Sever's disease is a term used to describe inflammation of the calcaneal apophysis which occurs in children and adolescents. Sever first described the condition in 1912. Further studies have suggested that the condition is due to repeated 'microtrauma' at the site of the attachment of the Achilles tendon to the apophysis of the heel, often as a result of sporting activities.

The disorder can be classified among the general osteochondrosis syndromes such as Osgood-Schlatter disease.[1]

Sever's disease is the most common cause of heel pain in children and adolescents, usually occurring between 9 and 12 years of age during their rapid period of growth in those involved in sports.[2]

In a retrospective study of injuries among players aged 7-19 years in a German football academy the incidence was 0.36 per 100 athletes per year.[3]

The line of ossification in the calcaneal apophysis is thought to develop microfractures due to recurrent stresses on the heel, combined with the growth spurt of puberty. As in similar conditions (eg, Osgood-Schlatter disease), it is believed to be caused by decreased resistance to shear stress at the bone-growth plate interface.

Heel pain, usually in young physically active individuals, which is:

  • Gradual in onset and worse on exercise, especially running or jumping.
  • Relieved by rest.
  • Often bilateral.

Ask specifically about:

  • The nature of the pain.
  • Aggravating or relieving factors.
  • History of trauma.
  • Physical activities - sports, dance, etc:
    • How often do you train?
    • How often do you compete?
    • At what level?
  • Type of shoes normally worn.
  • Any other medical conditions or medications.

On examination, the typical signs are:

  • Tenderness on palpation of the heel (the 'heel squeeze') - particularly on deep palpation at the Achilles tendon insertion.
  • Pain on dorsiflexion of the ankle - particularly when doing active toe raises; forced dorsiflexion of the ankle is also uncomfortable.
  • Swelling of the heel - usually mild.
  • Calcaneal enlargement - in long-standing cases.

Carefully examine the whole foot and ankle because Sever's disease may be associated with other foot abnormalities such as flat feet or high arches.

The diagnosis is clinical and investigations are not routinely required.[5] However, investigation to look for other causes is suggested if:

  • Pain is persistent or significant at rest.
  • Pain disturbs sleep.
  • There is significant swelling.
  • There is reduction of subtalar movement (suggests tarsal coalition).


  • X-ray of the heel may show increased sclerosis and fragmentation of the calcaneal apophysis - but these features are nonspecific and it may be normal.[7] The value of X-ray is to exclude fracture or a rare tumour. The diagnosis is clinical, not radiological.[8]
  • One small study suggests that ultrasound may be useful.[9]
  • CT or MRI scan may be useful to exclude osteomyelitis or fusion of the small bones of the hindfoot. It is not always required.

Treatment options include a combination of stretching, strengthening exercises, limiting physical activity and sports participation, ice, heel lifts for removal of tensile forces on the calcaneus, correction of malalignment through orthotic use, and anti-inflammatory drugs. However, there is no strong evidence for any specific form of treatment.[10]

The aims are to reduce trauma to the heel, allow rest/recovery and prevent recurrence. Most cases are successfully treated using:

  • Physiotherapy and exercises - eg, to stretch the gastrocnemius-soleus complex; to mobilise the ankle mortise, subtalar joint and medial forefoot.[11]
  • Soft orthotics or heel cups.[12]
  • Advice on suitable athletic footwear.

Other modes of treatment are:

  • In severe cases: temporarily limiting activity such as running and jumping.
  • Ice and non-steroidal anti-inflammatory drugs (NSAIDs), which can reduce pain.
  • In very severe cases, a short period of immobilisation (eg, 2-3 weeks in a cast in mild equinus position) has been suggested.

In general, management is along the normal lines for sports injuries. Explain to the child and parent that this is an overuse injury, common in the growing child. It has a good prognosis but it is necessary to ease back on any sports training for a while to let it recover. During abstinence from normal training, cardiovascular fitness can be maintained by non-weight-bearing exercise such as swimming or cycling.

The condition is normally self-limiting and a return to normal sports activities is usually possible within two months.[10] However, the condition may recur.

Are you protected against flu?

See if you are eligible for a free NHS flu jab today.

Check now

Further reading and references

  1. Achar S, Yamanaka J; Apophysitis and Osteochondrosis: Common Causes of Pain in Growing Bones. Am Fam Physician. 2019 May 1599(10):610-618.

  2. Smith JM, Varacallo M; Sever Disease.

  3. Belikan P, Farber LC, Abel F, et al; Incidence of calcaneal apophysitis (Sever's disease) and return-to-play in adolescent athletes of a German youth soccer academy: a retrospective study of 10 years. J Orthop Surg Res. 2022 Feb 917(1):83. doi: 10.1186/s13018-022-02979-9.

  4. Fares MY, Salhab HA, Khachfe HH, et al; Sever's Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clin Med Res. 2021 Sep19(3):132-137. doi: 10.3121/cmr.2021.1639.

  5. Perhamre S, Lazowska D, Papageorgiou S, et al; Sever's injury: a clinical diagnosis. J Am Podiatr Med Assoc. 2013 Sep-Oct103(5):361-8.

  6. Gao Y, Liu J, Li Y, et al; Radiographic study of Sever's disease. Exp Ther Med. 2020 Aug20(2):933-937. doi: 10.3892/etm.2020.8796. Epub 2020 May 26.

  7. Tu P; Heel Pain: Diagnosis and Management. Am Fam Physician. 2018 Jan 1597(2):86-93.

  8. Kose O, Celiktas M, Yigit S, et al; Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever's disease)? J Pediatr Orthop B. 2010 Sep19(5):396-8.

  9. Hosgoren B, Koktener A, Dilmen G; Ultrasonography of the calcaneus in Sever's disease. Indian Pediatr. 2005 Aug42(8):801-3.

  10. Elengard T, Karlsson J, Silbernagel KG; Aspects of treatment for posterior heel pain in young athletes. Open Access J Sports Med. 2010 Dec 61:223-32. doi: 10.2147/OAJSM.S15413.

  11. Leri JP; Heel pain in a young adolescent baseball player. J Chiropr Med. 2004 Spring3(2):66-8.

  12. Alfaro-Santafe J, Gomez-Bernal A, Lanuza-Cerzocimo C, et al; Effectiveness of Custom-Made Foot Orthoses vs. Heel-Lifts in Children with Calcaneal Apophysitis (Sever's Disease): A CONSORT-Compliant Randomized Trial. Children (Basel). 2021 Oct 258(11):963. doi: 10.3390/children8110963.