What Is Sever's Disease? A Guide to Heel Growing Pains
Sever's Disease is the most common cause of heel pain in growing children, yet many parents have never heard of it until their own child starts limping after practice. This guide will walk you through everything you need to know: what Sever's Disease is, why it happens, how it's diagnosed, and most importantly—what you can do about it.
If your child is complaining about heel pain during or after sport, you're in the right place.
Understanding Sever's Disease
Sever's Disease (also called Sever Disease, calcaneal apophysitis, or just Sever's) is a growth-related overuse injury that causes pain at the back of the heel, where the Achilles tendon attaches to the heel bone.
Despite its name, it's not actually a "disease" in the traditional sense—it's a stress injury that occurs when growing bones outpace the muscles' ability to adapt. Sound familiar? It's the same mechanism behind Osgood-Schlatter Disease, except Sever's affects the heel instead of the knee.
The condition affects the calcaneal apophysis, which is the growth plate at the back of the heel bone (calcaneus) where the Achilles tendon inserts. This is the exact spot where your child will point when they tell you their heel hurts.
Sever's Disease typically appears during periods of rapid growth, most commonly affecting girls aged 8-13 and boys aged 10-15—slightly younger than the typical Osgood-Schlatter age range. Active athletes in sports involving running, jumping, and hard surfaces are at highest risk.
The condition is incredibly common, accounting for the most heel pain presentations in pediatric sports medicine clinics. It's particularly prevalent in soccer, basketball, gymnastics, track, dance, and football—any sport with running on hard surfaces, repetitive jumping, or cleated footwear.
What Actually Happens in a Sever's Heel
To understand what Sever's Disease is, you need to understand what's happening mechanically in your child's growing body.
During the adolescent growth spurt, bones grow rapidly thanks to open growth plates—and interestingly, the feet and shin bones are often one of the first body parts to grow. The problem is that muscles and tendons can't keep pace with this rapid bone growth. This creates a length-tension mismatch.
Here's what happens: The calcaneus (heel bone) and tibia grow rapidly during a growth spurt, but the calf muscles—the gastrocnemius and soleus—struggle to keep up with this bone growth, becoming relatively tighter. These tight calf muscles then pull on the Achilles tendon with every step, jump, and landing. The tendon attaches to the calcaneal apophysis, a growth plate that's still partly cartilage in children. Repeated impact and traction forces create stress at this vulnerable attachment site, and pain and inflammation develop from the ongoing mechanical stress.
The growth plate at this attachment site is particularly vulnerable to pain and injury for two reasons.
- The growth plate is not fully ossified (hardened into solid bone) in children. The calcaneal growth plate typically doesn't close until around age 14-15, remaining partly cartilage to allow for continued growth. This makes it more susceptible to stress than fully mature bone.
- The heels absorb enormous forces during sport. Running, jumping, and landing all transmit significant impact forces through the heel—approximately 60% of weight-bearing load occurs through the rear foot when standing, and this multiplies dramatically during athletic activity.
Who Can Get Sever's Disease?
Sever's Disease doesn't affect all young athletes equally. Certain factors increase risk.
Age and Growth play a significant role, with peak incidence occurring during rapid growth spurts. Girls typically develop Sever's between ages 8-13 due to earlier growth spurts, while boys are more commonly affected between ages 10-15. Interestingly, feet often grow before the rest of the body, making Sever's one of the earliest growth-related injuries to appear.
Activity Level is a major factor. Sever's is more common in athletes playing year-round sports, particularly soccer (running on hard surfaces, cleated footwear), basketball (jumping, landing, hard courts), gymnastics (repetitive impact landings), track and field, dance, football and rugby, and tennis. Any sport combining running, jumping, and hard surfaces increases risk.
Movement skill and technique can exacerbate symptoms too, heavy heel-strike running patterns, and hard landing and jumping can both contribute to more heel pain and make Sever's worse.
Physical Factors also contribute. Tight calf muscles in the gastrocnemius and soleus are common findings, along with weak foot and ankle muscles. Foot posture abnormalities like flat feet or high arches may play a role, as can previous foot or ankle injuries.
Training Factors matter too. High training volumes across multiple teams or year-round seasons increase exposure. Hard playing surfaces like concrete, artificial turf, and hardwood courts amplify impact forces. Poor footwear—especially worn-out shoes, inadequate heel cushioning, or cleats—can aggravate the condition. Sudden increases in training intensity or starting a new sport are also common triggers.
One notable characteristic of Sever's Disease is that it frequently affects both heels—approximately 60% of cases are bilateral. It's common for one heel to become painful first, with the other following weeks or months later.
