The following symptoms commonly presents with calcaneal apophysitis or Sever disease:

• Pain and swelling at the posterior heel [5]
• Walking on toes
• Pain is aggravated with use of heel [6]
• Limping
• Difficulty in running and jumping
• Tenderness when the sides of the heel are squeezed

• Pain

  Pain goes away when the overuse is over, or when the growing is done. Hence, the disease is self-limited, in that the pain goes away eventually when growth in the heel bone is complete at about age 13. [orthoseek.com]

  Other conditions that cause heel pain Heel pain can also be caused by a stress fracture in the heel, bursitis, tendonitis, bone cysts, and rheumatologic disorders. [healthychildren.org]

  The pain had been ongoing for several weeks, caused a limp, and at times precluded the patient from performing tumbling maneuvers in cheerleading practice. [jaoa.org]

  Complaints most often include heel pain, tightness, swelling and sometimes bruising. The pain will increase with running and jumping activities, and may be exacerbated with a tight sneaker or cleat. [goalnation.com]

  Sever disease is the most common cause of heel pain in children in one or both heels. Unlike adult heel pain that is relieved by walking around, pain in calcaneal apophysitis does not resolve in this manner. [symptoma.com]

• Inflammation

  Sever’s Disease Treatment With John Gallucci Sever’s Disease is painful but usually not long lasting — and due to inflammation in the heel but can be a real problem for youth soccer players. [goalnation.com]

  Sever disease is a common and painful inflammation of the calcaneal apophysis. [symptoma.com]

  Repetitive stress on the heel’s growth plate can trigger painful inflammation. The clinical term for the condition is calcaneal apophysitis. It’s an inflammation of the growth plate in the heel. [healthline.com]

  Nonsteroidal anti-inflammatory drugs: NSAIDs, such as ibuprofen, help reduce the pain and inflammation. Ice: Ice the area to reduce inflammation. [kansascityfootandankle.com]

  Sever’s disease also called calcaneal apophysitis, is a condition caused due to inflammation of the growth plate in the calcaneus (heel bone). [njorthoinstitute.com]

• Swelling

  Athletes will often have to sit out for a period of time to allow the pain and swelling to subside. [goalnation.com]

  Use an elastic wrap or compression stocking to help with pain and swelling. Try physical therapy (PT) or a home exercise program given to you by the health care provider to help with stretching and strengthening. [kidshealth.org]

  This will help reduce the swelling. Ingest over-the-counter medications that focus on reducing swelling and pain. These include acetaminophen like Tylenol or ibuprofen like Advil and Motrin, not aspirin. [pediatricfootankle.com]

  […] use an elastic wrap or compression stocking that is designed to help decrease pain and swelling take an over-the-counter medicine to reduce pain and swelling, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) Note: Children should not be given [hopkinsallchildrens.org]

• Weakness

  Apophyses are open areas in the bone and are a “weak link” making these areas more prone to injury. As the child matures these areas fuse together and become a solid bone. [tria.com]

  Related to adolescent growth spurt with weak ankle dorsiflexion and tight gastrocsoleus complex. May be overuse injury caused by repetitive microtrauma to the trabecular metaphyseal bone. (Ogden JA, JPO 2004;24:488). [eorif.com]

  We don’t believe that the foot or ankle is weak and so loading it isn’t necessary. [sydneyheelpain.com.au]

  Until then, new bone is forming at the growth plate (physis), a weak area located at the back of the heel. When there is too much repetitive stress on the growth plate, inflammation can develop. [foothealthfacts.org]

• Severe Pain

  Symptoms of Sever's Painful heel No swelling or warmth Night pain is absent Pain is worse with increased activity Pain which is usually relieved by rest Children often hobble or limp from the sports field Care and Management See a Podiatrist Minimise [podiatry.org.nz]

  Plantar fasciitis is another common cause of heel pain, but unlike Sever's disease, the pain is mostly felt when the activity is first started. After 10 to 15 minutes of activity, the pain will "work itself out" and resolve its own. [verywellhealth.com]

  Sever’s disease is a painful condition of the heel that occurs in growing children. [nationwidechildrens.org]

  Limping also occurs, more severe pain after walking or exercise, and increased difficulty walking, especially pain during running or playing a sport. This pain and swelling usually is diagnosed as Sever’s Disease. [jagpt.com]

