Sever's Disease (Calcaneal Apophysitis)
This 8-year-old boy with activity-related heel pain, localized tenderness, and negative radiographs most likely has Sever's disease (calcaneal apophysitis), which should be treated with activity modification, heel cups or insoles, stretching exercises, ice application, and NSAIDs if needed. 1, 2, 3
Clinical Diagnosis
The diagnosis is primarily clinical and does not require radiographic confirmation. 3, 4
- Sever's disease is the most common cause of heel pain in children aged 8-15 years, particularly in young athletes 1, 2, 3
- The condition occurs during peak growth spurts and is especially common in soccer players, which matches this patient's presentation 3, 4
- Perform the calcaneal squeeze test (compression of the heel from medial to lateral)—a positive test is highly diagnostic 1, 2, 4
- Tenderness localizes to the posterior heel at the Achilles insertion site 1, 3
- Radiographs are typically negative or show increased sclerosis and fragmentation of the calcaneal apophysis, but these findings do not confirm or exclude the diagnosis 2, 3
Treatment Protocol
Conservative management provides effective pain relief within 2 weeks to 2 months: 3, 5
- Heel cups or insoles are highly effective and allow continued sports participation—studies show significant pain reduction during physical activity without requiring activity cessation 5
- Ice application through a wet towel for 10-minute periods to reduce pain and inflammation 6, 3
- Stretching exercises for the calf muscles and Achilles tendon, performed 3-5 times daily 6, 3
- Activity modification (reduce high-impact activities temporarily, but complete rest is not necessary) 3, 4
- NSAIDs for pain relief if conservative measures are insufficient 2, 3
- In more severe cases, consider short-term immobilization with a walking boot 3, 4
Key Clinical Pearls
- The condition is self-limiting with no long-term sequelae 2, 4
- Patients can maintain high levels of physical activity when using appropriate insoles, contrary to traditional advice of complete activity restriction 5
- Assess for tight heel cords (Achilles tendon tightness), which is a common finding 3
- Obesity and high levels of physical activity are primary risk factors 2
Red Flags Requiring Further Evaluation
If the clinical presentation is atypical or symptoms persist beyond expected timeframes, obtain MRI to exclude other diagnoses: 7
- Constant pain at rest (not just with activity) 6
- Increasing swelling, redness, or systemic symptoms suggesting infection 6, 7
- Failure to improve after 6-8 weeks of appropriate conservative treatment 6
- Severe pain that prevents weight-bearing 1
Rare complications such as osteomyelitis have been reported, though MRI is only indicated for atypical presentations 7