Sever's Disease
Radiology Cases in Pediatric Emergency Medicine
Volume 1, Case 20
Erin A. Nakano, MD
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
     A 10 year male presents to the acute care clinic with 
a 3 month history of intermittent right heel pain.  There 
was no inciting specific injury that he could recall.  He 
first noticed the pain while playing basketball.  The heel 
pain would worsen with running and playing sports, 
especially basketball and soccer.  The longer he 
played, the worse the pain would become.  There was 
no history of fever or any other bone or joint complaints.
     Exam:  T37.0, P81, R24, BP 126/78.  He was of an 
average size for age, alert, active, in no discomfort.  
The extremities were without swelling or deformities.  
There was no erythema or evidence of external 
infection over the heels.  There was moderate 
tenderness to compression over the right posterior heel 
at the insertion of the achilles tendon (calcaneal 
apophysis).  Both ankles and all other joints were 
normal.  He ambulated normally and he could jump up 
and down without difficulty or pain.
     Radiographs of the right foot were obtained.

View radiographs:  Oblique view.

Lateral view.

     The main point of interest in this case is the heel at 
the achilles tendon insertion.  An AP view of the foot 
was excluded from this case since it was normal and 
the heel was not visible due to superimposition of other 
     The oblique view shows crescent-shaped lucencies 
over the posterior calcaneus in the area of concern.  
These lucencies represent the growth plate viewed 
obliquely.  The lateral view shows the physis in a truly 
lateral view.  These radiographs of the foot are normal.
Discussion and Teaching Points:
     The most common cause of heel pain in adolescents 
is calcaneal apophysitis (also known as Sever's 
disease).  Radiographs of the heel are felt to be normal 
as they were in this patient, although some authors 
have disagreed with this point.
     An apophysis is a growth plate that does not 
contribute to the length of the bone.  The achilles 
tendon inserts in the calcaneal apophysis.  The patellar 
tendon inserts into the tibial tuberosity apophysis.  The 
growth plate is weak and subject to micro-injury if there 
is excessive force placed on the growth plate.  
     Developmental changes of the calcaneal apophysis 
include the onset of ossification at an average age of 8 
years in boys and 6 years in girls.  For 2 to 3 years 
thereafter, the ossification appears irregular and there 
may be deep narrow clefts segmenting the apophysis.
     Similar to Osgood-Schlatter disease (tibial tuberosity 
apophysitis), Sever's disease (calcaneal apophysitis) is 
an overuse syndrome frequently seen in adolescents in 
their growth spurt, who are physically active.  The most 
common sports found to exacerbate the heel pain are 
soccer, basketball, gymnastics, and baseball.  Sports 
that involve sprinting with cleated shoes result in the 
most force exerted by the ankle flexors on the calcaneal 
apophysis.  Examination of the heel typically reveals 
tenderness to compression of the medial and lateral 
sides of the calcaneal apophysis and decreased 
dorsiflexion of the ankle without any swelling or 
erythema.  Findings are bilateral in about 60% of 
patients.  Radiographs are generally not necessary.
     Heel pain in this disorder is felt to be secondary to 
repetitive microtrauma where the achilles tendon inserts 
into the apophysis.  Successful treatments have 
included foam heel pads to elevate the heel and 
reduce the stretch of the achilles tendon.  Physical 
therapy with gastocnemius-soleus stretching and 
dorsiflexion strengthening has been useful as well.  
Discontinuing aggravating activities is probably the 
simplest treatment.  Instructing patients to rest when 
the pain worsens allows them to continue in their sports 
without the need for orthopedic restrictions.  For 
persistent pain unresponsive to these therapies, short 
leg walking casts have been used.

     1.  Meehan P.  Heel Pain.  In:  Morrissy RT (ed).  
Lovell and Winters Pediatric Orthopedics, 3rd edition.  
Philadelphia, J.B. Lippincott Co., 1990, pp. 1001-1002.
     2.  Micheli LJ, Ireland ML.  Prevention and 
Management of Calcaneal Apophysitis in Children:  An 
Overuse Syndrome.  Journal of Pediatric Orthopedics 
     3.  Tolo VT, Wood B.  Pediatric Orthopaedics in 
Primary Care.  Baltimore, Williams and Wilkins, 1993, 
p. 229.

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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine