Sever’s Disease: Heel Pain in Growing Adolescents

Calcaneal Apophysitis: A Growth-Related Heel Pain in Adolescents

Calcaneal apophysitis, also known as Sever’s disease, represents a painful condition that develops during the remodeling process between the calcaneal process and the body of the heel. This process occurs before the calcaneus reaches full bone maturity. The calcaneal process is a layer of cartilage located near the end of the calcaneus, where bone growth is particularly active in adolescents. It is precisely this cartilaginous area that becomes vulnerable and prone to this condition.

The pathophysiology of calcaneal apophysitis is closely linked to inflammation of the calcaneal process. This inflammation frequently occurs in adolescents during periods of rapid growth, when the calcaneus undergoes significant stress, particularly through sporting activities involving repetitive movements of the heel. The Achilles tendon, which attaches to the calcaneal process, is under excessive tension, resulting in constant traction on this growth area. These repeated stresses trigger an inflammatory response, causing the characteristic pain associated with calcaneal apophysitis.

The increased vulnerability of this region in adolescents results from the cartilaginous nature of the calcaneal process, which is still developing. Intensive sports activities, repetitive movements and excessive stress on the Achilles tendon during the period of rapid growth can aggravate the condition. The quality of the bone growth process may be compromised, leading to symptoms such as heel pain.

Although calcaneal apophysitis can be painful, it is essential to recognize that this condition is usually temporary. Over time, as growth slows and tissues adapt, symptoms tend to improve. Treatment measures often include rest, ice application, and specific stretches to relieve pain and speed healing.

In conclusion, calcaneal apophysitis highlights the particular sensitivity of the region of bone growth in adolescents during periods of rapid growth. Thorough understanding of the pathophysiology of this condition is crucial to guide treatment approaches aimed at adaptively alleviating pain and facilitating recovery. Appropriate management, combined with preventive measures, can help minimize the long-term impact on the musculoskeletal health of adolescents affected by this condition.

Anatomy of the Adolescent Heel: A Foundation for Understanding Sever’s Disease

The anatomy of the adolescent heel is key to understanding why conditions like Sever’s disease, or calcaneal apophysitis, develop during growth.

At the back of the heel lies the calcaneus, or heel bone. In children and adolescents, this bone includes a growth region called the calcaneal apophysis—a secondary ossification center that appears around ages 7–9 and gradually fuses with the main body of the calcaneus by age 14–16.

This apophysis serves as the attachment site for the Achilles tendon, the largest and strongest tendon in the body. The Achilles connects the calf muscles to the heel and plays a major role in walking, running, and jumping. During growth spurts, the calcaneal apophysis is still cartilaginous and softer than mature bone, making it more vulnerable to stress.

When repetitive forces—like those from high-impact sports—are applied to the Achilles, they create traction on the growth plate. This tension, especially in periods of rapid bone elongation, may outpace the adaptability of surrounding tissues. The result? Inflammation, microtrauma, and heel pain.

Unlike adults, where heel pain is often due to plantar fasciitis or bursitis, heel pain in adolescents is frequently linked to this growth zone. Recognizing this anatomical context allows clinicians and osteopaths to tailor their diagnosis and treatment plans to the unique features of a developing musculoskeletal system.

Understanding this structural vulnerability is the first step toward preventing and managing calcaneal apophysitis in growing individuals.

What Triggers the Pain? Understanding the Causes of Sever’s Disease

Calcaneal apophysitis, also known as Sever’s disease, is an inflammation of the growth plate of the heel in children and adolescents. Causes of this condition typically include excessive strain on the Achilles tendon, rapid bone growth, strenuous physical activities, rapid changes in physical activity, poor shoe support, or abnormal biomechanics of the foot.

It is essential to recommend that patients reduce excessive physical activity, wear appropriate shoes with good support, and sometimes use orthotics to relieve pressure on the heel. Rest, stretching, and icing may also be recommended to relieve symptoms. However, as an osteopath, you may have specific approaches to treating this condition based on your experience and expertise.

