Sever's Disease
Sever's disease (calcaneal apophysitis) is heel pain in growing children, near the growth centre where the Achilles tendon attaches to the heel bone. It affects children and young teens rather than adults. Pain is often worse during or after sport, and the heel may also feel tender.
Key points
- What usually helps
- Adjusting your child's running and jumping, with calf stretching and strengthening.
- What you can do now
- Cut running and jumping back, not out. Stretch both calf muscles twice a day.
- How long it takes
- Often improves within 2 to 4 weeks and clears within 2 to 6 months. It does not come back once the growth plate closes.
- When to see a doctor first
- Some signs need medical care the same day. Check the list before you start treatment.
Symptoms
Does this sound like you?
- Heel pain with activity, worse during and straight after sport
- Pain when the back of the heel is squeezed from both sides
- Morning stiffness and pain that improves with gentle movement and warm-up
- Difficulty with running, jumping and sport
- Pain eases with rest and when the activities that aggravate it stop
- Often affects both heels
Often alongside it
- Limping, with less time spent standing on the sore side
- Tight calf muscles (the gastrocnemius and soleus)
- Reluctance to participate in previously enjoyed physical activities
- Pain made worse by walking barefoot on hard floors
- Symptoms that line up with growth spurts and busier periods of activity
- Moving differently to keep weight off the heel
Pain typically follows a predictable pattern: it comes on with activity, eases with rest, and lines up with growth spurts. Symptoms are often worse at the start of a sports season, when activity jumps quickly. Morning symptoms are common but usually ease with gentle movement.Book an assessment for Sever's disease
When to see a doctor first
Get seen today
Fever, or a red, hot, swollen heel
Same-day medical assessment to rule out a bone or joint infection
Check with your doctor
Severe pain at rest or at night, or pain that stops your child putting weight on the foot
See your family doctor before physiotherapy starts, for an X-ray to rule out a fracture or another bone problem
Numbness, tingling, or weakness in the foot
See your family doctor promptly; this is not typical of Sever's disease
No improvement after 8-12 weeks of appropriate conservative treatment
I flag it to your family doctor, who can arrange imaging to look for another cause
Persistent symptoms beyond expected age of growth plate closure (typically 16 years)
See your family doctor for a review, as another heel problem is more likely
Treatment
How it is treated
Main approach. Adjusting how much running and jumping your child does, with calf stretching and strengthening, is the main treatment. Symptoms usually settle over a few months and do not return once the growth plate closes.
Alongside it. Heel padding and supportive shoes reduce impact and ease symptoms while your child keeps taking part in activity.
Managing it over time. Building up activity gradually during growth spurts and keeping the calves flexible may reduce the risk of symptoms in young athletes at risk.
A typical rehabilitation progression
Three phases, from settling symptoms to returning to full activity.
Recovery from Sever's disease is usually staged: calm the symptoms first, then rebuild the strength and capacity of the area, then return to your full activities. The phases below show how that can progress.
Phase 1Settle the Heel (Weeks 1 to 3)
Calm the at the back of the heel (the ) by reducing running and jumping, stretching the calf muscles, and cushioning the heel as it lands. The aim is to keep your child in sport in some form while the growth plate settles.
Example exercises
- Calf stretch against a wall with the knee straight (gastrocnemius), 3 sets of 30 seconds, both sides, twice a day
- Lower calf stretch against a wall with the knee bent (soleus), 3 sets of 30 seconds, both sides, twice a day
- Heel cup or gel heel pad in both sport and school shoes
- Temporary reduction of running and jumping to roughly 50 percent of usual weekly volume, with cross-training like swimming or cycling to maintain fitness
- Ice for 10 to 15 minutes after any aggravating session
Possible progression milestones
Clearly less tenderness when the heel is squeezed from both sides, pain during normal walking at 2 out of 10 or less, and no more than mild symptoms the next morning after adjusted training, for 7 days in a row.
Phase 2Rebuild Calf and Foot Strength (Weeks 3 to 8)
Restore calf strength and foot control so the muscles at the back of the leg can absorb running and jumping again. Calf stretching continues. Exercise is added gradually, checking how the heel responds over the next 24 hours.
