Sever’s Disease in Children: Know Why Your Child’s Heel Hurt

Heel pain in children who participate in sports is not always caused by an injury.

One common explanation is Sever’s disease, a growth-related condition affecting the developing heel.

It commonly occurs in physically active children during periods of growth.

Running, jumping and repeated sprinting can aggravate the pain, sometimes making it difficult to continue sports comfortably.

Although the name may sound concerning, Sever’s disease is generally temporary.

Appropriate activity modification, symptom management and individualized physiotherapy can help most children return to their usual activities.

What Is Sever’s Disease?

Sever’s disease, medically known as calcaneal apophysitis, affects the developing growth area at the back of the heel bone (calcaneus).

The heel contains a developing area of bone called the calcaneal apophysis.

This is where the Achilles tendon attaches and transfers force from the calf muscles to the heel.

During childhood, this area is still maturing.

Repeated loading during running, jumping and other high-impact activities is thought to irritate the developing apophysis, resulting in heel pain and tenderness.

The exact mechanism is not fully understood.

Repetitive traction and loading around the growth area are considered important contributors, rather than a single injury or infection.

Despite its name, Sever’s disease is not an infection.

It is a common growth-related musculoskeletal condition seen in active children and adolescents. (Fares et al., 2021)

At What Age Does Sever’s Disease Occur?

Sever’s disease most commonly affects children between approximately 8 and 15 years of age.

The exact age varies according to growth and skeletal maturity.

It is frequently seen during periods of rapid growth, when the heel apophysis is still developing.

Children involved in the following activities may experience symptoms:

• Football and basketball.
• Tennis and athletics.
• Gymnastics and dance.
• Running and jumping sports.
• Other activities involving repeated acceleration and landing.

The condition is not restricted to competitive athletes.

Children participating in recreational sports or suddenly increasing their physical activity can also develop symptoms. (Kothari et al., 2023)

Why Does Heel Pain Develop During Sports?

The Achilles tendon connects the calf muscles to the back of the heel.

It plays an important role in walking, running, jumping and pushing the body forward.

During sports, the calf muscles repeatedly contract and transfer force through the Achilles tendon.

In growing children, repeated loading around the developing heel apophysis may contribute to irritation and pain.

Activities that can aggravate symptoms include:

• Sprinting and accelerating.
• Repeated jumping and landing.
• Running uphill.
• Frequent changes in direction.
• Playing sports on hard surfaces.
• Sudden increases in training intensity.

Pain usually develops gradually rather than after one specific injury.

A child may initially experience discomfort only after sports.

As symptoms become more noticeable, pain may occur during training, walking or climbing stairs.

What Are the Common Signs and Symptoms?

The most characteristic symptom is pain around the back or sides of the heel, particularly during or after physical activity.

Parents may notice:

• Heel pain during running: Discomfort increases when the child runs or sprints.
• Pain while jumping: Repeated jumping and landing may aggravate symptoms.
• Tenderness around the heel: Pressing the back or sides of the heel may reproduce pain.
• Limping: Some children walk on their toes or avoid putting full pressure on the painful heel.
• Pain after sports: Symptoms may become more noticeable after training or competition.
• Calf tightness: The calf muscles may feel tight, and ankle movement may be restricted.
• Pain in both heels: The condition can affect one or both feet.

Some children walk comfortably at the beginning of the day but experience pain after sports or prolonged activity.

Symptoms can fluctuate depending on training intensity, recovery time and growth.

What Causes Sever’s Disease?

There is no single confirmed cause in every child. Research has identified several factors associated with calcaneal apophysitis.

1. Growth and skeletal development

The heel apophysis is still developing during childhood. Repeated loading during this stage may make the area more vulnerable to irritation.

2. Repetitive running and jumping

Sports involving frequent running, jumping and landing place repeated demands on the heel. Insufficient recovery between demanding activities may aggravate symptoms.

3. Limited ankle dorsiflexion

Ankle dorsiflexion is the movement that brings the foot upwards towards the shin.

Restricted dorsiflexion, which may be associated with calf muscle tightness, is one of the factors studied in children with Sever’s disease.

4. Sudden changes in training

Increasing training frequency, duration or intensity too quickly can increase the physical demands placed on the heel.

5. Foot structure and loading patterns

Foot alignment, midfoot movement and plantar pressure have been investigated as possible associated factors.

However, evidence is not consistent enough to conclude that flat feet, high arches or one particular foot posture causes Sever’s disease.