1. Repetitive stress: Calcaneal apophysitis is often linked to repetitive physical activities and excessive stress on the Achilles tendon. This can include activities such as running, jumping, soccer, basketball, and other sports that involve repetitive heel movements.
2. Rapid bone growth: During the period of rapid growth in adolescence, bones can grow faster than the tendons and muscles attached to them. This can create excessive tension on the calcaneal process.
3. Hormonal Changes: Hormonal changes that occur during adolescence may also play a role in the development of calcaneal apophysitis.
4. Wrong shoes: Wearing inappropriate shoes, especially those that do not provide adequate support, can contribute to the occurrence of calcaneal apophysitis.
5. Excessive training: A sudden increase in training intensity or duration can increase the risk of developing this condition.

Biomechanical Factors and Gait Patterns

While rapid growth and repetitive stress are central to the development of calcaneal apophysitis, biomechanical imbalances and gait patterns often play an underestimated but crucial role. In many adolescents, subtle postural adaptations and mechanical dysfunctions create abnormal loads on the heel — particularly at the insertion of the Achilles tendon on the calcaneal apophysis.

During walking or running, the foot and lower limb must absorb ground reaction forces and transfer them efficiently through the kinetic chain. However, poor foot alignment, muscle imbalances, or inefficient gait cycles can increase the mechanical stress placed on the posterior heel. This is especially significant during adolescence, when tissues are rapidly remodeling and are more susceptible to traction injuries.

🔹 Flat feet (pes planus) and overpronation

One of the most common contributors is excessive foot pronation, often associated with flat feet. In this condition, the medial arch collapses during the stance phase of gait, causing the heel to evert and rotate internally. This movement alters the alignment of the Achilles tendon and increases the tractional force on its insertion site at the growth plate of the calcaneus. The result is increased irritation and microtrauma during high-impact activities.

🔹 Limb length discrepancies and pelvic asymmetry

Even small differences in leg length, whether structural or functional, can disrupt symmetry in gait. The longer limb may strike the ground with more force, while the shorter limb compensates through pelvic tilt or early heel lift. These compensations affect shock absorption and create unequal loading across the heels — again stressing the vulnerable apophyseal zone.

🔹 Tight or weak muscle chains

Tightness in the gastrocnemius–soleus complex limits ankle dorsiflexion, leading to compensatory toe-walking or early heel rise during gait. This places repetitive tensile load on the Achilles tendon, increasing strain on its insertion. Conversely, weak hip stabilizers or intrinsic foot muscles can contribute to poor shock absorption and overuse of the heel.

🔹 Gait patterns under stress

In athletic children and teens, gait is often altered by fatigue, overtraining, or poor footwear. Excessive forefoot striking, abrupt heel contact, or an asymmetrical running gait can cumulatively irritate the heel. When these altered gait mechanics become habitual, they increase the likelihood of chronic heel pain and prolong recovery.

Clinical relevance in osteopathic practice

A biomechanical and postural assessment is essential in children with suspected Sever’s disease. Observing gait, foot strike, lower limb alignment, pelvic balance, and even spinal posture provides key insights. Osteopathic treatment aimed at restoring mobility, reducing fascial tension, and correcting asymmetries can significantly reduce strain on the heel and speed up recovery.

By addressing these hidden contributors, osteopaths can not only relieve current symptoms but also prevent recurrence. Education on proper footwear, warm-up routines, and muscle balance is also vital in active youths.

Spotting the Signs: Common Symptoms of Calcaneal Apophysitis

Calcaneal apophysitis, also known as Sever’s disease, is a painful condition that mainly affects children and adolescents during their growth period. Symptoms of this condition appear primarily in the heel, where the calcaneal process, a site of bone growth, is located.

Heel pain is one of the most characteristic symptoms of calcaneal apophysitis. Young patients typically experience a dull, persistent pain in the back of the heel, usually more pronounced during or after physical activities such as running, jumping, or other sports that involve repetitive movements.

Another common manifestation of this condition is morning stiffness. Children may experience discomfort and difficulty walking the first few minutes after getting up in the morning. This stiffness tends to ease as the day progresses, but it can return after prolonged periods of inactivity.

Some patients may also experience slight swelling in the affected heel. Although the swelling is usually not as pronounced as in other conditions, it may be noticeable and accompany pain and stiffness.

Physical activities, especially those that involve repeated impacts on the heel, can worsen symptoms. Sports like basketball, soccer, and gymnastics, which require jumping and pushing movements, can exacerbate pain in people with calcaneal apophysitis.

It is crucial to note that calcaneal apophysitis is often associated with the period of rapid growth in children and adolescents. Growing bones may be more vulnerable to stress and strain, contributing to the development of this condition. Additionally, factors such as inappropriate shoes, hard surfaces, and strenuous training can increase the risk of developing Sever’s disease.

The management of calcaneal apophysitis often relies on conservative approaches. This includes rest, modification of physical activities, application of ice to reduce inflammation, and sometimes the use of heel lifts to relieve pressure on the calcaneal process.

1. Heel pain: Pain is usually felt in the heel, especially at the back and below.
2. Pain during physical activity: Pain is often exacerbated during activities that strain the Achilles tendon and calf muscles, such as running, jumping, or prolonged walking.
3. Morning stiffness: Some individuals may experience stiffness in the heel in the morning when they wake up.
4. Swelling: Slight swelling can sometimes accompany the painful area.
5. Pressure sensitivity: The area around the calcaneal process may be sensitive to touch.
6. Lameness: Due to the pain, it is possible to notice a limp while walking.
7. Increased pain during growth: Sever’s disease is more common in adolescents during their period of rapid growth.

Inside the Heel: The Mechanism Behind Sever’s Disease

The pathophysiology of calcaneal apophysitis is linked to the calcaneal process, an area of ​​bone growth located at the heel. During growth, bones experience gradual development, but the growth of the calcaneal process can sometimes be faster than the rest of the bone. This creates increased tension and traction on the growth plate, which can lead to inflammation and pain.

Sever’s disease is frequently associated with intensive physical activities, particularly those that involve repeated impacts on the heel. When young athletes participate in sports such as soccer, basketball, or gymnastics, the heel experiences excessive stress, adding stress to the growing calcaneal process.

The constant traction of the Achilles tendon on the calcaneal process is also a contributing factor. The Achilles tendon, which attaches to the heel, exerts force on this growth area. In individuals with calcaneal apophysitis, this pulling can cause increased irritation and inflammation.

Anatomical and biomechanical factors may also play a role in the development of this condition. Flat feet, excessive pronation (inward rotation of the foot), or inequalities in the length of the lower extremities can create conditions conducive to increased loading on the calcaneal process.

The pathophysiology of calcaneal apophysitis manifests clinically as pain, stiffness and sometimes slight swelling in the heel. The pain is often more severe during or after physical activities and may be felt primarily in the back of the heel.

The management of calcaneal apophysitis generally relies on conservative approaches. Rest is essential to allow the calcaneal process to heal, thereby reducing pressure on this area. Specific Achilles tendon stretches, use of ice to reduce inflammation, and proper footwear may also be part of the treatment plan.

1. Rapid bone growth: During puberty, adolescents experience rapid bone growth. The calcaneal process is a growth area where the Achilles tendon attaches to the calcaneus (heel bone). When bones grow quickly, this area can be put under excessive strain.
2. Stress on the Achilles tendon: Sports activities that involve repetitive movements of the heel, such as running, jumping, and other sports, can place constant stress on the Achilles tendon. This can cause excessive traction at the calcaneal process.
3. Inflammation and Pain Reaction: Repetitive stress on the calcaneal process can lead to inflammation of the growth area. The inflammation causes a painful reaction, resulting in the characteristic pain associated with calcaneal apophysitis.
4. Hormonal factors: Hormonal changes that occur during puberty may also play a role. Growth hormones and changes in bone metabolism may influence the pathophysiology of this condition.

Osteopathic Approach to Calcaneal Apophysitis

Calcaneal apophysitis, or Sever’s disease, presents a unique therapeutic opportunity for osteopathy. Unlike structural foot injuries, this condition reflects a functional overload of a growth zone, occurring at the intersection of mechanical forces, growth dynamics, and tissue adaptability. Osteopathic treatment offers a global and gentle approach, ideal for adolescents experiencing pain during a sensitive developmental stage.

🔹 A tension-adaptation imbalance

From an osteopathic perspective, Sever’s disease can be seen as a loss of adaptive capacity in the face of tension — notably at the junction where the Achilles tendon inserts into a still-maturing calcaneal apophysis. The repetitive traction imposed by sports, compounded by poor biomechanics or postural asymmetries, overwhelms the tissue’s ability to remodel harmoniously. Osteopathy seeks to reduce this mechanical overload while restoring the body’s ability to self-regulate and heal.