Example exercises
- Heel raises on both feet, 3 sets of 12 to 15, progressing to a controlled speed (2 seconds up, 2 seconds hold, 3 seconds down)
- Single-leg heel raise, building from 6 to 15 reps as tolerated
- Single-leg balance work (30 to 45 seconds per side), progressing to balance on foam or uneven surface
- Short-foot holds (gently raising the arch without curling the toes) and toe yoga (lifting the big toe and the other toes separately) to build the small muscles inside the foot
- Gradual reintroduction of running, starting with run/walk intervals on soft surfaces
Possible progression milestones
15 controlled single-leg heel raises without heel pain, calf flexibility within a few centimetres of the unaffected side on a knee-to-wall lunge test (weight-bearing lunge test), and pain-free jogging for 10 minutes on a supportive surface.
Phase 3Return to Sport with Load Management (Months 2 to 4)
Rebuild the demands of the sport (changing direction, repeated jumping, sprinting) with gradual increases in volume. The goal is not just freedom from pain; it is teaching your child and family to recognise sudden jumps in activity, growth spurts and footwear problems that usually bring it back.
Example exercises
- Jumping on both feet with soft landings, 2 sets of 10, progressing to single-leg hopping in straight lines
- Short acceleration drills (10 to 20 metres), progressing to change of direction work
- Progressive return to team training, increasing running and jumping volume in small weekly steps
- Full sport practice with one modified session per week during early return
- Ongoing calf flexibility and heel raise work 2 to 3 times per week as a maintenance habit
Possible progression milestones
Two weeks in a row of full team training and competition without heel pain, calf strength about equal on both sides (single-leg heel raises within 2 repetitions of the other side), and a family plan for managing the next growth spurt or season change.
What you can do now
- Cut running and jumping back, not out. For now, reduce your child's running and jumping to roughly half their usual weekly amount, and keep them fit with swimming or cycling. Many children can keep playing in some form if pain during and after activity stays manageable and settles overnight.If your child is limping when they walk or play, take a break from running and jumping sport until the limp has gone, and have it reviewed. Severe pain at rest or at night, or pain that stops your child putting weight on the foot, needs your family doctor before physiotherapy starts.
- Stretch both calf muscles twice a day. With hands on a wall, stretch with the back knee straight, then with it bent, holding each for 30 seconds, 3 times on both sides. Keeping the calves flexible may reduce the pull on the growth plate at the back of the heel.The stretch should feel comfortable, not painful.
- Use heel cups and cushioned shoes. A heel cup or gel heel pad in both sport and school shoes cushions the heel as it lands and can reduce pain enough to keep playing. Pair it with well-cushioned running shoes that have a firm back around the heel (heel counter), and avoid flat, unsupportive shoes, worn-out cleats and barefoot-style shoes during a flare.Check the pad fits without making the shoe tight; shoes may need to be slightly larger, and worn pads and shoes should be replaced.
- Ice after sessions that flare it. Ice for 10 to 15 minutes after a session that aggravates the heel can ease pain and help your child keep playing in a modified way. It is a comfort measure rather than a treatment on its own.Put a cloth between the ice and the skin.
- Smooth out jumps in activity. Sever's tends to flare when training jumps quickly, such as the start of a season or a growth spurt combined with new activity. Build new activity up gradually, and keep up calf stretching year round rather than only when the heel hurts.Heel pain that carries on past the age the growth plate usually closes (typically 16) needs a review with your family doctor, as another heel problem is more likely.
What I use in clinic
- Calf stretching program. Commonly used alongside activity changes; trial evidence is limited.
- Heel cups and cushioned insoles. Can ease symptoms while a child keeps taking part in activity.
Recovery
How long it takes
Symptoms usually improve within 2 to 4 weeks of the right treatment and clear completely within 2 to 6 months. Once the growth plate fuses (usually by age 16), symptoms do not come back.
Sever's disease settles completely on its own (it is self-limiting) once the bones finish growing. It does not cause long-term complications and does not come back once the growth plates close. Most children return to full sport without restrictions.