  Here’s what you need to know: What is Sever ’ s Disease? Sever’s has often been referred to as ‘growing pains’, though this does not describe how and why the pain occurs. [performpodiatry.co.nz]

• Heel Pain

  Other conditions that cause heel pain Heel pain can also be caused by a stress fracture in the heel, bursitis, tendonitis, bone cysts, and rheumatologic disorders. [healthychildren.org]

  Sever disease ( sē'vĕr ), an osteochondrosis of the heel, probably secondary to microfractures in the bone where the Achilles tendon attaches to the posterior calcaneus; an overuse injury and a common cause of heel pain in older children. [medical-dictionary.thefreedictionary.com]

  It is the most common cause of heel pain in children, and it can occur in one or both feet. Heel pain in children differs from the most common type of heel pain experienced by adults. [foothealthfacts.org]

  It is the most common cause of heel pain in children, and can occur in one or both feet. Heel pain in children differs from the most common type of heel pain experienced by adults. [acfas.org]

  Calcaneal Apophysitis is the most common cause of heel pain in children. Heel pain in children differs from the most common type of heel pain experienced by adults. [kansascityfootandankle.com]

• Foot Pain

  Foot pain is not only limited to grown-ups. Often, healthy and active children will complain of pain in one or both heels shortly after running, engaging in sports or even walking. The pain is centered at the back of, or under the heel. [footlogics-shop.com.au]

  Certain foot shape variations can predispose to Sever’s disease, such as a very flat foot or the opposite, a foot with very high-arches. SYMPTOMS Heel pain may extend into the Achilles tendon or the arch of the foot. [onsmd.com]

  We might also recommend rest, applying ice, elevating the foot, and over-the-counter pain medication. [lexingtonkypodiatry.com]

  If your child notices foot pain or heel pain after exercising, have the doctor look at it. [health.clevelandclinic.org]

• Muscle Strain

  In growing children, excessive weight bearing on the heel bone (calcaneus) causes excessive traction as the bones and tendons are still developing and are still soft; resulting in muscle strain and inflamed tissue. [riverdalept.com]

  The heel’s growth plate is sensitive to repeated running and pounding on hard surfaces, resulting in muscle strain and inflamed tissue. For this reason, children and adolescents involved in soccer, track or basketball are especially vulnerable. [foothealthfacts.org]

  The heel’s growth plate is sensitive to repeated running and pounding on hard surfaces, resulting in muscle strain and inflamed tissue. For this reason, children and adolescents involved in soccer, track, or basketball are especially vulnerable. [acfas.org]

  Repeated running and pounding on hard surfaces can exasperate muscle strain and inflammed tissue. Children and adolescents tend to be quite physically active, and this activity contributes to the pain! [kansascityfootandankle.com]

• Ankle Pain

  Quite often when we see this condition, it’s been palmed off as growing pains but any sort of foot and ankle pain is not normal in children. [tfcpodiatry.com.au]

  The main thing to remember is that kids should not be having foot or ankle pain unless they have had an injury — like stepping on something and breaking a bone. [health.clevelandclinic.org]

  Why Kinesiology Tape Helps Reduce Swelling and Bruising Quicker Call PhysioWorks Book Online Related Injuries General Information Heel Pain Ankle Pain Foot Pain Heel Pain Heel Spur Traumatic Ankle Ligament Injuries Sprained Ankle High Ankle Sprain Tendinopathies [physioworks.com.au]

• Heel Swelling

  […] activity; * Pain in the heel in the morning, or when the heel is squeezed; Treatment of Sever’s Disease Treatment is aimed at reducing the swelling and inflammation that is occurring in the heel which then reduces the pain. [neurohealthchiro.com.au]

  […] and symptoms associated with infracalcaneal bursitis include: Pain directly under of the heel Pain or discomfort that increases with prolonged weight-bearing activities Pain and swelling under the heel Redness under the heel Treatment The first and most [nwfootankle.com]

• Irritability

  Wear shoes that are open in the back so the heel is not irritated. Use an elastic wrap or compression stocking to help with pain and swelling. [kidshealth.org]

  Sever's Disease is an irritation of the back of the calcaneus ( heel ) at a growth plate where the Achilles tendon inserts. [tendontrak.com]