🔹 Global assessment: beyond the foot

Osteopathic care begins with a comprehensive evaluation:

• Foot and ankle mobility
• Tension in the gastrocnemius-soleus complex
• Pelvic alignment and sacroiliac function
• Lumbar spine and postural chains
• Fascial restrictions, especially in the posterior kinetic chain

Postural imbalances, such as anterior pelvic tilt or leg length discrepancies, may amplify heel loading during gait. The osteopath’s role is to identify these contributors and help the child regain a balanced, fluid locomotion.

🔹 Manual techniques: gentle, targeted, integrative

Osteopathic treatment for calcaneal apophysitis focuses on relieving tension, restoring mobility, and supporting growth dynamics. Techniques may include:

• Myofascial release of the calf muscles, plantar fascia, and Achilles tendon
• Articular mobilization of the ankle, subtalar joint, and pelvis
• Functional techniques to offload the apophysis
• Craniosacral and diaphragmatic work to regulate overall tissue tone and autonomic balance
• Indirect strain-counterstrain methods when inflammation is active or pain is acute

Treatment is always adapted to the child’s age, pain level, and tissue reactivity, with care not to overstimulate an inflamed apophysis.

🔹 Education and movement re-education

Beyond manual therapy, osteopathy empowers patients and families through education. Adolescents and parents are advised on:

• Appropriate footwear and shock absorption
• Avoidance of high-impact surfaces
• Restoring physical activity progressively
• Daily stretching (e.g. calf and hamstring)
• Hydration, sleep, and general recovery factors

If necessary, the osteopath may refer for custom orthotics or coordinate with physiotherapy for a tailored strengthening plan.

Look-Alike Conditions: Differential Diagnoses of Heel Pain in Youth

1. Plantar fasciitis: Plantar fasciitis is an inflammation of the plantar fascia, the tissue that connects the heel to the toes. It can cause heel pain, especially in the morning or after a period of rest.
2. Achilles tendonitis: Inflammation of the Achilles tendon can cause heel pain, particularly where the tendon attaches to the calcaneus. However, Achilles tendonitis is usually associated with pain along the tendon rather than the area of ​​bone growth.
3. Heel spurs (Lenoir’s spur): A heel spur is a small bony spike that can form where the plantar fascia attaches to the calcaneus. Although the presence of a heel spur may be associated with heel pain, it is not always the primary cause of the pain.
4. Retrocalcaneal bursitis: Inflammation of the bursa (a small pocket of fluid) at the back of the heel can cause heel pain. This can be caused by excessive friction between the Achilles tendon and the heel bone.
5. Juvenile idiopathic arthritis (JIA): JIA can affect joints, including those in the foot, and can cause heel pain in children.
6. Calcaneus Fracture: A calcaneus fracture can cause heel pain, especially after trauma, such as a significant fall.
7. Haglund syndrome: Also called “posterior spur”, this syndrome is characterized by a bony outgrowth

From Assessment to Action: Diagnosis and Treatment of Sever’s Disease

Diagnosis of calcaneal apophysitis:

The diagnosis of calcaneal apophysitis is generally based on clinical examination, medical history, and symptoms reported by the patient. The doctor can perform the following actions:

1. Physical examination: The doctor will assess the painful area in the heel, paying particular attention to the calcaneal process. He or she can also observe the patient’s gait and look for signs of inflammation.
2. Assessment of medical history: The doctor will ask about the patient’s symptoms, frequency and intensity of pain, and recent physical activities.
3. X-rays: X-rays may be taken to rule out other possible causes of heel pain, such as fractures or heel spurs.
4. MRI or ultrasound: In some cases, an MRI (magnetic resonance imaging) or ultrasound may be used to assess inflammation and the condition of the surrounding soft tissues.

Stretching and Exercise Recommendations

While rest and reduction of activity are cornerstones in the management of calcaneal apophysitis, targeted stretching and corrective exercises play an equally important role in relieving pain and restoring functional balance. These exercises aim to reduce tension on the Achilles tendon, improve foot biomechanics, and support healthy tissue adaptation during growth.

Properly guided movement doesn’t just support healing — it also empowers adolescents to become active participants in their recovery and reduces the likelihood of recurrence.

🔹 1. Stretching the Posterior Chain

Tightness in the gastrocnemius, soleus, hamstrings, and plantar fascia increases tension on the calcaneal apophysis. Gentle, regular stretching helps reduce this load.

