Sever’s Disease in Children: Symptoms, Treatment and Returning to Sport
Has your child started complaining of pain at the back or underneath their heel, particularly after football, running, gymnastics or another active day? Perhaps they are limping after training, walking on their toes or finding that the pain settles with rest but returns as soon as they run or jump again.
One possible cause is Sever’s disease, a common growth-related heel condition in children and young teenagers. Despite its name, it is not a disease and it does not cause permanent damage. However, the symptoms can become frustrating and may continue to affect sport, PE and everyday activity if they are not managed appropriately.
An early assessment can confirm what is causing the heel pain, help your child understand what is happening and provide a realistic plan for staying active while their symptoms settle.
The short answer: what is Sever’s disease?
Sever’s disease, also known as calcaneal apophysitis, is irritation of the growth area at the back of a child’s heel bone. This is where the Achilles tendon attaches.
It commonly appears during a period of rapid growth and is often aggravated by repeated running, hopping and jumping. Pain is usually felt at the back or underside of the heel, becomes worse during or after activity and improves with rest.
Treatment usually involves temporarily adapting painful activities, improving strength and flexibility, reviewing footwear and gradually rebuilding sporting load. Complete rest is not always necessary, but a child should not be expected to repeatedly push through pain or continue if they are limping.
Why does Sever’s disease happen?
Children are not simply smaller adults. Their bones contain growth areas that are still developing, and these can temporarily become more sensitive to repeated load.
At the heel, the calf muscles connect to the heel bone through the Achilles tendon. During a growth spurt, the heel bone may grow more quickly than the surrounding muscles and tendons adapt. This can increase tension around the back of the heel.
Running, jumping and changing direction also place repeated impact through the foot. If there is a sudden increase in these activities, the developing heel may be asked to manage more load than it is currently ready to tolerate. Sever’s disease rarely has one single cause. Symptoms may be influenced by a combination of:
- A recent growth spurt
- A sudden increase in training or matches
- Returning to sport after a holiday, illness or injury
- Starting a new sport or attending a sports camp
- Regular running, jumping or hopping activities
- Playing for several teams or clubs
- Tightness around the calf and ankle
- Reduced strength or movement control
- Hard training surfaces
- Footwear that provides little cushioning or has become too small
- Insufficient sleep or recovery
It is the relationship between the child’s current capacity and their total activity that matters, not simply whether they play a particular sport. Read more about why children get sports injuries.
Who is most likely to develop Sever’s disease?
Sever’s disease usually affects growing children and young teenagers, often between approximately eight and fifteen years old. The exact age varies because children experience growth spurts at different times. It is particularly common in active children who participate in sports involving repeated running and jumping, including:
- Football and rugby
- Netball and basketball
- Athletics and running
- Gymnastics and trampolining
- Dance
- Tennis and other racket sports
- Hockey
It can affect one or both heels. A child does not have to be an elite athlete to develop it; school PE, playground activity and several recreational sports can create a significant overall weekly load.
What are the symptoms of Sever’s disease?
Common symptoms include:
- Pain at the back or underside of the heel
- Pain during or after running, jumping or hopping
- Symptoms that improve with rest
- Tenderness when the sides or back of the heel are gently squeezed
- Limping after sport or later in the day
- Walking on tiptoes to avoid loading the heel
- Difficulty keeping up with training or matches
- Tightness around the calf or ankle
- Pain in one or both heels
- Occasional mild swelling around the painful area
Some children only mention the pain after sport. Others may become reluctant to take part, change how they run or regularly ask to come off during a match. These changes are useful clues. Children do not always describe pain clearly, so changes in movement, enthusiasm or performance can be just as important as what they say.
Is all heel pain in children Sever’s disease?
