KIDS INJURIES: HEEL PAIN
That painful growth injury that makes your child limp on and off the field.
with Doug James – intraining Running Injury Clinic Physiotherapist & Podiatrist
READ Doug’s article below and download the “ACTION PLAN for Heel Pain” at the bottom to give you and your child a quick guide to help you tackle Heel Pain in kids.
Calcaneal Apophysitis (formerly known as “Sever’s Disease”)
Calcaneal Apophysitis is one of the most common injuries in early adolescents, though its name is probably unfamiliar to most who would refer to it as “Sever’s Disease”, or more simply “Sever’s”. It is pain felt on the back of the heel bone (calcaneus) around the base of the Achilles tendon in some young people sometime between the age of 7-15 years old [1-5] (the age ranges vary by source but usually falls within 1-2 years of the upper and lower limits). This injury was first identified in 1912 by Dr James Sever, after whom the injury was named.
What’s in a name?
While the term “Sever’s Disease” is commonly used today, it is falling out of favour with the medical world. In the past, a medical condition or disease would often be named after the person that studied and identified it. Injury names become increasingly difficult to pronounce when a team of people lay claim to the identification of a condition such as the wordy “Sinding-Larsen-Johansson Syndrome” (a knee pain condition in teenagers), or Klippel–Trénaunay–Weber Syndrome (a blood vessel disorder).
The favoured and current approach is to refer to these “diseases” with a more accurate pathophysiology (problematic process) title so as to better describe the “where and what” of the condition. This move also aims to replace using inaccurate and vague terms such as “syndrome” and “disease” as these names can carry a certain stigma.
So, what is a Calcaneal Apophysitis?
The individual components within the name “Calcaneal Apophysitis” gives a clue as to its nature and location. The Calcaneus is the heel bone. An Apophysis is a bone protuberance or small lump formed on the bone where tendons or ligaments attach, in this case, it is on the back part of the bone where the Achilles tendon attaches. Lastly, the term “-itis” refers to an irritation or inflammation of an attachment site on the heel bone. Put together, these terms describe irritation of the back of the heel bone.
How does it develop?
There are a few theories about the factors that lead to how and why Calcaneal Apophysitis develops and what the actual source of pain is. One theory is that the Apophysis becomes painful from the Achilles tendon applying repeated or continuous tension to it .
Another thought is that the underlying Calcaneus bone (not simply the apophysis) that may be the source of pain. The human skeleton grows primarily from ossification centres. These are the foundations from which bones lengthen and expand making us taller (and wider). The calcaneus has two ossification centres that are located in the middle and rear of the bone, which eventually disappears once the bone has finished growing – usually in the early teenage years. The rear ossification centre is thought to become painful as it undergoes stress from tension. Clinically, it’s not uncommon to observe tenderness in the lower part of the Achilles tendon as a standalone presentation, or along with the bony heel pain, again possibly due to tension, or possibly trauma. In more severe cases the growth plate can become fragmented (see image 1).
What is the source of the tension?
Calcaneal Apophysitis is often observed in young people that have had a recent growth spurt (but not always). When the shin bones grow (resulting in increased overall height), the muscles and tendons need time to elongate to the optimum length for the newly lengthened legs. In the weeks (and sometimes months) following a growth spurt, adolescents may complain of calf muscle tightness due to the relative shortness of their calf muscles. This muscle tightness can exert a constant strain on the Achilles tendon and the Calcaneal Apophysis which serves as its anchor point and may irritate the Calcaneal Ossification Centre .
The Achilles tendon is also subjected to increased tension in flat-soled, and low heel drop shoes. Adolescents with heel pain should be encouraged to avoid walking around in flat shoes, thongs, or bare feet. Calcaneal Apophysitis is fairly common in active young people [1-5]– notably those playing one of the football codes. Many football boots have a low heel drop (minimal height difference between heel and forefoot) which increases pressure on the calf muscle, Achilles tendon and heel. Playing football involves bursts of sprinting which is another activity known to irritate the injury.
Management of the injury
Just as there is little consensus as to the exact nature of the injury, there is no agreement on a universal fix. This may be due to the fact that there are a number of different contributing factors in each individual presentation. As such, each case needs to be assessed and managed uniquely. The most common theme in management strategies is finding a balance of rest and sport/running within an acceptable level of discomfort, as rest alone doesn’t lead to faster improvement . In cases where pain levels are severe, abstaining from any pain provoking activity becomes necessary, though this is thankfully usually rare.
Footwear factors can play a major role in the successful management of the injury, and being able to modify aspects such a heel drop by using firm heel lifts, or cushioned heel cups can be beneficial. Research has also examined whether orthotics play a role in managing Calcaneal Apophysitis though the results are inconclusive  (possibly due to the limitations of research that requires a standardised orthotic be used in all patients). Addressing muscle tightness issues when present is also important for managing pain levels, and expediting recovery time. This can take the form of calf muscle massage, ankle mobilisation, and where appropriate – a targeted stretching program.
How long does the injury last?
It can be difficult to predict how long Calcaneal Apophysitis will last. In a majority of cases, there is a resolution of symptoms soon after the sporting season finishes. In a smaller number of cases, the pain can persist for up to a year, or longer in an unlucky few.
Imaging such as X-rays are not always necessary, but in more severe cases can be helpful to assess any derangement of the Calcaneal growth plate which is often associated with greater pain and longer recovery times.
When to seek treatment?
It is useful to have an assessment when heel pain symptoms first present (which is often in the first few weeks of a new sports season or following a significant growth spurt). Learning ways to manage the pain is crucial to helping settle the symptoms and improve quality of life, while hopefully allowing a continuation of physical activity. An assessment of the patient’s footwear, walking and running biomechanics, and muscle testing can help to develop a personalised treatment and successful treatment approach.
For a thorough assessment of adolescent heel pain, contact the intraining running injury clinic for an appointment to see a Podiatrist or Physiotherapist who can assess the injury and design a custom management plan.
Doug James – intraining Running Injury Clinic Physiotherapist & Podiatrist
- Uvelli, K. O., Neher, J. O., & Safranek, S. (2017). Treatment for Calcaneal Apophysitis. American Family Physician, 96(2), 126–127.
- James, A. M. M., Williams, C. M. P., & Haines, T. P. (2013). “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (sever’s disease): A systematic review” Journal of Foot and Ankle Research, 6(1), 16. https://doi.org/10.1186/1757-1146-6-16
- James, A., Williams, C., & Haines, T. (2013). Contributing factors in children who present with calcaneal apophysitis. Journal of Science and Medicine in Sport, 16, e26–e26. https://doi.org/10.1016/j.jsams.2013.10.064
- James, A. M., Williams, C. M., Luscombe, M., Hunter, R., & Haines, T. P. (2015). Factors Associated with Pain Severity in Children with Calcaneal Apophysitis (Sever Disease). The Journal of Pediatrics, 167(2), 455–459. https://doi.org/10.1016/j.jpeds.2015.04.053
- Williams, C. (2016). Wait and see, heel raise and eccentric exercise may be equally effective treatments for children with calcaneal apophysitis [commentary]. Journal of Physiotherapy, 62(2), 112–112. https://doi.org/10.1016/j.jphys.2015.12.003
Image 1: Sourced on 07.10.20 from https://radiopaedia.org/cases/sever-disease-6