What is Sever's Disease (Calcaneal Apophysitis)?
Sever's disease, also known as calcaneal apophysitis, is the most common cause of heel pain in adolescents, resulting from inflammation of the growth plate (apophysis) at the back of the heel bone (calcaneus). 1
Epidemiology and Population Affected
- Primarily affects children and adolescents aged 8-15 years, with peak incidence during periods of rapid growth 2
- Incidence is 3.7 per 1,000 registered patients in general practice, making it a common pediatric condition 3
- More prevalent in physically active children, particularly those participating in high-impact sports such as soccer, basketball, track, gymnastics, tennis, and ballet 4, 2
- Can occur in both sexes, though some studies show higher representation in girls 5
Pathophysiology
- Results from repetitive stress and traction forces on the calcaneal growth plate during periods of skeletal immaturity 6, 2
- The condition occurs when the open growth plate in the immature calcaneus is subjected to excessive pulling forces from the Achilles tendon during physical activity 2
- Repetitive microtrauma from running, jumping, and other high-impact activities leads to inflammation at the apophysis 4, 6
Clinical Presentation
- Heel pain that worsens with activity and improves with rest 6, 2
- Can present as unilateral or bilateral heel pain 6
- Pain typically located at the posterior and plantar aspects of the heel 4
- Positive "squeeze test" (medial-lateral compression of the heel) is the hallmark diagnostic finding on physical examination 6, 2
Risk Factors
- Limitation of ankle dorsiflexion is the most frequently studied intrinsic risk factor 7
- Obesity and high levels of physical activity are primary risk factors 2
- Foot malalignment, midfoot stiffness, and abnormal plantar pressures have been associated with the condition 7
- Age during puberty when growth plates are open 2
Prognosis
- Palliative treatment is almost always successful according to the American College of Foot and Ankle Surgeons 1
- No long-term effects or complications have been associated with Sever's disease 2
- The condition is self-limiting and resolves once the growth plate closes 6
- Most patients can return to sport within two months with appropriate conservative management 4
Diagnostic Approach
- Diagnosis is primarily clinical, based on history and physical examination 6, 2
- Positive squeeze test is usually sufficient to establish diagnosis 6
- Radiographic imaging (plain x-rays) may show increased sclerosis and fragmentation of the calcaneal apophysis, but imaging is mainly used to exclude other differential diagnoses rather than confirm Sever's disease 2