Sever's disease: load and activity in children and adolescents

Sever's disease, also called calcaneal apophysitis, is an irritation of the growth plate at the back of the heel bone, where the Achilles tendon attaches [1][2]. The condition is most common between 8 and 15 years and is rare in older teenagers, because the heel stops growing at around the age of 15. The pain affects both heels in about two thirds of cases [1]. What the condition is and how it feels is described on the page about Sever's disease. This article is about load and activity.

The condition is caused by overloading of the tendon attachment, most often repeated pulling from the Achilles tendon on the weaker structures of the growth plate [2]. Children who run and jump a lot have a higher risk, and the symptoms often start after a new sports season, a new sport or periods of extra loading [1].

Better Health Channel in Victoria, Australia, also mentions growth spurts, increased training volume, intensity or frequency, changing sport or season, shoes with a low heel, running barefoot and flip-flops as factors that may increase the risk [4]. The source describes the cause as multifactorial and not fully known [4].

NHI describes that the child should be relieved from the activity that triggers or worsens the pain, and that loading within the pain limit is acceptable. Alternative activities that load the heels less, such as cycling or swimming, can be kept [1]. Lægehåndbogen recommends alternative exercise instead of running, and points out that it is the pain that sets the limit for what the child can do [2].

Better Health Channel describes a stepwise approach. Painful activities are limited for a short period during a flare-up, and the load is then increased gradually. The source emphasises that loading is important for the tendon, heel bone and growth plate, and that activity should therefore be dosed rather than avoided completely. It also recommends paying attention to transitions to new sports, changes in surface and footwear, and keeping a log of pain, activity and growth [4].

The sources do not agree on stretching. NHI and Lægehåndbogen describe stretching of the calf muscles as useful [1][2], while Better Health Channel recommends avoiding stretching and eccentric exercises in the initial phase [4]. What suits the individual child can be clarified with a practitioner.

NHI mentions rest between training sessions, a warm-up adapted to the sport, variety in training and good fit of footwear, especially around the heel, as preventive measures. With marked pain, an ice pack on the heel after activity can be used, and pain relief is usually not necessary [1].

Well-fitting heel cups under both heels can be used for a period. They lift the heel slightly, relieve the Achilles tendon and give shock absorption, and are used only in activities where this is needed [1]. Lægehåndbogen describes raising the heel in the same way [2].

A systematic review of treatment for Sever's disease found limited evidence for heel lifts and orthoses. Heel lifts were almost always used together with other measures, and in some studies orthoses gave better short-term pain relief than heel lifts. The quality of the studies was low [3].

The prognosis is good. NHI states that the symptoms can last from one to four years for some, but that they resolve on their own [1]. Lægehåndbogen describes the condition as harmless, and that it disappears when growth is complete [2]. Most can continue or resume their sport, and activity can often be maintained at a lower level during treatment [1].

Better Health Channel writes that the pain often eases within one to two weeks with adaptation, but that it can take longer. The growth plate matures over about two years, and flare-ups can occur in that period [4].

The diagnosis is made mainly from the history and a clinical examination, and imaging is usually unnecessary [1][2]. Lægehåndbogen points out that referral or other diagnoses should be considered if the pain persists, causes symptoms at rest, wakes the child at night or causes marked swelling [2].

Better Health Channel mentions that other causes of heel pain, such as a heel fracture after a fall from height, stress fracture and bursitis, may need to be ruled out, and that a GP should be contacted for persistent pain, swelling or uncertainty [4].

A chiropractor can examine the heel, look at what triggers the pain and, together with the child and parents, plan how activity and load can be adapted. At our clinics, Solemaids insoles can be considered for children and adolescents with Sever's disease. Read more about chiropractic.

Does the child have to stop sport with Sever's disease?

The sources do not describe complete rest. Activities that trigger or worsen the pain are reduced, loading within the pain limit is acceptable, and alternative activities can be used for periods [1][2][4].

What can the child do instead of running and jumping?

NHI mentions cycling and swimming as alternative activities that load the heels less [1].

How long does Sever's disease last?

The symptoms can last one to four years for some, but resolve on their own. Lægehåndbogen describes that the condition disappears when growth is complete [1][2].

Do heel lifts or heel cups help?

Heel cups and heel raises are used to relieve the Achilles tendon and absorb shock [1][2]. A systematic review found limited evidence for heel lifts and orthoses, and the studies were of low quality [3].

When should the child see a doctor?

With pain that persists, symptoms at rest, pain that wakes the child at night or marked swelling, further assessment should be considered [2][4].

Foot analysis in children is a separate topic and is described in its own article. You can find more articles in the overview of articles.

This article was written by Dr.Dropin Fysikalske and is based on the sources listed below. It gives general information and does not replace an examination by a healthcare professional.

The websites were accessed and read on 22 October 2026.

1. Betennelse i hælsenefestet (Severs sykdom) (Inflammation at the heel tendon attachment, Sever's disease). NHI.no, based on Legehåndboka. Last updated 13 January 2023. Link

2. Kold S, Larsen EP. Apofysitis calcanei. Lægehåndbogen, sundhed.dk. Professionally updated 10 June 2025. Link

3. James AM, Williams CM, Haines TP. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review. J Foot Ankle Res. 2013;6:16. Link

4. Sever's disease. Better Health Channel, Victoria State Government, Australia. Reviewed 2021. Link