  Sever’s Disease is an irritation to the growth plate in the heel bone, brought on by too much traction from the Achilles tendon. [ssmc.com.au]

  The most common cause of heel pain is plantar fasciitis, which occurs when the tough band of tissue on the sole of the foot becomes irritated and inflamed. However, plantar fasciitis is not particularly common in children. [smgortho.com]

• Forgetful

  Don’t forget to stretch after the activity as well. Stretches to Help Ease Pain With Sever’s Disease Hamstring stretches – Lie flat on the ground and lift one leg. Extend the knee fully with the leg perpendicular to the rest of your body. [nortonchildrens.com]

  What she forgets to do is work on her flexibility and her stretching. In fact, she rather do 20 pull-ups, 100 crunches, and run a few laps rather than sit in her splits for a minute. [allgymnasts.com]

Patients with Sever disease are usually diagnosed by means of a thorough clinical history and physical examination which demonstrates the characteristic pain in the foot.

Diagnostic tests like radiographic test may be used to rule out concomitant illness that could be potentially serious and present similarly to calcaneal apophyisitis [7]. The following imaging techniques are implored in patients carrying a high suspicion of Sever disease:

• Radiographic X-ray: This procedure will demonstrate any lesions like stress fractures in the calcaneum or bone cysts. It is a tool which is neither diagnostic nor prognostic in Sever disease.
• Computed Tomography (CT) Scan: This set of x-ray beams elucidates the tarsal area and differentiates calcaneal apophysitis or Sever disease from a rare clinical disorder called tarsal coalition which is the failure of the hind bones to physiologically separate. 
• Magnetic Resonance Imaging (MRI): This radiographic imaging modality may elucidate the bones and the muscles clearly; thereby ruling out possible osteomyelitis from Sever disease. 

It should be understood that athletic children who starts at a younger age may fall victim to overuse syndrome of the foot due to increasing frequency of use through practice and actual sport. For this reason, growing child athletes are more prone to Sever disease than the other children in their adolescence [8].

Treatment is primarily focused in reducing pain symptoms, overcoming limitations of movement, and prevention of recurrence. Patients with Sever disease may need to rest for at least 2 months for recuperation before they resume back to sporting activities. The affected foot may be placed on top of a half an inch inner sole lift or molding orthoses to stretch the calf muscle persistently and prevent it from abruptly pulling or straining the calcaneal attachment [9].

Pre-activity and post-activity icing may also prevent apophysitis swelling after an event. Oral antiinflammatory medications may be used to control pain in the heels. Reports on the use of ketoprofen gel in heel pain among children have shorten recuperation time to 18 days [10]. In severe cases of Sever disease may benefit from a 2 to 3 weeks of casting in mild equinus orientation of the foot. Physical therapy may help allay the symptoms and reduce recurrence rate of Sever disease.

By definition, Sever disease is an affliction of childhood which resolves beyond 15 years old due to the complete ossification of the apophysis of the heel.

Any incomplete healing and microfractures by the apophysial line will spontaneously resolve with the bone formation. Stress fractures and bone cysts however may coexist with Sever disease and present symptoms in the same way. Both conditions may persist beyond 15 years old and may need surgery or rehabilitation if they chronically persist with some discomfort.

Complications

There has been no evidence so far that Sever disease can cause any long term pathology or complications to affected children.

The basic etiology involved in Sever disease is stress and overuse upon the calcaneum during physical activities like prolonged running, persistent straining of the calf muscle and continuous impact during jumping.

These foot mechanics are typically seen among children involved in soccer, tracks, and basketball. Obese and overweight children can cause undue strain on the heel bone and cause the disease.

Flat footed individuals with biomechanical defects or biomechanical malalignment on the natural plantar arch may inherently pull on the calcaneal attachments and cause perennial inflammation of the apophysis [2].

There are no available statistical data on the international incidence of Sever disease but it is commonly seen among growing children worldwide. There are no mortalities associated with Sever disease.

The long term pain felt in the heel can essentially limit the child’s range of activity from his sports performance to his daily simple chores. Sever disease has a predilection to male children with a ratio of 13 males to 7 female patients. An Irish study reveals that the average age of presentation was 11.83 years old among boys and 8.67 years old among girls [3].