✅ Calf Stretch (Gastrocnemius)

• Stand facing a wall. Step one foot back, keeping the heel on the floor.
• Bend the front knee while keeping the back leg straight.
• Hold for 20–30 seconds. Repeat 2–3 times per side.

✅ Soleus Stretch (Knee-Bent Calf Stretch)

• Same position as above, but this time, bend the back knee slightly.
• Focuses the stretch lower down toward the Achilles.
• Hold and repeat as above.

✅ Hamstring Stretch (Straight Leg on Chair)

• Rest one heel on a chair, keeping the knee straight.
• Lean forward from the hips, keeping the spine long.
• Feel the stretch along the back of the thigh.

✅ Plantar Fascia Stretch

• While seated, place the affected foot over the opposite knee.
• Pull the toes gently back to stretch the sole.
• Hold for 15–20 seconds.

🔹 2. Strengthening and Stabilization

Weak intrinsic foot muscles and hip stabilizers can alter foot mechanics and overload the heel. A simple strengthening plan improves long-term resilience.

✅ Toe Curls with a Towel

• Place a towel on the floor and try to scrunch it toward you using the toes.
• Repeat for 30 seconds per set.

✅ Heel Raises

• Stand on both feet, lift heels slowly, then lower with control.
• Progress to single-leg heel raises if pain-free.
• Focus on eccentric control to protect the Achilles.

✅ Glute Bridge

• Lie on your back, knees bent, feet hip-width apart.
• Lift hips slowly while engaging the glutes and core.
• Improves posterior chain activation and pelvic stability.

🔹 3. Exercise Dos and Don’ts

• ✅ Do stretch after warm-up or activity, not cold.
• ✅ Do keep stretches gentle and pain-free.
• ✅ Do be consistent: a little daily movement is better than sporadic sessions.
• ❌ Don’t force through heel pain during dynamic movements.
• ❌ Don’t stretch aggressively during acute inflammatory phases.

Prevention Strategies for Young Athletes

While calcaneal apophysitis is often self-limiting, its impact on young athletes can be significant — affecting performance, confidence, and long-term biomechanics. Fortunately, many cases are preventable with early awareness and a proactive approach. Prevention begins with understanding the risk factors, educating families, and making simple but strategic changes in training, equipment, and recovery habits.

🔹 1. Adapt Training to Growth Phases

One of the most overlooked risk factors for Sever’s disease is rapid growth. During growth spurts, bones can lengthen faster than muscles and tendons can adapt, creating excessive tension on the calcaneal apophysis. Coaches and parents should:

• Monitor height changes over weeks/months.
• Reduce training volume or intensity during growth peaks.
• Alternate high-impact activities (e.g., jumping, sprinting) with low-impact training (e.g., swimming, cycling).
• Avoid pushing through heel pain — early signs should never be ignored.

🔹 2. Prioritize Proper Footwear

Inadequate footwear is a common trigger for heel overload. Shoes that lack proper heel cushioning, arch support, or that are worn out can increase ground reaction forces transmitted to the heel.

✅ Recommendations:

• Choose age-appropriate athletic shoes with rearfoot shock absorption.
• Replace shoes every 6–9 months or when wear patterns are evident.
• Avoid minimalist or unsupportive footwear during sport unless specifically advised.

Some athletes may benefit from heel lifts or custom orthotics to reduce traction on the Achilles during sports. Osteopaths can help assess this need.

🔹 3. Encourage Recovery and Body Awareness

Adolescents are often highly motivated but unaware of their body’s limits. Education is key:

• Emphasize rest as a part of training, not a weakness.
• Teach body awareness: recognizing tension, fatigue, and compensation patterns.
• Include warm-up and cool-down routines with stretching and mobility drills.
• Promote hydration, sleep, and balanced nutrition, all of which affect tissue recovery.

🔹 4. Strengthen the Kinetic Chain

A strong and well-balanced musculoskeletal system helps absorb and distribute forces evenly:

• Strengthen the calf, hamstrings, glutes, and core.
• Improve foot intrinsic muscle activation with simple exercises like toe curls.
• Use proprioception drills (e.g., single-leg balance) to improve joint control.

Working with an osteopath, physiotherapist, or movement coach can help personalize a conditioning plan.

🔹 5. Screen and Intervene Early

Early signs of Sever’s disease — such as morning heel pain, limping after activity, or swelling — should prompt immediate rest and evaluation. The earlier the intervention, the shorter and smoother the recovery.

