Sever's disease: heel pain in growing children

Sheffield Children's describes Sever's disease as pain and discomfort in the heel where a tendon attaches to the bone, sometimes with painful swelling. Kent Community Health calls it a painful inflammation of the heel's growth plate, and notes the heel bone is not usually fully developed until about 14.

The name is misleading. A NELFT parent guide says it is not actually a disease but a growth-related condition. It can affect one or both heels, and Kent says it is more common in boys.

It belongs to the same family of growth-plate overuse problems as pain below the kneecap in adolescents, a pattern covered on our Osgood-Schlatter page.

Cambridge University Hospitals explains the mechanism simply. During a spurt, bones grow quicker than muscles and tendons. The calf muscles must catch up and become tight, so the Achilles tendon pulls repeatedly on the heel bone, causing pain and swelling, especially with running and jumping.

Kent Community Health adds three contributors: repeated heel trauma from lots of running and pounding on hard surfaces, a tight Achilles tendon, and flat or high-arched feet. NELFT also lists poor footwear and tight calf muscles among risk factors.

Sheffield Children's says symptoms are often worse after a recent growth spurt, and may continue for several months.

The pattern is usually clear from the story: heel pain that comes on with sport and eases with rest. Leaflets from several NHS trusts describe the same features.

• Pain at the back or bottom of the heel, worse during or after running, jumping or sport.

• Tenderness, and sometimes mild swelling or redness, at the back of the heel.

• Pain when the heel is squeezed from the sides.

• Limping, or walking on tiptoes to avoid putting the heel down.

• Tight or weak calf muscles.

• In more severe cases, pain even when just walking around.

The leaflets describe Sever's disease from the history and the findings on the heel, and none of the ones read for this page describes a specific test. Whether a clinician orders any scan is a matter for individual assessment.

Not all heel pain in a child is Sever's. The NHS heel pain page says not to try to diagnose the cause yourself, and lists other possibilities including a broken heel or ruptured Achilles tendon after sudden injury, plantar fasciitis, Achilles tendonitis and bursitis.

See a GP, the NHS says, if pain is severe, getting worse or keeps coming back, has not improved after two weeks of home care, or comes with tingling or loss of feeling in the foot.

Treatment is practical and focuses on load. Sheffield Children's suggests rest from sports with lots of running or jumping, limiting sport to what is comfortable, ice for 10 to 15 minutes after activity, shock-absorbing insoles and calf stretches. Pain relief can be discussed with a pharmacist or GP.

Cambridge recommends low-impact activity such as swimming and cycling while the heel is very sore, elevating the leg after sport, and supportive footwear, noting that barefoot activity may hurt. Kent suggests shoes with a soft back or open backs, avoiding flat shoes, and a daily Achilles stretch held for 30 seconds and repeated three times.

Kent adds that shoe inserts called orthoses may be prescribed if there is an underlying foot problem such as flat feet, and that an anti-inflammatory such as ibuprofen may help if a pharmacist or doctor advises it.

The NELFT guide says to keep moving with activities that do not worsen symptoms, such as swimming, cycling or climbing. It suggests restarting one activity at a time, warming up and cooling down, and continuing calf stretches and strengthening. It treats a small amount of discomfort as acceptable if it does not worsen and settles soon after stopping.

As a useful check, NELFT says being able to hop, skip and jump quietly without pain is a sign of readiness. Once pain has gone, Cambridge says activity should be built up gradually.

Recovery is not always in a straight line. Sheffield says the problem may return with future growth spurts, so the stretching routine is worth keeping.

Sheffield says it may take several weeks or months for pain to resolve completely. NELFT says that ongoing pain over several years can be normal with the condition and that it can last up to three years while a child is growing. Cambridge says the heel will no longer be painful once the young person stops growing.

Kent says that once the pain has gone and the bone has stopped growing, you cannot get it again, and that the condition does not affect bone growth.

Most children with typical symptoms are managed by a GP, pharmacist, school physiotherapy advice or an NHS podiatry or paediatric physiotherapy service. Kent's podiatry service accepts self-referral, though services differ by area.

A private podiatrist or physiotherapist can assess footwear, calf flexibility and training load in more detail. The advice described in NHS leaflets is generally the same.