A systematic review of risk factors identified limited ankle dorsiflexion as one of the most frequently studied associations, while also highlighting disagreements between studies. (Nieto-Gil et al., 2023)

How Is Sever’s Disease Diagnosed?

Diagnosis is usually based on the child’s symptoms, activity history and physical examination.

A doctor or physiotherapist may ask about:

• When the heel pain started.
• Whether symptoms increase during or after sports.
• Recent growth spurts or training changes.
• Whether one or both heels are affected.
• Whether walking, running or climbing stairs has become difficult.

The physical examination may include:

• Checking tenderness around the back of the heel.
• Assessing ankle dorsiflexion with the knee straight and bent.
• Examining calf flexibility and Achilles tendon function.
• Checking foot and ankle movement.
• Observing walking, running and standing.
• Performing a gentle heel squeeze test to assess whether compression reproduces the familiar pain.

The heel squeeze test can support the clinical assessment, but it does not confirm Sever’s disease on its own.

Does Your Child Need an X-ray?

X-rays are not routinely necessary when the symptoms and examination are typical of Sever’s disease.

Changes in the appearance of the heel growth area can also occur in children without symptoms.

Therefore, an X-ray finding alone cannot establish the diagnosis.

Imaging may be recommended when pain is unusual, severe, persistent or associated with an injury, or when another condition needs to be investigated. (Kothari et al., 2023)

Other Conditions That Can Cause Heel Pain

Not every case of heel pain in a child is Sever’s disease. Other conditions may produce similar symptoms.

Condition	How it may differ
Achilles tendinopathy	Pain is more directly associated with the Achilles tendon.
Plantar fasciitis	Pain is usually felt along the bottom of the heel or arch.
Calcaneal stress fracture	Pain may progressively worsen with weight-bearing and repetitive loading.
Heel bone infection	May cause significant pain, warmth, swelling or fever.
Inflammatory joint condition	May involve morning stiffness, swelling or pain in other joints.

A proper assessment helps distinguish these conditions and prevents persistent heel pain from being incorrectly attributed to a growth-related problem.

How Can Pediatric Physiotherapy Help?

Pediatric physiotherapy aims to reduce heel pain, improve lower-limb function and help children return to sports comfortably.

Treatment should be based on the child’s symptoms, calf flexibility, ankle movement, strength, activity requirements and functional limitations.

1. Activity Modification

The first step is to reduce activities that repeatedly aggravate the heel.

A physiotherapist may recommend:

• Temporarily reducing running and jumping.
• Limiting repeated sprinting and high-impact drills.
• Avoiding painful training sessions.
• Including recovery days between demanding activities.
• Maintaining comfortable low-impact activities such as swimming or cycling.

Complete inactivity is not necessary for every child. The aim is to find an activity level that does not repeatedly worsen symptoms.

2. Calf Stretching

Calf muscle tightness and restricted ankle movement may contribute to increased loading around the heel.

When assessment identifies restricted flexibility, a physiotherapist may introduce gentle stretching exercises for the gastrocnemius and soleus muscles.

Examples include:

• Standing calf stretch with the knee straight.
• Soleus stretch with the knee slightly bent.
• Gentle ankle mobility exercises.

Stretching should be comfortable and should not produce sharp pain at the heel.

3. Progressive Strengthening

Strengthening helps improve the calf muscles’ ability to manage the demands of walking, running and jumping.

Depending on symptoms, exercises may include:

• Seated calf raises.
• Supported standing calf raises.
• Resistance-band ankle movements.
• Controlled heel raises.
• Progressive single-leg calf strengthening.

The exercise difficulty should increase gradually as pain and movement tolerance improve.

4. Foot and Ankle Strengthening

The foot and ankle help absorb and transfer forces during running and landing.

If an assessment identifies reduced foot or ankle strength or control, exercises may include:

• Short-foot exercises.
• Controlled toe raises.
• Single-leg balance.
• Ankle resistance-band exercises.
• Balance activities on stable surfaces.

These exercises are not necessary for every child. They should address specific limitations identified during assessment.

5. Balance and Movement Training

Children participating in sports need to control their bodies during acceleration, landing and changes in direction.

Physiotherapy may include:

• Single-leg balance activities.
• Controlled step-ups and step-downs.
• Progressive hopping drills.
• Landing technique practice.
• Sport-specific movement training.

These activities should be introduced progressively when the child’s symptoms allow them.

6. Footwear and Heel Support

Appropriate footwear can improve comfort and reduce pressure-related discomfort during activity.

