Sever’s disease in children: stopping sport?

Has your child just been diagnosed with Sever’s disease, or do you have doubts about it because of pain in his heel after playing sports?

Having been in this situation as well as being a physiotherapist, I found that there was very little information on the web that was both precise and helpful/concrete on the subject, on what to do.

So here I am, writing this article based on three things:

• my knowledge of physiotherapy;
• my documentary research in international medical literature;
• my experience as the mother of an 8-year-old boy with this diagnosis.

♻️ Last updated: September 4, 2024.
👩‍⚖️ Declaration of financial interests: amazon affiliate link. My complete declaration of financial interests is in legal mentions.
Written by Nelly Darbois, physiotherapist and scientific editor

How can you be sure it’s Sever’s disease?

Sever’s disease (also known as calcaneal apophysitis) is a heel pain that occurs mainly in growing children and adolescents, generally between the ages of 8 and 15.

It occurs when the growth plate at the back of the heel, where the Achilles tendon attaches to the calcaneus bone, becomes irritated or inflamed.

A simple clinical examination and questioning may suffice for the diagnosis to be made by the attending physician.

X-rays are sometimes performed if there is any doubt about the diagnosis, particularly to rule out a fracture.

The symptoms are highly characteristic.

• Heel pain (generally at the back of the heel), especially during physical activity (running, jumping, prolonged walking)
• Sensitivity or pain on pressure on the heel, 2/3 cm above the heel
• Lameness or difficulty walking properly, especially after sports activities
• Stiffness in the heel or ankle (especially after a period of rest)
• Slight swelling around the heel
• Bilateral pain (affecting both heels in 6 out of 10 children, although sometimes only one is affected)
• First appears between the ages of 8 and 15.

Illustration with a concrete case (my 8 year old son): as there are several cases of chronic rheumatic diseases in the family (spondylitis and rheumatoid arthritis), we took a blood sample to quantify the CRP, and rule out a rheumatic origin. We didn’t do any other tests, apart from the attending physician’s clinical examination.

Source : Smith 2024

What causes it?

Here are the characteristics often (but not always) found in children diagnosed with Sever’s disease:

• intense or excessive sporting activity involving repetitive running and jumping, such as basketball, soccer, track and field, running and gymnastics;
• High BMI ;
• limited ankle range of motion, especially in dorsal flexion (when the tip of the foot is raised);
• poorly cushioned or worn sports shoes,
• deformities of the lower limb varum knee, varus forefoot, hollow foot or flat foot.

Personal note : in our case, it appeared over the summer, when our son gained 2 cm in 1 months. He did a lot of trampolining that summer, and the first major pain appeared after walking for several hours in a museum. The pain would then appear after running or playing soccer with his friends.

Source : Nieto Gil 2023

What treatment should I use?

There are few studies evaluating how Sever’s disease evolves over time, with or without treatment. There are even fewer studies evaluating the efficacy of one treatment versus another.

That’s why, for this section, I’m also relying on the results of studies on Osgood-Schlatter disease, which is basically the same thing but in the knee, and which is better studied.

Here is the number of scientific publications on Osgood-Schlatter disease:

and the number of scientific publications on Sever’s disease:

Basically, the treatment of Sever’s disease is based on 2 things:

• adapting the level of physical activity to the pain: with a very conservative approach in which all weight-bearing physical activity is banned for at least a month (sports, but also leisure activities), or a more liberal approach in which the child’s pain level is adapted, so that he or she can continue to play sports, even in a club;
• relieve pain by stretching, physiotherapy, splinting, wearing insoles, physical therapy or even medication. Diet has no direct impact.

Now let’s go into a little more detail.

Personal note : our GP recommended: 1/ no medication; 2/ strict sports rest (except cycling, swimming) for at least 1 month, then gradual resumption: no sports activities requiring running or jumping, even at school or playtime; 3/ stretching. We only followed point 1/. I’ll explain why and what we did in the next section.

