Sever's Apophysitis

Sever’s calcaneal apophysitis is a common of heel pain in children.  The 8 – 12 year old age group is most commonly affected.  Boys are affected a bit more than girls.

The pain associated with Sever’s calcaneal apophysitis is a the back of the heel, and can extend a bit to the bottom back of the heel.  It is worse during exercise activity and can linger afterward.

The pain represents a strain of the back portion (apophysis) of the heel bone (the calcaneus) as it is in the process of consolidating or fusing to the main portion of the heel bone.  Typically, the pull of the Achilles tendon on this portion of the heel bone while it is in the process of fusing to the main bone can potentially cause the strain and pain.  Because it is the pull of the Achilles tendon that is the aggravating factor, things that create more pulling tension from the Achilles onto the back portion of the heel bone can be contributing factors.

Possible Contributing Factors

• Tight calf muscle / Achilles tendon
• Footwear with inadequate heel lift (Vans, Sketchers, Canvas tennis shoes)
• Increased sports activities (particularly those with footwear without a raised heel, like football, baseball, soccer, and basketball)
• Overweight

The diagnosis is typically made by examination.  The classical examination findings in the at-risk age group are usually all that is needed.  X-Rays are not typically needed, but can be used to make sure that other, less common causes of heel pain are not present.

Treatment of Sever’s calcaneal apophysitis should include multiple non-surgical measures (see next page / section), used concurrently.  After resolution of the pain, attention should be paid to continuing measures like appropriate footwear, shoe inserts, and stretching exercises, in order to prevent recurrences.  Typically the condition resolves without using a cast, but in rare, non-responding cases, casts may be applied.  Surgery is never required.  The propensity to developing Sever’s calcaneal apophysitis typically resolves once the back portion of the heel bone fuses to the main portion at about 13 years of age in females and 14 years of age in males.

What can I do for myself?

 Wear supportive shoes with adequate heel lift.  Avoid flat shoes like Vans, Sketchers, and canvas tennis shoes.
 Add a good arch support or orthotic in your shoe.  The following is the recommended option: green Superfeet.
 Initially, also add a felt heel lift to both of your shoes (underneath the Superfeet).
 Avoid standing or walking barefoot or in unsupportive footwear like slippers or sandals.
 Perform calf stretching exercises for 30-60 seconds on each leg at least two times per day.  (Stand an arm’s length away from the wall, facing the wall. Lean into the wall, stepping forward with one leg, leaving the other leg planted back. The leg remaining back is the one being stretched. The leg being stretched should have the knee straight (locked) and the toes pointed straight at the wall. Stretch forward until tightness is felt in the calf. Hold this position without bouncing for a count of 30-60 seconds. Repeat the stretch for the opposite leg.)
 If overweight, weight loss is advised.  Please discuss this with your pediatrician.
 Modify your activities.  (Decrease the time that you stand, walk, or engage in vigorous exercise.  Convert impact exercise to non-impact exercise – cycling, swimming, and pool running are acceptable alternatives.)
 Use ice on the painful area for 15-20 minutes, at least 2-3 times per day -especially in the evening. (Option A – Fill a styrofoam or paper cup with water and freeze it. Peel back the leading edge of the cup before application. Massage the affected area for 15-20 minutes.  Option B – Fill a small 2-3 inch diameter plastic bottle with water and freeze it.  Roll your heel/arch back and forth over the bottle for 15- 20 minutes.  Option C – Rest the affected area on an ice pack for 15-20 minutes.  CAUTION: AVOID USING ICE WITH CIRCULATION OR SENSATION PROBLEMS.)
 Use an oral anti-inflammatory medication. (We recommend over-the-counter ibuprofen.  Please consult with your care provider for dosing recommendations.)
 See your doctor when you have failed to respond to the above regimen after three months of application.

What can my doctor add?

 Put you in a cast.  A cast is applied from below the knee to the toes typically for 3-6 weeks.  After the cast is removed, then treatment with the above recommendations is resumed.