No. Sever’s is a common cause of heel pain in growing children, but it is not the only possible explanation. Pain can also follow a direct knock, ankle injury, change in footwear, irritation of a tendon or another problem affecting the foot and heel. This is why it is better to assess the individual child than to rely on an online symptom list. A clinician will consider:
- Exactly where the pain is felt
- How and when it started
- Whether there was a specific injury
- Which activities aggravate it
- Whether the child is limping
- Recent growth and changes in activity
- Footwear and playing surface
- Calf and ankle movement
- Strength, balance and control through the whole leg
Does my child need an X-ray or scan?
Sever’s disease can usually be identified from the child’s history and a physical examination. An X-ray or scan is not normally needed when the symptoms and examination are typical. Further investigation may be considered if the pain followed significant trauma, the symptoms are unusual, the child cannot bear weight or the problem is not improving as expected. Imaging should be requested only when it is clinically appropriate. A scan is not usually required simply to confirm a straightforward case of Sever’s disease.
Can a child continue playing sport with Sever’s disease?
In many cases, yes, but their activity may need to be adjusted. Continuing some sport is not generally thought to damage the heel in the long term. However, repeatedly provoking significant pain can make symptoms harder to settle and may lead to limping, reduced confidence and loss of strength. A useful guide is that activity should not:
- Cause more than mild discomfort
- Make the child limp or noticeably change how they run
- Lead to pain that lasts for a long time after the session
- Cause worse pain later that day or the following morning
- Make everyday walking uncomfortable
If this is happening, their current activity level is probably too high. They may need fewer sessions, shorter playing time or a temporary break from the most aggravating running and jumping activities.
Swimming, cycling or suitable strength work may help them maintain fitness and involvement while reducing impact through the heel. The right alternative will depend on the child and should remain comfortable. For more severe symptoms, a short period away from high-impact activity may be appropriate. This should be a planned part of recovery rather than an open-ended instruction to stop everything.
How is Sever’s disease treated?
Treatment should be tailored to the child’s symptoms, sport and stage of development. It may include the following.
1. Adjusting activity The first step is often to identify which activities are aggravating the heel and temporarily reduce them. This might mean:
- Reducing the number of weekly training sessions
- Shortening playing or running time
- Avoiding repeated jumping drills for a period
- Taking a temporary break from matches while continuing modified training
- Spacing higher-impact sessions further apart
- Replacing some running with cycling or swimming
The aim is to find a level the heel can tolerate, not necessarily to remove all activity.
2. Improving strength and movement Pain can lead a child to use the affected leg less, which may reduce strength and make returning to sport more difficult. A rehabilitation programme may work on:
- Calf strength
- Hip and thigh strength
- Balance and single-leg control
- Ankle movement
- Landing and change-of-direction skills
- Running tolerance
- Sport-specific movement
Exercises should be appropriate for the individual child and should not significantly increase heel pain during or afterwards.
3. Addressing calf tightness Gentle calf mobility or stretching can be useful for some children. However, a stretch that directly compresses or aggravates the painful heel is unlikely to help. This is one reason generic online exercises are not always ideal. An assessment can establish which muscles and movements need attention and how the exercises should be progressed.
4. Reviewing footwear Supportive, comfortable footwear with suitable cushioning can make activity more comfortable. Check that school shoes, trainers and sports boots still fit, particularly following a growth spurt. Very flat, hard or worn-out shoes may aggravate symptoms. Some children find a cushioned heel cup or insole helpful, but this should complement rehabilitation and activity management rather than replace them. Children do not automatically need orthotics because they have Sever’s disease. Foot supports should be considered according to their individual assessment and symptoms.
5. Settling short-term discomfort An ice pack wrapped in a towel may help reduce soreness after activity. Do not place ice directly against the skin. Parents should speak to a pharmacist, GP or other qualified healthcare professional before giving medication to a child. Pain relief should not be used simply to hide symptoms so the child can continue pushing through an unsuitable level of activity.
