Severs Disease: Heel Pain

Severs disease is a common cause of heel pain in young athletes, usually in those who are training hard, or who are undergoing or have undergone a growth spurt.

Severs disease occurs in children when the growth plate (which is the growing part of the heel bone) is injured. Tendons attach muscles to bones, and it is the Achilles tendon that attaches the calf muscles to the heel bone. During growth, bones will tend to grow faster than muscles and tendons, which means that in a growth spurt, children and adolescents will tend to become less flexible in all of their muscles. More strain is therefore put on the tendons, which can then cause the tendons to pull too hard on the attachment to the bone or growth plate. In the case of Severs disease, the pull is at the attachment of the Achilles tendon onto the heel bone.

Severs disease is most common in physically active girls 8 years to 10 years of age and in physically active boys 10 years to 12 years of age. It can affect one or both heels. Severs disease rarely occurs in older teenagers because the back of the heel has typically finished growing by 15 years of age.

Causes of Severs Disease

The most common causes of Severs disease are:

  • Growth spurts
  • Poor flexibility – due to growth, activity, lack of stretching or postural issues
  • Increased exercise intensity
  • Starting a new sport
  • Foot biomechanics ( ie flat feet, high arches)
  • Gait issues (walking)
  • Leg length difference
  • Pelvic and spine alignment issues
  • Poor strength
  • Poor functional stability – core, balance.

Signs and Symptoms of Severs disease

The following signs and symptoms can be in one or both heels:

  • Pain in the back of the heel
  • Walking with a limp
  • Increased pain with running or jumping
  • Walking on tiptoe
  • Pain if you squeeze both sides of the back of the heel
  • Tightness and pain in Achilles tendons
  • Pain in the heel when stretching the calf.

Physiotherapy assessment of the causes of Severs Disease

The child should be assessed fully by a physiotherapist and a podiatrist if necessary.

The assessment will include:

  • Postural and biomechanical alignment assessment
  • Strength testing of all of the muscles of the lower limbs – quadriceps, hamstrings, calves and gluteal muscles
  • Flexibility testing of all of the muscles of the lower limbs
  • Assessment of the foot and ankle
  • Functional movements testing – balancing, squatting, lunging, running etc
  • Assessment of leg length difference
  • Referral to the podiatrist if required

The child’s pelvis and back may be slightly twisted, not symmetrical or stiff. This can be caused by tight muscles, weakness in the core muscles, poor posture, slips or trips and general activity. This malalignment of the pelvis and spine can change the child’s posture and alter how the child moves, which can then alter muscle firing or place added stress on the feet, and Achilles tendon.

Pain will generally be greater with activities requiring running, jumping. Symptoms are usually worse the faster the growth spurt or the less flexible the athlete.

Treatment of Severs Disease

The physiotherapist will take a thorough case history and will assess all of the causative factors described above.
Treatment will then begin to address these issues, aiming to increase flexibility and strength, and also looking at biomechanics and technique if required. Treatment can include

  • stretching exercises
  • strengthening exercises
  • massage – soft tissue work
  • advice – about activity levels, application of ice to the area
  • Gait re-education
  • re-alignment of the pelvis and spine
  • mobilisation of other joints: knees, ankles, feet and hips
  • podiatrist referral if required- if appropriate, an orthotic (innersole) may be prescribed to change the foot position to allow the foot to work better. A difference in leg length should also be addressed.

Although each child will vary in recovery rates, we have great success at rapidly reducing pain from Severs disease. With massage and stretching exercises, the child will become more flexible, reducing both the stress on the tendon and pull on the bone. This allows the area to heal and the pain to decrease. Improved flexibility will also mean that the child will begin to move better, which further reduces the stress on the tendon.

Our expert advice on activities, exercises and return to sport will help to rehabilitate the child safely back to their pre-injury level of activity and may decrease other related problems in the future.

Exercising with Severs disease

Exercising with Severs disease should be guided by pain. For example if an activity is pain free, it is generally possible to continue with that exercise ie it may be painful to run, but cycling may be painfree. Painful activities should be reduced. If the child is undergoing a growth spurt and the symptoms are worse, the child should increase their stretches and stick with painfree activities only

Stretching should be done as shown by the physiotherapist – as often as possible

Icing for 5 minutes several times a day, always after sport and after stretching if possible

How to help prevent Severs disease from reoccurring

Continue to:

  • Stretch on a daily basis
  • Warm-up and cool down before and after activity.
  • Stretch the calf muscles before sport and any other muscles that are particularly tight.
  • Seek treatment if stretching doesn’t relieve tight muscles around the area
  • Monitor the growth rate of the child ( ie measure their height on a weekly basis) and increase the amount of stretching done when the child is in a growth spurt.

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