How to Pronounce Sever's Disease
Before we go further, let's address a common point of confusion: how do you actually say "Sever's"?
Phonetic pronunciation: Se-verz
Not "severe" but like "sever" (as in to cut). It rhymes with "sever" with an "s" at the end.
This is important because many people—including some healthcare providers—mispronounce it as "Severe's Disease," which not only sounds alarming but is incorrect.
Other names you might hear for the same condition include Sever Disease (without the apostrophe), calcaneal apophysitis (the preferred medical term), heel apophysitis, calcaneoapophysitis, or colloquially "growing pains in the heel".
Why Is It Called "Sever's Disease"?
Like many medical conditions, Sever's Disease is named after the physician who first identified and described it. Unlike Osgood-Schlatter Disease, which was discovered simultaneously by two physicians on opposite sides of the world, Sever's Disease was described by a single American physician.
The Sever Origin Story
Dr. James Warren Sever (1878-1964) was an American orthopedic surgeon who first described this condition in 1912. He published his findings in the New York Medical Journal under the title "Apophysitis of the Os Calcis" (apophysitis of the heel bone).
Dr. Sever was a prominent figure in American orthopedics. He went on to become affiliated with Harvard Medical School and later published "The Principles of Orthopaedic Surgery" through Macmillan Company in 1940.
His original 1912 paper documented the clinical presentation of heel pain in active children and correctly identified it as a growth-related injury at the calcaneal apophysis—observations that still hold true today, over a century later.
The Original Medical Term:
Before it became widely known as Sever's Disease, this condition was described as:
- Apophysitis of the os calcis (Sever's original term)
- Calcaneal apophysitis (current preferred medical term)
- Traction apophysitis of the calcaneus
These terms are still used in medical literature and are considered more accurate than "disease," but "Sever's Disease" remains the most commonly used name in clinical practice.
Is Sever's Disease Actually a Disease?
Here's something that confuses many parents: despite its name, Sever's Disease isn't actually a "disease" in the traditional sense. It should probably be thought of more as an overuse injury that effects young growing bodies.
Disease vs. Injury
A disease typically implies:
- A pathological condition with an infectious or genetic cause
- Something that progresses without intervention
- Often requiring pharmaceutical treatment
- Something "wrong" with the body that needs to be cured
Sever's Disease doesn't fit this definition. It's more accurately described as:
- A growth-related overuse injury
- A mechanical stress condition
- A normal response to abnormal loading during growth
The term "disease" is a historical holdover from when the condition was first described in 1912. In that era, any medical condition was often called a "disease" regardless of its underlying nature.
Why This Distinction Matters
Thinking of Sever's Disease as an injury rather than a disease is more than semantic—it changes how we approach treatment:
If it's a disease:
- We wait for it to "run its course"
- Treatment focuses on symptom management
- The assumption is nothing can be done except wait for growth to stop
- Complete rest is prescribed
If it's an injury:
- We can actively rehabilitate it
- Treatment addresses root biomechanical causes
- We strengthen, mobilize, and retrain movement patterns
- Athletes can stay active during recovery
At Core Advantage, our methods treat Sever's Disease as an injury that can be rehabilitated, not a passive disease. This perspective shift is why our athletes return to sport in weeks rather than sitting out for 12-24 months waiting for their growth spurt to stop.
The condition responds to proper treatment because it's fundamentally a mechanical problem—tight muscles pulling on a vulnerable growth plate combined with repetitive impact—not a disease process that must simply be endured.
Learn more about the Core Advantage Sever's Disease Treatment Program here →
Sever's Disease ICD-10 Code
For medical records, insurance claims, and formal diagnosis, Sever's Disease has specific ICD-10 codes (International Classification of Diseases, 10th Revision).
The official codes are
- M92.60 for juvenile osteochondrosis of tarsus (unspecified foot),
- M92.61 for the right foot, and
- M92.62 for the left foot.
"Juvenile osteochondrosis" is the broader medical category that includes Sever's Disease along with similar growth plate conditions.
These codes help ensure insurance claims are processed correctly, create standardized documentation across healthcare systems, allow tracking of condition prevalence for research purposes, and may be required by some insurance companies for physical therapy coverage authorization.
If you're dealing with insurance claims or requesting medical records, knowing these codes can be helpful, although your healthcare provider will most likely handle this when filing documentation.
How Is Sever's Disease Diagnosed?
Sever's Disease is typically diagnosed through clinical examination rather than imaging. In most cases, the diagnosis is straightforward based on history and physical assessment alone.