Resting

In Sever’s disease, pain is increased or triggered when the child is on his or her feet, especially when walking, running or jumping for long periods.

The main course of treatment is therefore relative rest, for at least 1 month (or much longer). With great differences in recommendations, as illustrated by 2 different sources:

On the other hand, it is possible to recommend a less stringent approach:

✅🛑 If your child isn’t particularly bothered by the idea of completely stopping sport at school and on the side, then it seems suitable to stop for at least a month, then gradually resume.

During this rest period, walking is possible, as well as physical activities with friends, as long as they don’t revive the pain too much.

Cycling and swimming are also suitable, as it’s important to keep children active for their current and future health!

Your doctor can prescribe a sports exemption for school.

✅🟧 If your child finds stopping sport a tragedy and is inconsolable at the thought, then another approach is possible.

It consists in letting your child practice as much as he or she wants, and trusting him or her to stop or reduce the frequency or intensity if it’s unbearable…

This choice is not irresponsible: it can be based on the fact that there is no guarantee that rest will lead to recovery. It is not uncommon for pain to return after several months’ (or even years’) absence from sport.

Similarly, I’ll come back to this later, but there is no strong evidence in favor of complications or sequelae in children who continue to play strenuous sports.

Of course, the best thing is to be able to discuss this with your child’s doctor or physiotherapist, and with your child, in order to consider the various possible scenarios in your case.

Note that some orthopedic surgeons may go so far as to prescribe a cast or walking boot, to force the child to rest. The child must then use a wheelchair or crutches.

Here again, there ‘ s little evidence of any benefit , apart from relieving pain that would otherwise go unnoticed.

Personal note: we chose option 2: let our child dose. Stopping athletics and sports at school, which he had just resumed after a 2-month vacation, was quite unthinkable for him. We decided to focus on the pain rather than the sadness… Re-evaluating over time whether this was the best option.

Stretching

You’ll probably read on the right and left that calf stretching (triceps surral and gastronemius muscles), in dorsal flexion, is to be adopted in cases of Sever’s disease.

Here are the advantages and disadvantages of adopting them, alone at home or at your physiotherapist’s.

✅ Advantages :

• the Achilles tendon exerts significant traction on the heel bone, especially during children’s rapid growth. Stretching the muscle connected to this tendon can, in theory, help to lengthen shortened muscles and tendons, thus reducing the pressure exerted on the painful area;
• they enable the ankle to regain its flexibility (if it has become stiff), as stiffness can cause discomfort.

❌ Disadvantages:

• no clinical trial has shown that children who practice regularly have less pain or can resume sport as they wish more quickly;
• Stretching is difficult for most people, especially children;
• Stretching the musculature can also lead to renewed stress and inflammation.

Personal note: as our son has no particular stiffness in his ankle at rest, and continues to put a lot of strain on his ankle’s range of motion, we didn’t feel it was appropriate to introduce stretching.

Splint, sole, heel-piece

In the few studies on the subject, wearing a splint, insole or heel cup seems to reduce pain. Regardless of the type of orthosis used!

Here are the different types tested in the studies:

• prefabricated heel pads made from silicone gel (consider gluing them to the shoe with strong glue, otherwise they’ll slip off and be useless),
• Reinforced soles in the heel (you’ll probably have to go up a shoe size to be able to fit it in);
• rigid thermoplastic heel pads ;
• prefabricated calf-stretching orthoses;
• custom-made foot orthotics for calf stretching ;
• neoprene ankle brace with integrated heel pad;
• Elastic foot splint with integrated silicone band on the heel strap.

The insoles provide cushioning and therefore reduce the force of impact on the calcaneus when striking the heel, the bone that causes problems in Sever’s disease.

In practice: if you want to test this, I’d advise you to opt first for the easiest thing to test: a simple standard heel cup or sole, bought in a sports store or on the internet (see an example on amazon).

You can also find this type of heel-piece at Décathlon.