What changes the timeline
- Age, and how close the growth plate is to closing: older children who have nearly finished growing recover faster
- How well your child sticks with the activity changes and stretching, which matters a great deal for symptoms to clear
- How tight the calves are affects both how strong the symptoms are and how long recovery takes
- What the sport demands, and how training is adjusted, directly influence how fast it heals
- Good footwear, and using heel cups or inserts consistently, affect how well symptoms are controlled
- Your child's own growth pattern, and when growth spurts happen, which influence how long symptoms last
How I track it. I track your child's pain during different activities, check whether the heel is less tender when squeezed from both sides, measure gains in calf flexibility, and see how well they can take part in sport and daily activities
Similar conditions
Conditions that can feel similar
- Calcaneal Stress Fracture
- More severe pain, often present at rest, a fracture that shows on imaging, and typically in older teenagers
- Plantar Fasciitis
- Pain mainly under the heel, worse with the first steps in the morning, and uncommon in children under 10
- Achilles Tendinopathy
- Pain and tenderness along the Achilles tendon itself rather than where it attaches to the heel bone; more common in teenagers
- Calcaneal Bursitis
- Swelling and tenderness over the bump at the back of the heel, linked with shoes rubbing
- Tarsal Coalition
- A stiff flat foot, little side-to-side movement of the heel (limited subtalar motion), and pain when standing that is not limited to the heel
Questions
What patients ask me most
Will my child grow out of Sever's disease?
In most cases, yes. Sever's is irritation of the growth plate at the back of the heel bone, where the Achilles tendon pulls (a calcaneal apophysitis), and once that growth plate fuses (typically around age 14 to 16), the vulnerable structure no longer exists. Most children return to full activity well before they finish growing, often within a few months of starting sensible management. It is a self-limiting condition, not a progressive injury.
Does my child need to stop sports completely?
Often not. The usual plan is a temporary reduction in running and jumping volume rather than complete rest. Many children can keep playing in some form while the heel settles, provided pain during and after activity stays manageable and settles overnight. If your child is limping when they walk or play, take a break from running and jumping sport until the limp has gone, and have it reviewed.
How long until the pain goes away?
With activity modification, calf flexibility work, heel cups, and supportive footwear, many children feel better within a few weeks, and full resolution can take a few months. Cases in both heels tend to take longer than one-sided cases. The condition does not recur once the growth plate has closed.
Why does the pain come back every season?
Sever's tends to flare when training load jumps quickly, like the start of a soccer season or a growth spurt combined with new activity. A common pattern is a child who felt fine all summer, starts three practices a week in September on turf, and has heel pain soon after. What often helps is smoothing out those load spikes and maintaining calf flexibility year round rather than only when symptoms appear.
Do heel cups actually help?
For many kids, yes. They cushion heel strike and can reduce pain enough to keep playing. In trials, both heel lifts and custom orthoses reduced pain, and a 2026 Cochrane review found little to no difference between them. I usually start with a good heel cup and supportive footwear before moving to custom orthotics, since the simple options are cheap and often enough.
Do I need an X-ray?
Imaging is not usually needed to diagnose Sever's. It is a clinical diagnosis based on age, activity history, and pain when the heel is squeezed from both sides (the heel squeeze test). Imaging becomes relevant when the picture is unusual, when pain is present at rest or at night, when there is a history of a specific injury, or when symptoms fail to improve with appropriate management over 8 to 12 weeks. In those cases I flag it to your family doctor and refer you for imaging to rule out other causes.
What footwear helps most during a flare?
Well-cushioned running shoes with a firm back around the heel (heel counter), replaced when they are visibly worn. Avoid flat, unsupportive shoes (including worn-out cleats and barefoot-style shoes) during a flare. On hard indoor court surfaces, adding a heel cup often makes a noticeable difference.
The science
The Science of Sever's Disease
Sever's disease, formally known as , represents an inflammatory condition of the posterior calcaneal in skeletally immature children and adolescents. The calcaneal is a secondary that appears around age 8 and typically fuses with the main body of the calcaneus between ages 14-16 years.
During periods of rapid skeletal growth, the bones often grow faster than the surrounding soft tissues, creating increased tension in muscles and tendons. The Achilles tendon and both attach to the posterior aspect of the calcaneus, creating a traction force on the growth plate during activities involving running, jumping, or rapid direction changes.