6. Supporting recovery Children need enough sleep, food and recovery to support both sport and normal growth. Look at the whole week rather than focusing only on their main team. School PE, playground activity, club training, matches, running, dance and other sports all contribute to the demand on their body. During rapid growth, illness, stressful periods or poor sleep, a child may temporarily tolerate less activity than usual. This does not mean they are unfit or failing; their body may simply need more time to recover and adapt.
How should a child return to sport after Sever’s disease?
Return to sport should be gradual. Moving directly from rest to a full training week or match can quickly flare the symptoms again. A progression may include:
- Comfortable everyday walking and stairs
- Strength, balance and controlled movement exercises
- Short periods of easy running
- Running at different speeds and changing direction
- Controlled jumping, hopping and landing
- Modified training
- Full training
- Matches or competition
The child should be monitored during the activity, afterwards and the following morning. If heel pain increases or they begin to limp, reduce the amount or intensity and return to the previous comfortable level before building again. Rehabilitation is not only about becoming pain-free. The aim is to rebuild enough strength, confidence and sporting capacity to tolerate their normal activities.
How long does Sever’s disease last?
The timescale varies. Some children improve within weeks once the contributing factors are addressed, while others have symptoms that come and go over several months. Symptoms can return during another growth spurt or after a sudden increase in sport. This does not necessarily mean that something has been damaged again. It usually means the heel’s current capacity and activity need to be reviewed. Sever’s disease settles once the growth area at the heel has matured and does not usually cause problems in adult life.
How can future flare-ups be reduced?
It is not possible to prevent every episode, but the following can help:
- Build training up gradually after holidays, illness or injury
- Avoid suddenly adding several new sessions in the same week
- Include recovery days between demanding running and jumping sessions
- Maintain age-appropriate strength and movement training
- Check footwear regularly during periods of growth
- Vary training intensity instead of working at maximum effort every day
- Encourage the child to mention pain early
- Prioritise sleep, food and hydration
- Complete a gradual return before full matches or competition
A simple weekly calendar can be helpful. Include school sport as well as club activities so that demanding days and sudden increases are easier to spot.
When should you seek urgent medical advice for heel pain?
Contact NHS 111 or seek urgent medical care if your child:
- Has severe heel pain following an injury
- Cannot walk or put weight through the foot
- Cannot walk on tiptoes or climb stairs
- Heard a snap, pop or grinding noise when the pain began
- Has a foot or ankle that looks deformed
- Has significant swelling or bruising around the calf and ankle
- Has a hot, very swollen heel or feels generally unwell
Arrange a non-urgent professional assessment if the pain is getting worse, keeps returning, affects normal activities or has not improved after a couple of weeks of appropriate self-management.
Children’s heel pain support in Chandler’s Ford
At goPhysio, we help children and teenagers from Chandler’s Ford, Eastleigh, Southampton and Winchester manage growth-related pain, recover from injury and return confidently to sport.
Our assessment considers the young person’s heel pain alongside their growth, weekly activity, strength, movement, footwear, recovery and individual goals. Treatment may include education, activity guidance, hands-on treatment and an age-appropriate rehabilitation programme.
Connie and Sophie have completed additional training through Kids Back 2 Sport in the assessment and management of musculoskeletal conditions and sports injuries in children and teenagers.
If your child has recurring heel pain, is limping after sport or is struggling to take part in their usual activities, an early assessment can help establish the right next step. No GP referral is normally needed.
Find out more about physiotherapy and rehabilitation for children and teenagers or call our friendly team on 023 8025 3317.
Frequently asked questions
Is Sever’s disease really a disease? No. The name is misleading. Sever’s disease is a growth-related irritation at the back of the heel bone where the Achilles tendon attaches. It occurs while the heel is still developing and normally settles once growth is complete.
What does Sever’s disease pain feel like? Children often describe pain at the back or underneath the heel during or after running and jumping. The heel may be tender when squeezed, and some children limp or walk on their toes when symptoms are worse. Pain commonly improves with rest.