Prognosis and Recovery Timeline

For adolescents and their families, one of the most pressing concerns when facing calcaneal apophysitis is: “How long will it last?” The answer depends on many factors — growth stage, activity level, treatment adherence — but overall, the prognosis is excellent. With proper management, most young athletes recover fully and without lasting effects.

🔹 1. A Self-Limiting Condition with a Favorable Outcome

Calcaneal apophysitis is a self-limiting condition, meaning that it tends to resolve naturally as the growth plate closes. The calcaneal apophysis typically fuses with the heel bone between ages 14 and 16, at which point the area is no longer vulnerable to traction injury.

In most cases, symptoms subside within 2 to 8 weeks, especially when activity is reduced and appropriate care is initiated early. However, some adolescents experience intermittent symptoms for several months, particularly if they return to high-impact activity too quickly.

🔹 2. Phases of Recovery

✅ Phase 1 – Acute Pain and Inflammation (Week 1–2):

• Activity modification or full rest is essential.
• Ice, gentle stretching, and supportive footwear are introduced.
• Osteopathic treatment focuses on relieving tension and inflammation.

✅ Phase 2 – Gradual Improvement (Weeks 2–6):

• Pain during daily activities begins to fade.
• Stretching becomes more regular; strengthening is introduced.
• Return to low-impact activities like swimming or cycling may be permitted.

✅ Phase 3 – Reintroduction to Sport (Weeks 6–12+):

• If pain-free during basic movements, progressive return to training is allowed.
• Heel raises, running drills, and proprioception work are reintroduced gradually.
• Monitoring for any recurrence of symptoms is crucial.

Recovery is not linear — flare-ups may occur if physical demands exceed tissue tolerance, particularly during a growth spurt. These episodes usually resolve quickly with temporary load reduction.

🔹 3. When Symptoms Persist

In rare cases, heel pain may persist beyond 3–4 months. Possible reasons include:

• Continued overuse despite symptoms
• Underlying biomechanical or postural imbalance
• Coexisting conditions (e.g., plantar fasciitis, bone bruises)
• Insufficient footwear support or lack of rest

A re-evaluation — including gait analysis or imaging — may be helpful. Collaboration with an osteopath can uncover hidden compensations and promote a more global recovery.

🔹 4. Return-to-Sport Considerations

Before resuming full sports participation, the adolescent should:

• Be completely pain-free during walking, jumping, and heel raises
• Demonstrate symmetrical strength and mobility
• Have proper footwear and a post-activity stretching routine in place
• Understand how to self-monitor and rest when needed

Frequently Asked Questions: Calcaneal Apophysitis (Sever’s Disease)

🔹 1. Can my child continue sports during Sever’s disease?

In the early phase, it’s usually best to pause high-impact activities such as running, jumping, or competitive sports to avoid worsening the condition. Low-impact activities like swimming or cycling may be allowed once pain decreases, under guidance.

🔹 2. Does Sever’s disease cause permanent damage to the heel?

No. Sever’s disease is a temporary condition linked to growth. Once the apophysis fuses with the calcaneus (around age 14–16), symptoms typically disappear. It does not lead to long-term deformities or chronic pain when managed properly.

🔹 3. How long does recovery usually take?

Recovery typically takes 4 to 8 weeks, but can vary depending on the severity of symptoms, rest, and activity modification. A gradual return to sport is recommended once the child is pain-free during daily movements.

🔹 4. Are special shoes or insoles necessary?

Supportive shoes with good heel cushioning and arch support are often sufficient. In some cases, heel lifts or custom orthotics are helpful to reduce traction on the Achilles tendon and improve foot mechanics.

🔹 5. Can Sever’s disease recur after healing?

Yes, especially during another growth spurt or if activity levels are increased too quickly. Preventive strategies — including stretching, strength work, and proper footwear — help reduce the risk of recurrence.

🔹 6. When should we consult an osteopath or healthcare professional?

If heel pain persists beyond two weeks, worsens with activity, or causes limping, a consultation is recommended. An osteopath can assess posture, biomechanics, and soft tissue tension, offering a global and personalized approach.

🔹 7. What signs indicate my child is ready to return to sport?

