What is the treatment for Severe's Disease (calcaneal apophysitis) in children?

Treatment of Sever's Disease (Calcaneal Apophysitis) in Children

The treatment of Sever's disease is conservative and should begin with a structured physical therapy program focused on heel cord stretching and ankle dorsiflexion strengthening, combined with custom-made foot orthoses or heel cups, which consistently resolves symptoms within 2 months and allows return to sport. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis clinically using specific physical examination tests, as radiographic findings are unreliable 3:

• One-leg heel standing test (100% sensitivity and specificity) 3
• Squeeze test of the heel (97% sensitivity, 100% specificity) 4, 3
• Direct palpation test (80% sensitivity, 100% specificity) 3

Do not rely on radiographic findings of sclerosis or fragmentation, as these appear in up to 50% of pain-free controls with high physical activity and represent normal growth patterns, not pathology 3.

First-Line Treatment (Tier 1)

Initiate the following interventions immediately upon diagnosis 1, 2:

Physical Therapy Program

• Heel cord (Achilles tendon) stretching exercises performed daily 1, 2
• Ankle dorsiflexion strengthening exercises 1, 2
• This combination allows return to sport within 2 months in all patients 2

Orthotic Devices

• Custom-made foot orthoses are superior to off-the-shelf options and should be the preferred choice, as they improve biomechanical alignment more effectively 1
• Soft Plastizote orthotics or heel cups can be used in 98% of patients 2
• For barefoot athletes (gymnastics, martial arts, dance), use either Tuli's Cheetah heel cup or Tuli's The X Brace, as both demonstrate equivalent efficacy at 3 months 5

Footwear Modification

• Recommend proper athletic shoes with adequate heel cushioning and support 2
• Ensure shoes accommodate orthotic devices without causing pressure points 1

Adjunctive Therapies (Tier 2)

Add these interventions for acute symptom management or when first-line treatment needs augmentation 1:

• NSAIDs (ibuprofen or naproxen) for acute pain relief during flare-ups 4, 1
• Cryotherapy (ice application) for 15-20 minutes after activity to reduce inflammation 4, 1
• Kinesio taping may enhance function, though pain relief is comparable to placebo 1
• Activity modification (not complete cessation) to reduce high-impact loading while maintaining fitness 4

Emerging Therapies (Tier 3)

Consider these options only if standard treatment fails after 2-3 months 1:

• Extracorporeal shockwave therapy (ESWT) shows promise but lacks robust evidence and should be reserved for refractory cases 1
• Short-term immobilization (walking boot) only for severe cases unresponsive to other measures 4

Common Pitfalls to Avoid

• Do not order radiographs routinely, as increased density and fragmentation occur in pain-free controls and do not guide treatment 3
• Do not use off-the-shelf orthoses as first-line treatment, as custom orthoses demonstrate superior biomechanical correction 1
• Do not recommend complete activity cessation, as all patients in successful treatment protocols maintained high physical activity levels and returned to sport within 2 months 2
• Do not assume bilateral involvement requires different treatment, as 61% of cases affect both heels and respond to the same conservative approach 2

Expected Outcomes and Follow-Up

• All patients should improve and return to sport within 2 months when treated with the structured physical therapy and orthotic program 2
• Pain during activities of daily living and sports should decrease significantly by 2 months 5
• Recurrence rate is low (approximately 2%) with proper treatment 2
• No long-term sequelae occur from Sever's disease, and symptoms resolve completely with skeletal maturity 4

Special Populations

For athletes with foot pronation (present in approximately 19% of cases), custom orthoses become even more critical to address the underlying biomechanical abnormality 2. For barefoot athletes, ensure compliance with brace wear during activity, as adherence rates of 64-82% are associated with successful outcomes 5.