Calcaneal Apophysitis

Aka: Calcaneal Apophysitis, Sever's Disease, Sever Disease, Calcaneoapophysitis, Apophysitis of the Achilles Tendon

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II. Epidemiology

  1. Most common cause of Heel Pain in children and Teens
  2. Occurs most commonly in boys, ages 8 to 14 years
  3. Associated with Running or jumping sports (esp. early season or at times of growth spurt)
    1. Basketball
    2. Soccer
    3. Track

III. Pathophysiology

  1. Traction Apophysitis at posterior Calcaneus in competitive child and teen athletes with immature skeletons
  2. Low grade inflammation and Apophysitis at achilles tendon insertion
  3. Associated with irregular ossification
    1. Sclerosis of calcaneal apophysis
  4. Images
    1. ankleLateralSevers.jpg

IV. Mechanism

  1. Traction injury of the achilles tendon insertion at the Calcaneus

V. Risk Factors

  1. Tight heel cord
  2. Running or jumping sports
  3. Early sports specialization

VI. Symptoms

  1. Heel Pain with insidious onset (bilateral in 60% of cases)
  2. Ambulation is not painful (but weight bearing may exacerbate the pain)
  3. Posterior Calcaneus pain
    1. Pain worse during or after high impact activity, and improves with rest
    2. Wearing shoes is painful (esp. soccer cleats)
    3. Pain is worse at the begining of a season or during a growth spurt

VII. Signs:

  1. Point tenderness over the achilles tendon insertion
  2. Calcaneus inflammation
    1. Achilles tendon pain and tenderness at the Calcaneus insertion
    2. Swelling may be present
  3. Tight heel cord
    1. Passive dorsiflexion of heel cord reproduces pain
  4. Provocative Testing (>95% Test Sensitivity and Test Specificity)
    1. Calcaneal Squeeze Test (medial and lateral compression of Calcaneus)
    2. One legged heel standing

VIII. Differential Diagnosis

  1. Plantar Fasciitis
  2. Achilles Tendinitis
  3. Calcaneal Stress Fracture

IX. Imaging: Foot Xray

  1. Indications
    1. Severe symptoms or refractory cases (e.g. >8 weeks)
  2. Typically normal
  3. May demonstrate sclerosis of calcaneal apophysis
    1. However sclerosis also seen in normal, asymptomatic feet
  4. Evaluate for alternative diagnoses (e.g. Calcaneal Stress Fracture)

X. Management

  1. General Measures
    1. NSAIDs or Acetaminophen
    2. Local heat
    3. Ice Therapy
    4. Relative Rest
      1. Limit activity to pain free sports during recovery
  2. Physical Therapy
    1. Calf and Heel Cord StretchingExercises
    2. Focus on gastrocnemius Muscle and soleus muscle Stretching
  3. Orthotics
    1. Available as off-the-shelf products, but custom Orthotics are most effective
    2. Padded heel cup
    3. Heel lift (1.25 cm)
      1. Diminishes heel cord stress
  4. Short Leg Walking Cast (resistant cases)
    1. Foot in slight equinus (plantar flexion)

XI. Course

  1. Anticipate return to activity within 6 weeks
  2. Anticipate full recovery within 2 months

XII. Prognosis

  1. Self limited condition with good overall prognosis
  2. Typically resolves with Epiphyseal Plate closure at age 15 to 16 years old

XIII. References

  1. Achar (2019) Am Fam Physician 99(10): 610-8 [PubMed]
  2. Atanda (2011) Am Fam Physician 83(3): 285-91 [PubMed]
  3. Lintner (2023) Am Fam Physician 108(6): 544-553 [PubMed]
  4. Madden (1996) Am Fam Physician 54(6):1995-2000 [PubMed]
  5. Morancie (2025) Am Fam Physician 112(6): 648-56 [PubMed]
  6. Ogden (2004) J Pediatr Orthop 24(5): 488-92 [PubMed]
  7. Tu (2018) Am Fam Physician 97(2):86-93 [PubMed]

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