Can Sever’s disease affect both feet? Yes. It can affect one or both heels, although one side may be more painful than the other.
Does my child need to stop sport completely? Not always. Many children can continue a modified level of activity if their discomfort remains mild, they are not limping and symptoms settle soon afterwards. More painful cases may need a short break from high-impact sport. The plan should be based on the individual child’s symptoms.
Can physiotherapy help Sever’s disease? Yes. Physiotherapy or sports rehabilitation can help identify contributing factors, guide activity, improve strength and movement, advise on footwear and support a gradual return to sport.
Are heel cups or insoles helpful for Sever’s disease? Cushioned heel cups or insoles may make activity more comfortable for some children. They are not essential for every child and work best alongside appropriate activity management and rehabilitation. An assessment can help determine whether they are suitable.
Will Sever’s disease cause permanent damage? No. Sever’s disease is not normally associated with lasting damage and usually resolves once the heel’s growth area matures. Symptoms may recur during growth spurts, but this can usually be managed by reviewing activity and rehabilitation.
When should my child be assessed for heel pain? Arrange an assessment if the pain keeps returning, is getting worse, causes a limp, affects everyday walking or stops your child participating in normal activities. Seek urgent help following significant trauma, if your child cannot walk or if the foot or ankle looks deformed.
Severs Case Study
11 year old Joe came to see us complaining of a 3 month history or worsening heel pain. Joe was an extremely enthusiastic grass roots football player, training and playing 4 times a week. He’d recently started trampolining, which he loved! However, his heel pain was starting to get so severe, it was limiting his ability to play football, with him often limping off the pitch after 30 minutes.
When he came to see us, we found he had:
- A significant tender spot on both heels
- Naturally flattened arches in his feet
- Very tight, painful and tense calf muscles
Joe’s Management
The first steps we took, were to educate and reassure Joe about his condition. Sometimes this reassurance and understanding can be a turning point in recovery – it isn’t anything serious and it will get better!
We taught Joe’s parents a treatment protocol, called The Strickland Protocol. This is a set and timed programme of rest, muscle release and re-introducing activity and stretching.
Joe was advised a short period of complete rest from any impact activity (with the reassurance of the long term gains of this) with a gradual re-introduction. In Joe’s case, he was advised to stop trampolining and football completely for a few weeks, to try and help settle his symptoms as they were so severe. He started a daily treatment programme at home that his parents could help with – the aim of this was to reduce tension of calf muscles and start to reduce the pull on his heel bone. He also used ice on his heels and painkillers when necessary to ease the pain.
As his symptoms eased, stretching and foam rolling of his calf muscles was started and activity was carefully re-introduced.
It was concluded that trampolining was likely to have been one of the main triggers of his problem. Given that returning to football was his upmost priority, it was decided in conjunction with his parents that returning to trampolining was not advisable. Instead, Joe started swimming regularly. The benefits of this were that swimming would help maintain and improve his fitness, whilst being low impact and not irritating his heel pain. He gradually increased his football playing time, using pain levels as a guide and building on time gradually.
We also guided him on his choice of footwear – to wear supportive and cushioned trainers and school shoes and a really good, supportive football boot. Many of the football shoes that are now on the market look great but offer absolutely no cushioning or support. Particularly astro boots, which are like running around on a piece of cardboard! Joe opted for a traditional leather boot, which offered much more support. He was advised to minimise playing in astro boots as much as possible.
It has taken almost a year of guided management for Joe to return fully to normal activity free from pain. What has reassured Joe and his parents is that they understand what’s going on, have made the right informed choices to help recovery and enabled Joe to get back to doing what he loves, playing football! Much of this management was advice and education and Joe doing a regular programme of exercises himself at home.
Had he not had the right advice, Joe could have gone down a route of spiralling inactivity and developed secondary issues – not only physical but also psychological, if he couldn’t play football.
If you’d like some advice on managing Sever’s or any other growing pains, give us a call on 023 8025 3317.