• No heel pain during walking, running, or heel raises
• Full, pain-free ankle mobility
• Symmetrical leg strength and stability
• No limp or compensatory gait
• Ability to complete a full training session without symptoms

---

Bonus Tip

Many children recover more confidently when they understand their condition. Don’t hesitate to explain what’s happening in their heel using illustrations or simple analogies — this can ease anxiety and promote better self-care habits.

Treatment of calcaneal apophysitis

Treatment for calcaneal apophysitis aims to relieve pain, reduce inflammation, and promote healing. Common approaches include:

1. Rest: It is often recommended to reduce physical activities that exacerbate pain, giving the calcaneal process time to heal.
2. Applying ice: Regularly applying ice to the painful area can help reduce inflammation. It is generally recommended to do ice applications for 15 to 20 minutes at a time.
3. Stretching: Specific stretching exercises can help improve the flexibility of the muscles surrounding the calcaneal process, helping to relieve pain.
4. Anti-inflammatory medications: Nonsteroidal anti-inflammatory medications (NSAIDs), such as ibuprofen, may be prescribed to relieve pain and inflammation.
5. Appropriate footwear: Wearing shoes that provide good support and cushioning can help reduce pressure on the calcaneal process.
6. Orthotics: Orthotics or insoles may be recommended to provide additional support and correct foot posture.
7. Osteopathy: A physical therapist can recommend specific exercises to strengthen surrounding muscles and improve mobility.

In general, calcaneal apophysitis tends to improve over time as growth slows and the tissues adapt. However, medical monitoring is important to ensure appropriate management of the condition and rule out other potential problems. If you experience persistent pain or severe symptoms, it is advisable to consult a healthcare professional.

What Imaging Reveals: Radiographic Clues of Calcaneal Apophysitis

When a practitioner decides to perform x-rays to evaluate calcaneal apophysitis, they can look for specific signs. One of the most commonly seen radiographic findings is fragmentation or irregularity of the calcaneal process. These structural alterations may be the result of excessive stresses placed on the growth plate during the period of rapid growth.

Another radiographic sign that may be present is increased bone density at the calcaneal process. This may indicate a bone reaction to the constant inflammation and traction exerted by the Achilles tendon. However, these changes may not be apparent in the early stages of the disease and may progress over time.

It is essential to note that the absence of obvious radiographic signs should not exclude the diagnosis of calcaneal apophysitis. Due to its nature, the disease can be more clearly visualized using more advanced imaging modalities, such as magnetic resonance imaging (MRI). MRI can provide finer details of the soft tissues, including the growth plate, allowing for a more in-depth assessment of the condition of the calcaneal process.

In most cases, the practitioner relies primarily on the clinical examination, medical history and symptoms reported by the patient to diagnose calcaneal apophysitis. The use of radiographs or other imaging modalities is often reserved for cases where diagnostic confirmation is necessary or when atypical symptoms are present.

1. Enlargement of the calcaneal process: On x-rays, enlargement of the calcaneal process can sometimes be seen. This may indicate some reaction in the bone growth area due to stress and inflammation.
2. Blurred growth line: The growth zone, where growing bone turns into mature bone, can sometimes appear blurry or irregular on x-rays. This may be the result of changes in bone maturation due to inflammation.
3. Presence of bone fragments: In more severe or advanced cases, bone fragments can sometimes be seen near the calcaneal process. This may be the result of excessive traction on the Achilles tendon, leading to structural changes in the area.
4. Normal bone density: It is important to note that the overall bone density of the affected region generally remains normal. Unlike some conditions where areas of demineralized bone can be seen, calcaneal apophysitis generally does not show such signs.

Growing Pains with a Solution: Understanding and Managing Sever’s Disease

In conclusion, calcaneal apophysitis, commonly known as Sever’s disease, represents a painful condition that affects the region of bone growth in adolescents during periods of rapid growth. This condition is characterized by a painful remodeling process between the calcaneal process and the body of the heel, before the calcaneus reaches full bone maturity.

The pathophysiology of calcaneal apophysitis is closely related to inflammation of the calcaneal process, often triggered by significant stress on the Achilles tendon during sporting activities involving repetitive heel movements. The cartilaginous nature of the calcaneal process makes this area particularly vulnerable, putting adolescents at increased risk of injury.

It is important to note that, although painful, calcaneal apophysitis is usually a temporary condition that improves over time as growth slows and the tissues adapt. Treatment measures, such as rest, ice application, and specific stretches, are often recommended to relieve pain and speed healing.

