Calcaneal Apophysitis

Posted June 7th, 2010

Calcaneal apophysitis, also known as Sever’s disease, is an inflammation of the growth plates in the heel. It commonly affects athletes between ages 7 and 15. Dr. Sever described this condition in 1912 as severe pain at heel-strike and usually affecting the active male.
The calcaneal epiphysis begins a process of maturing and closing at puberty. Repeated micro-trauma disturbs this slow maturation of the bone and the result is pain. On x-ray, the calcaneal epiphysis resembles a crescent moon. Trauma can cause a fracturing of the delicate tips at either end of the crescent. Sever’s disease is self-limiting. Recovery will take place on its own with rest. The condition is not known to cause long-term disability. Recovery usually takes place in six to eight weeks of rest, however, recurrence is common if the problem is not properly treated.
A lot of research has taken place since 1912. Once thought to be a condition that affects bone growth called osteochondrosis, today, calcaneal apohysitis is generally agreed to be a mechanical overuse injury to the growth plate. Though the prognosis of Sever’s disease is benign, I become concerned with the discouragement to exercise that the pain causes. A young athlete will hesitate to go back to exercise if the result is pain.
A most recent British study focused on 3,805 injured young soccer players over the course of two seasons. Sever’s disease accounted for 5 percent of the injuries, with 11 being the mean age. The problem is common, and literature is replete with studies demonstrating that the common cause is repetitive micro-trauma to the epiphysis at heel strike, resulting in fragmentation of bone and delayed maturation.
The primary symptom of Sever’s disease is pain during or following activity that is severe enough to cause a cessation of athletics. The condition can affect anyone in puberty, but we most often see it between ages 10 and 15 in both girls and boys.
Pain at heel strike that is unrelenting until the foot is put to rest and activity stopped is the main concern. X-ray will usually show fragmentation of bone. Palpation of the heel with digital pressure applied from both sides will cause pain. A diagnosis can be made without x-ray, but I recommend diagnostic imaging to rule out other possible bone involvement including bone cyst.
Studies have shown that the athlete who hyperpronates will be more susceptible to calcaneal apohysitis. The compensatory motions that occur in the foot that hyperpronates will cause the heel to roll inward and this will put an excessive amount of stress and trauma on the inside plantar aspect of the calcaneal epiphysis.
Poor shoe choice has been the predominate predisposing factor in injuring the calcaneal epiphysis. Since 85 percent of the population hyperpronates, I feel that choosing a shoe that helps control biomechanical pathology will help prevent the onset of calcaneal apohysitis and its associated pain.
Today, athletic shoes are very sophisticated. They are the result of years of cumulative research in the field of biomechanics. Motion studies have repeatedly demonstrated the cause and affect of the shoe on foot function. The prevention of abnormal motion or the creation of excessive pronation begins with the shoe. Footgear can be the primary cause of calcaneal apophysitis, or the first line of defense in treating the problem.
When an adolescent complains of heel pain when exercising we must think of calcaneal apophysitis. Though the problem responds to rest and is thought to be self-limiting, I feel that it discourages the young athlete from exercising and for this reason should be aggressively treated. Rest alone is not the answer to the problem. Clinical studies performed over the past three decades have aptly and repeatedly demonstrated that Sever’s disease is most often seen in the active young athlete who hyperpronates. Standard treatment of Sever’s disease must then include establishing a diagnosis with a careful clinical history and exam. X-ray should be included to rule out other disease processes and solidify the clinical findings.
A biomechanical exam that includes a gait study and shoe exam should be performed. When hyperpronation is present it should be treated with appropriate orthotics and recommendations for athletic shoes as well as street footwear. Too often we see the athlete wearing inappropriate shoes for everyday use. Faulty biomechanics occurs with every step, regardless of activity, and for treatment to be affective, hyperpronation must be prevented during the active day, not just in the athletic activity. Successful treatment is highly affective and these young athletes can continue sports with no problem.

Rob Rinaldi DPM

Robert Rinaldi is a board-certified podiatrist and podiatric surgeon at the Gifford Medical Center in Randolph, VT. He is a fellow and a founding member of the American Academy of Podiatric Sports Medicine, and a podiatric consultant to the Dartmouth College track and cross-country teams. He is a former nationally ranked long-distance runner, having competed in 25 world-class marathons. You can reach him at Gifford Sports Medicine and Surgery Clinics in Randolph, VT, or at the Sharon Health Clinic in Sharon, VT, 802-728-2490 or 802-763-8000 or at