Physical Examination
A healthcare provider will perform several key assessments. The most important is the squeeze test—mediolateral compression (squeezing from the sides) of the heel to check for tenderness. This is the definitive diagnostic test for Sever's Disease. They'll also palpate the posterior heel, checking for tenderness at the back where the Achilles attaches.
Ankle range of motion will be assessed, particularly dorsiflexion (pulling the foot up toward the shin), which is often limited due to tight calf muscles. The provider will evaluate calf flexibility, as tight gastrocnemius and soleus muscles are a hallmark finding. They'll observe gait, watching for limping, toe-walking, or a forceful heel strike. Finally, they'll check for bilateral involvement by examining both heels, since the condition often affects both.
Medical History
Your doctor will ask about when the pain started and what activities make it worse. They'll want to know whether pain is present in one or both heels, and whether there have been recent growth spurts—a good indicator is if shoes or pants have recently become too small. They'll inquire about sports participation, training volume, type of footwear used, and any recent changes in activity level or new sports.
When Imaging Is Used
Most cases of Sever's Disease don't require X-rays or other imaging. In fact, X-rays are often unhelpful because the calcaneal apophysis can appear fragmented and dense in normal children without any pain.
However, your doctor may order imaging if the diagnosis is uncertain, they need to rule out other conditions like fractures or infections, symptoms don't match typical Sever's presentation, there's been a specific injury or trauma to the heel, or pain persists despite appropriate treatment.
X-rays of Sever's Disease may show fragmentation or increased density of the calcaneal apophysis, along with soft tissue swelling at the heel—though these findings can also be present in normal, pain-free children.
Ultrasound can be useful to visualize fragmentation of the calcaneal apophysis and to rule out Achilles tendinopathy or retrocalcaneal bursitis. It's a safe diagnostic tool with no radiation exposure.
MRI is rarely needed but may show signal changes (edema) in the calcaneal apophysis and helps localize inflammation to confirm the diagnosis in unclear cases.
Differential Diagnosis
Your doctor will also rule out other conditions that can cause similar heel pain. These include Achilles tendinitis (also known as tendinopathy), retrocalcaneal bursitis (inflammation of the bursa between the Achilles and heel bone), and calcaneal stress fracture (more severe pain, often with visible swelling). Plantar fasciitis is another potential different conditon that can impact the heels but this is rare in children but causes pain on the bottom of the heel. A heel bruise or fat pad contusion usually follows direct trauma. Tarsal coalition involves an abnormal bone connection in the foot. Bone tumors or infection are rare but must be ruled out if the presentation is unusual.
In most cases, the combination of age, activity level, location of pain, positive squeeze test, and tight calf muscles makes Sever's Disease diagnosis relatively straightforward.
What Causes Sever's Disease?
Sever's Disease occurs when rapidly growing bones outpace the muscles' ability to adapt, creating excessive tension at the calcaneal apophysis. The core mechanism is a length-tension mismatch between bone growth and muscle flexibility, combined with repetitive impact forces.
Rapid bone growth is the primary driver—the calcaneus grows faster than the calf muscles and Achilles tendon can adapt, creating tightness and increased pulling force at the growth plate attachment site. High activity levels compound this, as repetitive stress from running, jumping, and landing creates ongoing micro-trauma at the vulnerable growth plate, with impact forces being highest during running and jumping sports.
Tight calf muscles in the gastrocnemius and soleus become relatively shortened compared to bone length, increasing traction on the Achilles tendon and its insertion point. Weak supporting muscles in the foot and ankle reduce the ability to absorb and distribute impact forces effectively. Environmental factors like hard playing surfaces, poor footwear, and cleated shoes can all increase stress on the heel.
For a detailed guide on managing activity levels while dealing with Sever's:
Can You Play Sport With Sever's Disease? →
Symptoms of Sever's Disease
The hallmark symptoms of Sever's Disease are remarkably consistent.
The primary symptoms include localized pain at the back of the heel where the Achilles tendon attaches, pain during activity that worsens with running, jumping, or landing, and pain that improves with rest. Many children experience the "morning after" pattern where pain is worse the day following intense activity. The squeeze test—pressure applied to the sides of the heel—will reproduce the pain. Limping during or after sport is common.
Secondary symptoms often include tight calf muscles, difficulty walking on tiptoes, and toe-walking to avoid putting pressure on the heel. Stiffness in the morning or after periods of rest is typical, along with reduced performance or reluctance to participate in sport.
Unlike some conditions, Sever's Disease typically does NOT cause visible swelling at the heel (unless there's been shoe rubbing), redness or warmth, or a visible bump. This last point distinguishes it from Osgood-Schlatter, which creates a prominent tibial bump below the knee.