The pathophysiology of Sever disease is mainly due to the continuous stress exerted on the apophysial line which affects the fragile cartilages that are still starting to ossify. It is well established that the apophysis are formed with more fibrocartilage than the epiphysis of the long bones; thus, they are less resistant to persistent axial stress [4].

This undue stress causes microfractures which radiographically appear as resorption, fragmentation and diffuse sclerosis that may eventually lead to healing. Although clinical evidence of fragmentation does not necessarily mean fractures in Sever disease because ossification center in the rapid spurt of puberty may appear in multiple site at the same time.

The incidence of Sever disease can be significantly prevented in a child when the risks are identified early. The following preventive measures may help a child overcome the risk for Sever disease and prevent heel pain:

• Weight control: Parents must help their children control their weight. Overweight and obese children are more prone to the disease.
• Use of the proper supportive shoes: Children who are flat footed may benefit with the use of supportive shoes that maintains the plantar arch. For those who has experienced heel pain, an inner sole lift may keep the calf muscles stretched and firm.
• Cleated athletic shoes must be avoided.
• Children must not be forced to perform beyond his capacity.

Sever disease or calcaneal apophysitis is a clinical disease characterized by the swelling of the heel bone. The inflammation of the calcaneum is due to the frequent pulling of the gastrocnemius (calf muscle) on the calcaneal insertion where the bone is not totally mature yet. Sever disease is presently classified under the non-articular osteochondroses type of disease for adolescents and children [1].

This disease condition is common among athletic or active adolescents between the ages of 9 to 15 years old. Sever disease is the most common cause of heel pain in children in one or both heels. Unlike adult heel pain that is relieved by walking around, pain in calcaneal apophysitis does not resolve in this manner. Sever disease may cause heel discomforts for months in children and may resolve once the calcaneum bone matures fully.

Definition

Sever disease otherwise known as calcaneal apophysitis is the inflammation of the heel due to the chronic stress provided by the calf muscle on the immature heel bone.

Cause

Stress and overuse of the heel, obesity and overweight children, faulty footwear, Pes planus (flat foot) contribute to this condition.

Symptoms

Heel pain, and limitation of movement, impaired sporting performance  pain in squeezing the heel may occur.

Diagnosis

Diagnosis is mainly by clinical history and physical examination. Imaging techniques are implored to rule out other problems

Treatment and follow-up

Rest, use of supportive footwear, pain relievers, casts and rehabilitation. Patients should have regular visits with their physicians to prevent recurrence.

1. Katz JF. Nonarticular Osteochondroses. Clinical Orthopaedics and Related Research. 1981; 158:70.
2. Scharfbillig RW, Jones S, Scutter S. Sever's Disease: A Prospective Study of Risk Factors.J Am Podiatr Med Assoc. 2011; 101(2):133-45 (ISSN: 1930-8264)
3. Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. Jan-Feb 1987; 7(1):34-8.
4. Tu P, Bytomski JR. Diagnosis of heel pain. Am Fam Physician. Oct 15 2011; 84(8):909-16.
5. Sever JW. Apophysitis of the Os Calcis. New York Medical Journal. 1912; 95:1025-1029.
6. Weiner DS, Morscher M, Dicintio MS. Calcaneal apophysitis: simple diagnosis, simpler treatment. J Fam Pract. May 2007; 56(5):352-5.
7. Rachel JN, Williams JB, Sawyer JR, Warner WC, Kelly DM. Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)? J Pediatr Orthop. Jul-Aug 2011; 31(5):548-50.
8. Brenner JS. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. Jun 2007; 119(6):1242-5.
9. Gijon-Nogueron G, Cortes-Jeronimo E, Cervera-Marin JA, García-de-la-Peña R, Benhamu-Benhamu S, Luque-Suarez A. Foot orthoses custom-made by vacuum forming on the non-load-bearing foot: preliminary results in male children with calcaneal apophysitis (Sever's disease). Prosthet Orthot Int. 2013; 37(6):495-8 (ISSN: 1746-1553)
10. White RL. Ketoprofen gel as an adjunct to physical therapist management of a child with Sever disease. Phys Ther. 2006; 86(3):424-33 (ISSN: 0031-9023)