Sever’s disease (aka calcaneal apophysitis) is a common cause of heel pain in growing children, especially those who are physically active (ages 8–14). It results from inflammation at the growth plate (apophysis) of the heel bone (calcaneus) due to repetitive stress.
When evaluating heel pain in this age group, you should consider a differential diagnosis to rule out other causes.
Orthopedic / Mechanical Causes
These are the most common and often activity-related:
- Plantar Fasciitis
- More common in adults, but can affect kids.
- Pain is plantar, especially on first steps in the morning.
- Unlike Sever’s, tenderness is more anterior and medial.
- Achilles Tendinopathy / Tendinitis
- Pain is posterior, directly over or just above the insertion.
- Common in athletes. May have swelling, crepitus.
- Retrocalcaneal Bursitis
- Inflammation of the bursa between Achilles and calcaneus.
- Localized swelling, more proximal than Sever’s.
- Calcaneal Stress Fracture
- Insidious onset, worse with weight-bearing.
- Diffuse heel tenderness, may have pain at rest.
- Hop test often positive.
- Heel Pad Contusion (“Stone Bruise”)
- Local trauma to the plantar heel fat pad.
- Usually acute, with a clear history of impact.
- Tarsal Coalition
- Abnormal fusion between tarsal bones.
- Presents with rigid flatfoot, limited subtalar motion.
- Often bilateral; may have pain after age 10.
Inflammatory / Rheumatologic
Typically bilateral, morning stiffness is a clue.
- Juvenile Idiopathic Arthritis (JIA)
- Pain with stiffness, systemic signs possible.
- Often bilateral and non-traumatic.
- Reactive Arthritis
- Can follow infection. May involve heel and other joints.
- Look for enthesitis (insertional inflammation).
Infectious Causes
Less common, but important to rule out in febrile or toxic kids.
- Calcaneal Osteomyelitis
- Systemic signs: fever, warmth, redness.
- Pain severe, not activity-related.
- Usually unilateral, MRI helpful for early detection.
- Septic Arthritis (of subtalar or ankle joint)
- Severe pain, often with fever.
- Decreased range of motion, child avoids weight-bearing.
Neurologic / Other Considerations
- Sural or Tibial Nerve Entrapment
- Burning, tingling, neuropathic pain.
- Tinel’s sign may be positive.
- Baxter’s Nerve Impingement
- Psychogenic Pain / Non-Organic
- Pain without physical findings. Consider especially in adolescents.
Distinguishing Features of Sever’s Disease:
| Feature | Sever’s Disease |
|---|---|
| Age Group | 8–14 years (growth spurt) |
| Onset | Gradual, related to activity |
| Pain Location | Posterior heel, at calcaneal apophysis |
| Key Finding | Pain with squeeze test (medial-lateral heel compression) |
| Imaging | Usually clinical dx; x-ray may show apophyseal fragmentation (but not diagnostic) |
| Management | Conservative (rest, ice, NSAIDs, heel cups) |
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