Sever's disease

What it is

How a Cochrane review describes it

This page takes its description from a 2026 Cochrane review of lower-limb apophyseal injuries in children and adolescents¹. An apophysis is a bony bump where a muscle attaches that grows from its own growth plate. A growth plate is a layer of cartilage where a growing bone grows. The review calls the heel form calcaneal apophysitis and notes that Sever’s disease is its eponym¹.

The review’s plain-language summary describes apophysitis as growth-plate pain that children sometimes develop during puberty¹. It says the pain usually comes from repeated stress irritating the growth plate over time, not from a single event¹. The review describes these injuries in children and adolescents as non-infectious¹. It states that they do not result in bone destruction¹.

The review describes the common symptoms in children as pain at the apophysis that is worse with activity and eases with rest¹. It says the conditions are commonly identified through questions and a physical examination, and that medical imaging is rarely needed¹.

The bone and tendon involved

The calcaneal apophysis sits at the back of the calcaneus (heel bone) and develops in early childhood⁴. The Achilles tendon attaches to the middle of the bone’s back surface⁵. One study read 568 CT scans, detailed pictures built from X-rays, of Australian children⁴. The apophysis began joining the rest of the bone at a mean age of 11.2 years in girls and 13.3 in boys⁴.

The Cochrane review notes that the precise cause of apophyseal injuries is unknown¹. Many authors propose a pull from tight tendons and muscles during rapid growth¹. The review says research indicates this is unlikely for the heel¹. It says rapid growth and weight change in these years are considered the main contributing factor¹.

Who it affects

How often studies found it

A 2013 systematic review, a study that searches for all the research on a question, gives the usual ages as 8 to 15⁶. Incidence counts new cases in a group over a set time.

Group studied	What was found
Patients aged 6 to 17 at 34 general practices, over three years	61 children, an incidence of 3.7 per 1,000 registered patients2
Hospital records of patients aged 6 to 17 in Istanbul	A four-year incidence of 0.35%, or 74 of 20,967 patients7
Ten years of records for 612 players at a German youth soccer academy	22 cases, or 0.36 per 100 athletes per year, at a mean age of 11.8 years8

The general-practice authors wrote that the actual incidence may be higher, because their inclusion criteria were strict². The Cochrane review notes there are no data to work out point prevalence, the share of children who have it at one time¹.

Boys, girls and both heels

A 2023 review searched PubMed for studies in children and found 1,362 cases, of which 973 (71.4%) were in boys⁹. In the Istanbul hospital records, 59 of 74 young patients were male⁷.

A 2023 systematic review of risk factors noted that earlier studies disagreed about the split between the sexes³. It found no statistically significant difference itself³. Its authors wrote that the sports habits of boys and girls may influence the split³.

Of the 1,362 reported cases, 589 (43.2%) affected both heels and 433 (31.8%) one heel⁹. In the Istanbul records, 46 of 74 children (62%) had symptoms in both heels⁷.

Where studies disagree

The 2023 systematic review covered 11 observational studies, which watch what happens without assigning anything, with 1,265 participants under 18³. The studies disagreed about which factors are risk factors, associated factors or consequences³.

• Activity level: some authors in the review concluded that more frequent and intense activity raises the risk³. Others concluded that activity level does not affect it, and one that low activity raises it³. In 430 athletic children aged 6 to 14, it was more likely in those with fewer or shorter training sessions¹⁰. The Cochrane review states that children who routinely play sport are at higher risk of pain at an apophysis¹.
• Body mass: two studies in the review found no significant difference in body mass index between groups³. A third concluded that children with the condition have a higher one than healthy children³.
• Ankle range: three studies in the review linked the condition with limited dorsiflexion, pulling the foot up toward the shin³. A fourth found a large ankle range of movement³. The authors suggested that differing ways of measuring may explain the disagreement³.

What studies found

How it changes over time

The Cochrane review notes that apophysitis often gets better by itself as children grow and their growth plates close¹. Its plain-language summary says growth-plate pain is usually short-term with limited impact on a child’s life¹. It adds that the pain can sometimes lead children to limp, do less sport or be less active¹. The review also states that pain from these conditions often goes on for up to 12 months or more¹. It concludes that some children report effects on their quality of life and long-term consequences¹.

Two studies report how long children had pain before they were seen^7,11:

• 74 boys and girls in the Istanbul records: an average of 12.7 weeks from first complaints to the clinic⁷. The range was 2 to 108 weeks⁷.
• Children enrolled in one trial: an average of 10.8 months of pain before seeking care¹¹.

Across 22 cases at the German youth soccer academy, players took a mean of 60.7 days to return to play⁸. Seventeen cases took longer than four weeks, and none took a week or less⁸. Three of the 22 cases were recurrences, and return took longer after those: 181.0 days against 41.7⁸.

What X-rays and scans show

Studies of heel X-rays in children do not agree on whether the condition shows^12,13.