The growth plate cartilage is inherently weaker than mature bone and more susceptible to stress-related injury. Repetitive traction forces from tight posterior muscle groups, combined with impact forces from athletic activities, create microtrauma within the growth plate. This leads to localized inflammation, increased blood flow, and pain characteristic of the condition.
The condition is essentially a stress reaction rather than an acute injury, developing gradually as cumulative stress exceeds the growth plate's adaptive capacity. Unlike adult , the problem lies at the growing bone rather than in the tendon, which is why management centres on adjusting running and jumping load rather than on tendon treatments.
The self-limiting nature of Sever's disease relates directly to skeletal maturation. As the growth plate closes and the apophysis fuses with the main calcaneal body, the weak link in the posterior heel complex is eliminated, and symptoms resolve permanently.
Contributing factors
The posterior heel complex functions as an integrated system during weight-bearing activities, with forces transmitted from the calf muscles through the Achilles tendon to the insertion. In skeletally mature individuals, these forces are absorbed by mature bone tissue, but in growing children, the represents a point of relative weakness.
During the stance phase of gait, the gastrocnemius and soleus muscles contract to control forward progression of the tibia over the planted foot. This creates significant tension within the Achilles tendon, which translates to traction forces across the calcaneal . These forces are magnified during running and jumping.
Biomechanical factors that increase stress on the growth plate include excessive calf muscle tightness, which increases the baseline tension on the Achilles tendon throughout the gait cycle. Foot structure abnormalities such as pes planus (flat feet) or pes cavus (high arches) can alter the normal force distribution and increase stress concentration at the heel.
The also contributes to the biomechanical stress by creating a bowstring effect between the calcaneus and . During weight-bearing activities, tension in the plantar pulls on its calcaneal insertion, adding to the stress already created by Achilles tendon tension.
Poor footwear compounds the problem by failing to provide adequate shock absorption during heel strike, increasing the magnitude of impact forces transmitted through the growth plate. Hard playing surfaces similarly increase these impact forces, explaining why children playing on artificial turf or concrete surfaces often experience more severe symptoms.
Training errors, particularly rapid increases in activity intensity or duration, overwhelm the growth plate's adaptive capacity. The immature skeleton requires more gradual loading progressions compared to adult tissues, and violations of this principle commonly precipitate symptoms.
Research
What the studies show
The evidence for non-surgical treatments of heel and knee growth plate irritation is limited
A Cochrane review by Williams and colleagues (2026) of 10 randomised trials in 654 children, seven on Sever's disease, rated the evidence as mostly of low to very low certainty. Foot orthoses and heel lifts likely made little to no difference to pain or function compared with each other in the short term, and no harms were reported.
Simple, low-cost measures such as heel cups, supportive shoes and load changes are a sensible start, with custom orthoses kept for children who do not settle.
Williams CM, Krommes K, Paterson KL, et al. Non-surgical treatment for lower limb apophyseal injuries. Cochrane Database Syst Rev. 2026;7(7):CD015156. PMID: 42454655.
In one trial, children wearing custom orthoses reported less heel pain than those using heel lifts
In a randomised trial of 208 children aged 9 to 12 (Alfaro-Santafé and colleagues, Children, 2021), both custom polypropylene orthoses and off-the-shelf heel lifts reduced heel pain over 12 weeks, with greater improvement in the orthosis group. The authors work for a company that makes custom orthoses, and the later Cochrane review found little to no difference between the two.
Both options reduced pain; given the mixed evidence, I usually start with a heel cup or lift before considering custom orthoses.
Alfaro-Santafé J, Gómez-Bernal A, Lanuza-Cerzócimo C, et al. Effectiveness of Custom-Made Foot Orthoses vs. Heel-Lifts in Children with Calcaneal Apophysitis (Sever's Disease): A CONSORT-Compliant Randomized Trial. Children (Basel). 2021;8(11):963. PMID: 34828675.
Related Conditions
Conditions I commonly see alongside, or confused with, this one.
Getting back to it
Physiotherapy for Sever's disease, built around the activity you want back.
