Sever's Disease: Unilateral or Bilateral Presentation
Sever's disease (calcaneal apophysitis) can present as either unilateral or bilateral heel pain in physically active children and adolescents, with both presentations being well-documented in the clinical literature. 1, 2
Clinical Presentation Patterns
Sever's disease commonly manifests in two distinct patterns:
- Unilateral presentation: The condition frequently affects only one heel, particularly when there may be asymmetric biomechanical loading or sport-specific stress patterns 2
- Bilateral presentation: Many children present with pain in both heels simultaneously, reflecting the systemic nature of growth plate vulnerability during the pubertal growth spurt 2
The mean age of presentation is 10 years (range 7-15 years), occurring during periods of rapid skeletal growth when the calcaneal apophysis is most vulnerable to repetitive microtrauma 3
Clinical Significance of Laterality
The distinction between unilateral and bilateral presentation has important diagnostic implications:
- Unilateral cases with atypical features (such as night pain, absence of precipitating activity, localized swelling, or bony expansion) should raise suspicion for alternative diagnoses including benign or malignant tumors of the calcaneus, though these are extremely rare 3
- Bilateral presentation is more typical of classic overuse apophysitis and generally does not require additional workup beyond clinical examination if the presentation is otherwise typical 3
Diagnostic Approach
The diagnosis relies primarily on clinical examination regardless of laterality:
- Positive squeeze test (medial-lateral compression of the heel) is usually sufficient to establish diagnosis in both unilateral and bilateral cases 2
- Radiographic imaging is not routinely necessary but may show increased sclerosis and fragmentation of the calcaneal apophysis; imaging is more important in unilateral cases with atypical features to exclude other pathology 4, 3
Treatment Considerations
Conservative management is effective for both unilateral and bilateral presentations:
- First-line interventions include custom foot orthoses and physical therapy (heel cord stretching and dorsiflexion strengthening), which have shown superior outcomes compared to off-the-shelf options 1, 5
- Adjunctive therapies such as activity modification, ice, NSAIDs, and heel lifts provide symptomatic relief regardless of whether one or both heels are affected 1, 4
- The condition is self-limiting and resolves at skeletal maturity in both unilateral and bilateral cases, with no long-term sequelae 4, 3