Sever’s disease is not a disease – How to manage this injury in active children

Sever’s disease mostly affects active children between 9 and 15 years old. It involves the area where their Achilles tendon is attached to a part of their heel bone that is still growing at that stage. In this article, we discuss what predisposes children to getting Sever’s disease, the various ways of treating it while allowing the child to continue doing the sports or activities they love, and how to avoid the injury reoccurring once it has settled down. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

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In this article:

1. What is Sever’s disease?

2. Sever’s disease symptoms

3. Treatment options for Sever’s disease

4. How to prevent Sever’s disease from coming back

5. How we can help

We've also made a video about this:

What is Sever’s disease?

The name “Sever’s disease” sounds a bit scary and is, in my opinion, a bad choice of words. It is not something that a child can catch or that spreads between children. And the risk of getting this injury (because that is what it is) disappears totally after a certain age.

Sever’s disease is a type of injury called traction apophysitis. Let’s break down this term.

Children have growth plates in parts of their skeleton; this is where their bones grow and change shape. One of these is at the calcaneal apophysis, which is a normal part of the back of the heel bone in growing children to which the bottom end of the Achilles tendon is attached. The calcaneal apophysis becomes more pronounced at around age 7 to 9, and then, at age 15 to 17, the growth plate fuses, and the bone settles into the size and shape it’s going to be.

X-ray image showing the growth plate where the Achilles tendon attaches. From Kothari et. al (2023)

Traction refers to the pulling forces going through the Achilles tendon. During the age range mentioned above, too much traction on the tendon can irritate the calcaneal apophysis, making it sore and inflamed – hence the term apophysitis.

How long does Sever’s disease last? The good news is that this is a self-limiting condition, meaning that the problem goes away once the child grows out of the Sever’s disease age group and their calcaneal growth plate has fused.

What causes Sever’s disease? Because Sever’s disease is about traction going through the Achilles tendon, it is activity dependent. It occurs more in children who are active and less in children who are mostly sedentary.

The onset usually comes after sports or PE, especially when the child has been spending a lot of time on their feet anyway.

It also typically occurs when there’s a sudden increase in the load on the Achilles tendon, such as when children return to school after a summer holiday and start doing sport again, or at the start of the season for a specific sport.

A growth spurt can also predispose a child to getting Sever’s disease.

Sever’s disease symptoms

When a child has Sever’s, the heel is very tender right where the Achilles tendon attaches into the heel bone. Typically, children may be limping directly after an activity or later that day. Sometimes they don't even want to put any weight on their heel and walk on their tiptoes. The symptoms can be in one or both heels.

When we as physiotherapists assess a child with suspected Sever’s disease, we would look out for the typical profile for getting the injury, such as the age of the child, a possible recent growth spurt, activity levels, and exactly where the pain is.

We would also rule out other possible causes of the problem to make sure we are treating the right thing and then look at other things that could be linked with these symptoms, such as tightness of the tightness in the calf or foot muscles, reduced ankle mobility, and excessive pronation (the feet rolling inward excessively as the child walks or runs).

Treatment options for Sever’s disease

At Treat My Achilles we understand that most active children are eager to get back to playing their sport or doing their favourite activities.

So, educating the patient and their parents/carers should form part of any treatment plan for Sever’s disease.

The child needs to understand what is happening, why we're doing what we’re doing, and how we can then try and keep them active while still allowing their injury to heal.

They need to understand that we need to manage the symptoms right now so that they can get back to doing what they want to do later. However, this isn't a serious injury, and there are no signs that it sets the child up for Achilles tendon problems or any other heel problems later in life.

Relative rest

Relative rest – as opposed to total rest – is an approach that aims for the child to remain as active as possible while still allowing the injury to heal.

So, it’s important to have a discussion with the parents/carers and the child about prioritising which activities are the most important to the child and about modifying activities to calm down the pain to the extent that the child can walk normally again. This will then allow for other treatment options to be applied effectively. Here are some examples:

• Sporting activities that require a lot of running and jumping may be substituted for non-weightbearing sports such as cycling or swimming.

• Some children play the same sport on multiple teams, each with their own training sessions, e.g. football/soccer for their school as well as for a club. It may be useful to focus on playing for only one of those teams for now.

• It could be agreed with coaches that training sessions do not include as many sprinting or jumping drills and maybe focus on technique for now.

• Treadmill running in the gym could be substituted for spending some time on the cross-trainer.

• There may be non-sporting activities that require the child to spend a lot of time on their feet that they might want to consider dropping or reducing.

For the heel pain to calm down, the child will have to reduce their level of activity for some time.

Orthotics

Shoe inserts for Sever’s disease is an additional way of calming down the initial symptoms.

A gel heel cup (also called a heel wedge) is a cheap, off-the-shelf orthotic placed in the back of the shoe. The heel cups serve two purposes. It raises the heel slightly, which means that there’s less tension and traction on the Achilles tendon, and it cushions the heel bone.

Here are some heel wedge options on Amazon:

However, if over-pronation is a part of the problem, getting a podiatrist to prescribe custom-made insoles to also deal with that issue would be better.

In rare, severe cases that don’t want to calm down otherwise, sometimes the child’s foot is put in an orthopaedic boot for a brief time to immobilise the foot and take the weight off it until the pain has calmed down.

Anti-inflammatories

Unlike Achilles tendinopathy, inflammation does play a role in the pain caused by Sever’s disease. So, non-steroidal anti-inflammatory drugs may be useful to calm the pain down.