Personal note: for the time being, we didn’t want him to wear insoles, so that he’d feel the pain and slow down a bit… We do, however, make sure he wears sports sneakers all the time (even for walking), and in which he feels comfortable.

Source: Hernandez-Lucas, 2014

Medicines

Non-steroidal anti-inflammatory drugs (NSAIDs) are sometimes prescribed to relieve pain, but have no curative action (= do not cure). The same applies to paracetamol and other analgesics.

Source : Smith 2024

Personal note: we don’t give our son any painkillers, so that he doses the effort. What’s more, at rest (sitting or lying down) the pain disappears.

Physiotherapy treatment

Physiotherapy sessions are sometimes prescribed. Here again, recommendations and practices vary widely.

Here’s what you can read on a sports doctor’s website, which I mentioned earlier

These statements are based solely on the personal opinion of this doctor. There’s nothing to suggest that subjecting a child to a minimum of 30 minutes of passive stretching at the physiotherapist’s twice a week, in addition to exercises at home, is beneficial.

I don’t agree with such recommendations, whichseem to apply to ALL children, including those who are fed up with so much care.

Given the uncertainty of results, requiring children to attend this type of session seems disproportionate.

Some physiotherapists will take a more stretching and muscle-strengthening approach to the calf, aiming to gradually relieve stress on the joint.

Others take a more pain-relieving approach: kinesiotaping, shock waves, cryotherapy, massage.

In all cases, your physiotherapist can be your first port of call when it comes to adapting your child’s physical activity.

There are no studies available that would allow us to recommend one of these approaches, or even physical therapy versus doing nothing.

Personal note: my son has 2 parents who are physiotherapists, and our approach simply consisted in explaining the pathology to him, and the possible attitudes to adopt (don’t hesitate to stop activity if too much pain, don’t try to test his pain by doing certain exercises or movements).

What sports are allowed?

The least restrictive sports for Sever’s disease are the following:

• swimming, synchronized swimming, water polo
• riding ;
• cycling, mountain biking ;
• archery ;
• rowing, kayaking.

And on the other hand, the most restrictive :

• all team sports such as soccer, handball, basketball, volleyball, etc.
• athletics, particularly endurance ;
• trampoline ;
• gymnastics.

Now, there aren’t really any sports that are absolutely forbidden. It very much depends on the doctors you come across, your child’s pain, and the approach you want to take.

To illustrate: when our son’s illness struck, he was about to embark on his second year of athletics, a sport he is passionate about. He’d already done a year of swimming, which he’d stopped in the middle of the year for lack of interest, and was already doing a lot of cycling on a daily basis without getting carried away. As it was unthinkable for him to stop taking part in athletics at club and school, we initially authorized him to continue with athletics, adapting to the water course, and keeping ping pong or water polo as a wildcard in case athletics became impracticable…

How long does the pain or discomfort last?

There are many different evolutions, and no reliable data on the average duration of discomfort in children with Sever’s disease.

Best case scenario : a single painful attack leading to pain during sport for 1 or 2 months, with no recurrence and no need to stop sport.

Worst-case scenario : almost continuous pain when walking (and even more so when running or jumping) from the age of 8 to 15, leading to the child having to stop all sport for months or even years, and sometimes having to walk on crutches or use a wheelchair.

Chances are your child will fall somewhere between these 2 extremes.

Note that even in the worst cases, the pain eventually disappears at the end of growth, around age 15 or even earlier (although other types of pain, such as tendinopathy, may take over…).

Illustration: I’ll be updating this article as things progress in our case.

Are there any possible complications?

There are few complications described in the scientific literature, or even in groups of parents whose children are concerned.

The following are sometimes described (very rarely, and even anecdotally):

• foot complex regional pain syndrome ;
• plantar fasciitis;
• osteomyelitis (bone infection requiring antibiotics)

Important point: we have no empirical evidence to suggest that continuing sport or physical activity puts you at greater risk of developing any of these complications.

***

That’s all I wanted to say on the subject! Any questions or comments? See you in comments!