The particular sensitivity of the bone growth region in adolescents highlights the importance of understanding the pathophysiology of this condition. This understanding guides treatment approaches to appropriately alleviate pain and facilitate recovery. Additionally, preventive measures can be implemented to minimize the long-term impact on the musculoskeletal health of adolescents affected by calcaneal apophysitis.

In summary, although calcaneal apophysitis can present a painful challenge for growing adolescents, appropriate management and preventive measures can help alleviate symptoms and promote optimal recovery, allowing young patients to continue to actively participate in physical activities while preserving their musculoskeletal health.

References

1. Ramponi DR, Baker C. Sever’s Disease (Calcaneal Apophysitis). Adv Emerg Nurs J. 2019 Jan/Mar;41(1):10-14. [ PubMed ]2.
2. James AM, Williams CM, Haines TP. Health related quality of life of children with calcaneal apophysitis: child & parent perceptions. Health Qual Life Outcomes. 2016 Jun 24;14:95. [ PMC free article ] [ PubMed ]3.
3. Hart E, Meehan WP, Bae DS, d’Hemecourt P, Stracciolini A. The Young Injured Gymnast: A Literature Review and Discussion. Curr Sports Med Rep. 2018 Nov;17(11):366-375. [ PubMed ]4.
4. Belikan P, Färber LC, Abel F, Nowak TE, Drees P, Mattyasovszky SG. 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 09;17(1):83. [ PMC free article ] [ PubMed ]5.
5. Davison MJ, David-West SK, Duncan R. Careful assessment the key to diagnosing adolescent heel pain. Practice. 2016 May;260(1793):30-2, 3. [ PubMed ]6.
6. Howard R. Diagnosing and treating Sever’s illness in children. Emerg Nurse. 2014 Sep;22(5):28-30. [ PubMed ]7.
7. Agyekum EK, Ma K. Heel pain: A systematic review. Chin J Trauma. 2015;18(3):164-9. [ PubMed ]8.
8. Sweeney EA, Little CC, Wilson JC, Potter MN, Seehusen CN, Howell DR. Comparison of Braces for Treatment of Sever’s Disease (Calcaneal Apophysitis) in Barefoot Athletes: A Randomized Clinical Trial. J Athl Train. 2023 May 01;58(5):437-444. [ PubMed ]9.
9. McSweeney SC, Reed L, Wearing S. Foot Mobility Magnitude and Stiffness in Children With and Without Calcaneal Apophysitis. Foot Ankle Int. 2018 May;39(5):585-590. [ PubMed ]10.
10. Fares MY, Salhab HA, Khachfe HH, Fares J, Haidar R, Musharrafieh U. Sever’s Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clin Med Res. 2021 Sep;19(3):132-137. [ PMC free article ] [ PubMed ]11.
11. James AM, Williams CM, Haines TP. “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review”. J Foot Ankle Res. 2013 May 03;6(1):16. [ PMC free article ] [ PubMed ]12.
12. Launay F. Sports-related overuse injuries in children. Orthop Traumatol Surg Res. 2015 Feb;101(1 Suppl):S139-47. [ PubMed ]13.
13. Manusov EG, Lillegard WA, Raspa RF, Epperly TD. Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle. Am Fam Physician. 1996 Sep 01;54(3):1012-26, 1031. [ PubMed ]14.
14. Gao Y, Liu J, Li Y, Liu Q, Xu S. Radiographic study of Sever’s disease. Exp Ther Med. 2020 Aug;20(2):933-937. [ PMC free article ] [ PubMed ]15.
15. Mallia AJ, Ashwood N, Arealis G, Bindi F, Zamfir G, Galanopoulos I. Delayed recognition of pediatric calcaneal osteomyelitis: a case report. J Med Case Rep. 2015 Sep 02;9:185. [ PMC free article ] [ PubMed ]16.
16. Mustapić M, Borić I, Lepur D, Zadravec D, Visković K. Sever’s disease complicated with osteomyelitis. Acta Clin Croat. 2014 Jun;53(2):252-5. [ PubMed ]17.
17. James AM, Williams CM, Haines TP. Heel raises versus prefabricated orthoses in the treatment of posterior heel pain associated with calcaneal apophysitis (Sever’s Disease): a randomized control trial. J Foot Ankle Res. 2010 Mar 02;3:3. [ PMC free article ] [ PubMed ]