Depending on the assessment, a physiotherapist or doctor may recommend:

• Well-fitting sports shoes.
• Shoes with adequate cushioning.
• Soft heel cups or heel lifts.
• Custom foot orthoses when clinically indicated.

Heel cups and lifts may provide symptom relief for some children, but they do not replace activity modification and progressive rehabilitation.

A 2024 systematic review examined eight randomized controlled studies involving conservative treatments such as insoles, exercises, taping and foot orthoses.

The findings support conservative management, but the studies do not establish one treatment as universally best for every child. (Hernandez-Lucas et al., 2024)

How Does a Physiotherapist Assess a Child’s Movement?

Treatment should not focus only on the painful heel.

A physiotherapist also considers how the entire lower limb manages physical activity.

The assessment may include:

• Gait analysis: Observing whether the child avoids heel contact or changes walking patterns.
• Ankle mobility: Measuring dorsiflexion with the knee straight and bent.
• Calf strength: Checking the ability to perform controlled heel raises.
• Balance: Assessing single-leg stability and weight distribution.
• Functional movement: Observing squatting, hopping, jumping and landing when tolerated.
• Training demands: Understanding sports participation, session frequency and recovery periods.

These findings help the physiotherapist identify which movements or physical demands need attention.

Can Your Child Continue Playing Sports?

Not every child with Sever’s disease needs to stop all physical activity.

The decision depends on pain severity and how well the heel tolerates exercise.

If symptoms are mild, the child may be able to continue modified activities that do not significantly increase pain.

However, reduce or temporarily stop activities when:

• Heel pain increases during training.
• The child starts limping or walking on their toes to avoid pressure.
• Running and jumping become uncomfortable.
• Pain continues after exercise or affects normal walking.
• Symptoms become progressively worse.

Swimming and cycling may be suitable alternatives because they generally place less impact on the heel.

Children should not be encouraged to push through significant pain to finish a training session.

How Long Does Sever’s Disease Take to Heal?

Recovery varies depending on the child’s growth, activity levels and symptom severity.

Some children improve within a few weeks, while others experience recurring symptoms over several months.

The condition may flare up during growth spurts or when sports training increases.

Sever’s disease usually resolves once the heel growth plate matures and closes. It does not generally cause permanent damage or long-term limitations.

However, symptoms can return while the growth plate is still developing, particularly if high-impact activities are resumed too quickly.

When Should Parents Seek Medical Attention?

Although Sever’s disease is generally manageable, persistent heel pain should not automatically be attributed to growth.

Arrange a medical assessment if your child experiences:

• Heel pain that continues despite reducing sports activities.
• Persistent limping or difficulty walking.
• Significant swelling around the heel.
• Pain that occurs at rest or regularly wakes the child at night.
• Pain following a fall, collision or sudden injury.
• Symptoms that keep returning or progressively worsen.

Seek urgent medical attention if your child has severe heel pain with fever, redness, warmth or significant swelling, or suddenly becomes unable to bear weight.

These symptoms may indicate infection, fracture or another condition requiring prompt assessment.

What Can Parents Do at Home?

Parents can support recovery through a few practical changes.

• Modify sports activity: Reduce running, jumping and other movements that consistently trigger pain.
• Choose supportive footwear: Ensure sports shoes fit properly and provide comfortable cushioning.
• Try cold therapy: Apply a cold pack wrapped in a towel for around 10-15 minutes after activity if it helps relieve discomfort.
• Encourage comfortable movement: Swimming or cycling may help maintain activity when tolerated.
• Follow the exercise program: Perform calf stretching and strengthening exercises as recommended by the physiotherapist.
• Allow recovery time: Avoid repeated high-impact training when symptoms are active.
• Monitor symptoms: Pay attention to limping, changes in walking and pain during everyday activities.

Avoid forceful calf stretching or painful heel raises.

If symptoms worsen with an exercise, stop and discuss the response with the treating physiotherapist.

Conclusion

Sever’s disease is a common growth-related cause of heel pain in physically active children.

Repeated loading around the developing heel apophysis can cause tenderness and discomfort, particularly during running, jumping and sports.

Although the condition can temporarily affect a child’s ability to participate in physical activities, most children improve with appropriate activity modification, supportive footwear and gradual rehabilitation.

Pediatric physiotherapy can help improve calf flexibility, lower-limb strength, ankle control and movement confidence while guiding a safe return to sports.

The important thing for parents to remember is that children should not have to push through significant heel pain to stay active.

Recognizing symptoms early and adjusting activity appropriately can make recovery more manageable.

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