Calcaneal apophysitis (Sever’s disease) is the commonest cause of heel pain in children and adolescents. It is an overuse injury caused by micro-fractures of the calcaneal apophysis at the site of attachment of the Achilles tendon.

It typically presents between 8-14 years. It is rare after this age as the calcaneal apophysis should fuse around 15 years. It is commoner in more active children, especially in weight-bearing sports e.g. running, dancing.


  • Incidence: 50.00 cases per 100,000 person-years
  • Peak incidence: 1-5 years
  • Sex ratio: more common in males 2:1
Condition Relative
Plantar fasciitis40.00
Achilles tendon disorders4.60
Calcaneal apophysitis (Sever disease) 1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

It presents with gradual onset heel pain which may be worse on standing and with activity. It is typically relieved by rest. It can be unilateral but is often bilateral (60% of cases) . Medial and lateral compression of the heel i.e ‘squeezing’ causes pain.

Patients may also have:
  • Pain on ankle dorsiflexion, especially on active toe raise
  • Mild heel swelling
  • Calcaneal enlargement
    • Only if chronic which is rare


It is usually a clinical diagnosis.

Investigations are largely used to exclude alternative diagnoses. These include:
  • X-ray to exclude fractures or tumour
    • X-rays findings may be normal or non-specific sclerosis.
  • CT/MRI can be used to exclude osteomyelitis.

Red flag features suggestive of an alternative diagnosis include significant rest pain, night pain or large swelling.


Treatment is largely conservative
  • Avoid sports for 2 months
    • Can consider continuing non-weight bearing activities
  • Physiotherapy including stretching exercises
  • Footwear advice
  • Heel pads
  • Consider NSAIDs in severe cases
  • Rarely needs an orthopaedic referral