The pain typically follows a predictable pattern: it may warm up during sport, but returns or intensifies afterward or the next day. Many children report their heels feel fine while playing but hurt significantly when they cool down.
Sever's Disease Treatment Approaches
Treatment for Sever's Disease has evolved significantly. The outdated approach of "rest and wait until growth stops" has been replaced by active rehabilitation that addresses the root biomechanical causes.
Treatment Options
Physical therapy
Can be effective if the therapist understands sports rehabilitation and movement training, not just pain management. A physical therapist (physiotherapist, PT) or sports physician is probably your best option for receiving a thorough assessment and proper diagnosis.
Heel cups and orthotics
Deserve special mention. Unlike Osgood-Schlatter (where footwear makes little difference), heel cups and orthotics can be genuinely helpful for Sever's Disease. They reduce strain on the Achilles tendon and provide cushioning. However, orthotics alone don't address the underlying causes—tight calves, weak foot muscles, and poor load management.
Best Heel Cups and Inserts for Sever's Disease →
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Strapping and taping
Can provide some short term relief from pain and may be a key ingredient in your rehabilitation but like orthotics and heel cups taping does not fix the underlying root cause of Sever's Disease, just reduces symptoms.
Complete rest
Is still commonly prescribed but rarely the best solution. While activity modification may be needed in acute phases, complete rest doesn't address underlying causes and often leads to recurrence when sport resumes.
Surgery
Is almost never required for Sever's Disease. The condition is self-limiting and responds extremely well to conservative treatment.
Active rehabilitation programs (The Core Advantage approach)
Active rehabilitation focuses on releasing tight calf muscles through foam rolling and progressive stretching, building strength with calf raises, foot strengthening, and progressive loading, managing training loads to allow continued sport participation, and addressing footwear with appropriate cushioning and support.
This approach allows most athletes to see significant pain reduction within 2-3 weeks, return to full sport within 5-8 weeks, and build resilience to prevent recurrence.
We go deep into the Core Advantage approach to treating Sever's Disease in this blog post here →
Frequently Asked Questions About Sever's Disease
Is Sever's Disease serious?
No, Sever's Disease is not a serious medical condition.
It's painful and frustrating, but it's not dangerous and doesn't cause permanent damage to the foot or ankle. The growth plate will eventually close and fuse with the heel bone (typically by ages 14-17), at which point the vulnerability that causes Sever's Disease no longer exists.
However, the condition can significantly impact a young athlete's participation and development if not managed properly. The main "serious" aspect of Sever's Disease is the potential for young athletes to lose significant training and development time if treated with only rest rather than active rehabilitation.
Can Sever's Disease affect both heels (bilateral Sever's)?
Yes, and it commonly does. Approximately 60% of Sever's Disease cases are bilateral (affecting both heels). It's typical for one heel to become painful first, with the other following weeks or months later.
The same treatment approach works for both heels, and in fact, addressing both simultaneously—even if one is less painful—can help prevent the "second heel" problem that many families experience.
Why do cleats make Sever's worse?
Cleated footwear like soccer boots and football cleats can aggravate Sever's Disease for several reasons. They typically have less heel cushioning than regular athletic shoes, and the rigid sole increases stress on the Achilles attachment. Cleats often fit more snugly, putting pressure on the heel, and the playing surfaces for cleated sports (grass, artificial turf) can be hard and uneven.
If your child plays a cleated sport, ensure their boots fit properly, consider heel inserts for cushioning, and pay extra attention to calf flexibility.
Can adults get Sever's Disease?
No. Once the calcaneal growth plate closes (typically by ages 14-17), it's no longer possible to develop Sever's Disease because the underlying vulnerability—an open growth plate—no longer exists.
Adults can experience similar heel pain from conditions like Achilles tendinopathy, plantar fasciitis, or retrocalcaneal bursitis, but these are different conditions requiring different treatment approaches.
Understanding Sever's Disease Is the First Step
Now that you understand what Sever's Disease actually is—a growth-related overuse injury, not a disease that must be passively endured—you can make informed decisions about treatment.
The key points to remember: Sever's Disease is the most common cause of heel pain in growing children, caused by a mechanical mismatch between rapid bone growth and muscle adaptation. It responds well to active rehabilitation that addresses root causes, and most athletes can continue playing with appropriate modifications. Early intervention leads to faster recovery, and since both heels are often affected, consider addressing both from the start.
If your child has been diagnosed with Sever's Disease, you don't have to accept months or years of heel pain. Active rehabilitation offers a faster, more comprehensive solution.
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