Most physiotherapists are not trained to prescribe medicines, so have a discussion with a medical practitioner who is trained about whether this medication is appropriate for your child, given any other conditions they might have or other medication they might be taking.

One thing to consider is talking to that practitioner about whether it's worth taking it just when the child is doing activity, taking it little and often when it's painful, or taking it as a course over a few days to settle down the pain. And this may differ depending on the specific case and also how severe the problem is.

If the pain is severe, anti-inflammatory medication may be useful. Speak to your doctor about how to use it safely.

Ice

Another good way to settle the symptoms down is to ice the injured area. You can buy reusable ice packs online, but if you’re making your own one or using something like a bag of frozen peas, be sure to wrap a cloth around it so that the skin doesn’t get ice burns.

An ice pack is especially useful just before and then again just after exercise, whether it’s sports exercise or rehab exercises. Just before is to calm down the pain and irritation so that you’re able to do the exercise. The exercise increases your circulation, which carries away irritants from the injured area and brings in new nutrients. And the icing afterwards is to calm things down yet again.

Increasing mobility in the problem area

If, when diagnosing the problem, we find that tight calf muscles is an issue, it could be useful to do exercises to increase the range of movement of the foot.

At Treat My Achilles, we are wary of prescribing calf stretches for injuries that involve the Achilles tendon, because these push an already irritated tendon closer to the heel bone, which often irritate it even more during the early stages. However, many practitioners prescribe stretches for Sever’s disease, and we do add them in, when we think it will help, in the later stages of recovery. There isn’t any research to say whether this is a good idea or not, so the jury is out on this one.

Doing calf stretches during the early stage, when the heel is still very sensitive, often makes the pain worse.

So, what else can you do to help relieve some of the tightness in that calf?

Massaging the calf muscle can help. This can be done by a therapist, or you can do it yourself at home, using a foam roller, massage ball, or massage gun.

Foam rolling can help to reduce tightness in the calf muscles.

Strength training exercises for Sever’s disease

Which muscles need to be strengthened will depend on each specific case.

The most common weakness is in the muscles for dorsiflexion (those that tilt the foot upwards towards the shin bone).

However, weakness in one muscle group often has a knock-on effect on other muscles. So, it could be that the muscles for plantar flexion (pointing the toes like a ballet dancer) need to be strengthened and maybe also the muscles that prevent over-pronation.

Also, nobody uses only their Achilles tendons and calf muscles when they run, jump, and land; there’s a whole kinetic chain of muscles up the legs and to the buttocks that are involved. If any of these are weaker than what they should be, they need to be strengthened because their weakness could have an adverse effect on the calf muscles and Achilles tendon.

How to prevent Sever’s disease from coming back

Because this is an overuse injury brought on by too much and/or too intense activity, managing the child’s training programme is the most important part of preventing Sever’s disease from coming back after the initial bout has calmed down. Training should be looked at in terms of volume as well as intensity.

Training volume

Like I pointed out earlier in the article, the risk of Sever’s disease happening is higher when a child has a spike in activity at the start of a school term or a sports season. It could also happen when the type of activity changes suddenly, e.g. from cross-country running to doing lots of hill sprints.

A useful rule-of-thumb for running activities is that the volume shouldn’t increase by more than 10% per week. This is based on research that focused on running, but it has been shown that anything that jumps more than 30% can help to irritate injuries over a period of time.

Coaches are in the ideal position to help a child safely ease back into their sport.

If a coach or the school’s PE teacher, rather than the parents/carers, controls the child’s training programme, it may be a good idea to talk to the them about ways to keep the child’s training volume increases within that 10% range, for example by having them sit out some activities or reducing the time they spend on certain activities.

Pain or discomfort during or after activity should never exceed a score of 3 out of 10, with zero meaning all is good and 10 meaning intense pain.

Warning signs that the training volume is still too high include more pain or discomfort in a given week than the previous week, more “bad” days than “good” days, and an increase in the time it takes to recover after a large amount of activity.

If these warning signs are not heeded, a child can easily fall into the “boom-and-bust” cycle of overtraining, where they have to take a total break from training due to the Sever’s disease flaring up again, and then they go back to training at full tilt when the pain has calmed down, only to have to sit things out once more after the injury has reappeared yet again.

Training intensity

Low-intensity activities would be those where the child can have a normal conversation while doing it, moderate would be where they have to catch their breath every so often, and high intensity would be where they can’t get out more than a few words at a time.

A good rule-of-thumb here is 80% low to moderate intensity and 20% high intensity per week.

Again, this is a good basis for a talk with a coach about which activities the child should take part in and which ones they should sit out.

Rest days are important after high-intensity training sessions, and/or before an important race or match. These are also an opportunity to take stock of the situation. “How is my pain level compared to last week?”

Worn-out shoes can increase the risk of Sever's disease.

Other ways to avoid a recurrence

• Take care of the child’s general health, including a healthy diet, proper hydration, and enough sleep.

• Where possible, train on softer, sprung surfaces rather than hard floors.

• Don’t train in worn-out shoes. The rule of thumb for running shoes is that they should be replaced every 500 miles or 6 months, whichever comes first.

• If a sport is played barefoot, look at possibly doing some of the training, as well as warm-ups and cool-downs, in shoes.

• Is the child’s warm-up routine, including how they stretch, correct? Our sister site, Sports Injury Physio, has a good article about the components of a good warm-up routine and one about how to use static stretches correctly when warming up.

• Something that is being discussed in medical circles but that hasn’t been researched properly is whether specializing in a single sport from an early age, exerting the same forces on the child’s body over and over again, could predispose the child to getting Sever’s disease and other injuries.

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.

References

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