Children studied	What was found
61 patients with the condition, seen one after another	70 of 71 sets of foot X-rays were considered normal12
50 boys with the condition and 30 healthy boys	Two surgeons reading the X-rays without clinical information agreed only slightly14
392 healthy boys and 69 boys with the condition	A dense-looking growth centre was judged a normal feature; fragmentation (showing in pieces) was greater in the pain group15
30 highly active children with heel pain and 15 pain-free controls	Every child showed increased density; half the controls and almost 90% of the pain group showed fragmentation16
98 children with the condition and 120 controls, aged 8 to 15	Significant differences were reported in the density of the growth centre and in a line across it13

MRI is a scan that shows soft tissue in detail. The Cochrane review notes that a healthy heel apophysis can at times look similar on MRI to one in a child with pain¹.

What the Cochrane review compared

The review, searched to January 2025, included 10 randomised controlled trials, which assign people to groups by chance¹. Seven were on calcaneal apophysitis¹. Certainty of evidence is how sure reviewers are that a finding is right.

Comparison in children with calcaneal apophysitis	Evidence	What the review judged
Foot orthoses (shoe inserts) against heel lifts, short term	One study, moderate certainty	Likely little to no difference in overall pain or physical function1
Foot orthoses against heel lifts, medium term	One study of 208, very low certainty	Very uncertain for pain1
Heel cushioning against a heel strap, short term	One study of 43, very low certainty	Very uncertain for physical function1
Kinesio tape against placebo (dummy) tape, short term	One study of 22, very low certainty	Very uncertain for overall pain and physical function1

None of the three comparisons measured participation in sport¹. The review notes that short-term pain scores improved in both groups of the trials¹. It says this may be because the condition resolves naturally over time¹. It cautions that the trials included many more boys than girls and mostly very active children¹. So it is unsure whether the findings apply to children who are less active¹.

A 2024 systematic review of eight randomised studies concluded that insoles, exercises, Kinesio taping and foot orthoses were effective for easing symptoms¹⁷. The Cochrane review reported that this review applied risk-of-bias criteria inconsistently¹. It described its own reading of the same evidence as more cautious¹.

Individual trials

• 101 participants aged 8 to 15: the three groups were wait-and-see, a heel raise (a raised insert under the heel) and supervised exercise¹⁸. Each brought significant improvement, with no clinically relevant difference between them at 3 months¹⁸. At 6 weeks the heel raise group was more satisfied than both other groups¹⁸.
• 124 children aged 8 to 14: a heel raise was compared with off-the-shelf orthoses, and new footwear with no new footwear¹⁹. The heel raise showed an advantage at 1 and 2 months, on the physical part of one questionnaire alone¹⁹. No option showed an advantage on any outcome at 6 or 12 months¹⁹.
• 208 children aged 9 to 12: over 12 weeks, pain improved with custom-made orthoses and with off-the-shelf heel lifts²⁰. It improved more in the custom orthoses group²⁰.
• 51 boys aged 9 to 14: each boy used a heel cup and a heel wedge in turn²¹. The odds score for pain during sport fell to a fifth with the cup, against the wedge²¹.
• 22 junior football-club athletes aged 8 to 16: foot and ankle function scores were better with Kinesio tape than with sham (dummy) tape²². Pain scores afterwards did not differ significantly²².

Connections

The condition sits at the growth plate of the calcaneus, whose apophysis is described above⁴. The soleus joins the gastrocnemius to form the Achilles tendon, which inserts on the heel bone²³. One study compared 53 boys with the condition at a soccer academy with 53 boys without it²⁴. Limited dorsiflexion from the gastrocnemius on both sides was 8 times more likely in the first group²⁴.

One study used shear wave elastography, an ultrasound method that estimates how stiff a tissue is, on the Achilles tendon²⁵. It compared 17 patients with 24 children without symptoms, aged 8 to 13²⁵. It found no statistically significant difference in the tendon’s elasticity²⁵.

Apophyses sit where major tendons attach and mainly take tension²⁶. A study of 14 children with the condition and 14 without found no significant difference in peak vertical force during walking or running²⁷.

Sources

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2. Wiegerinck JI, Yntema C, Brouwer HJ, Struijs PA (2014). Incidence of calcaneal apophysitis in the general population.. European journal of pediatrics. doi:10.1007/s00431-013-2219-9 PMID 24297670
3. Nieto-Gil P, Marco-Lledó J, García-Campos J, Ruiz-Muñoz M, Gijon-Nogueron G, Ramos-Petersen L (2023). Risk factors and associated factors for calcaneal apophysitis (Sever's disease): a systematic review.. BMJ open. doi:10.1136/bmjopen-2022-064903 PMID 37280033
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6. James AM, Williams CM, Haines TP (2013). "Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review".. Journal of foot and ankle research. doi:10.1186/1757-1146-6-16 PMID 23641779
7. Ceylan HH, Caypinar B (2018). Incidence of calcaneal apophysitis in Northwest Istanbul.. BMC musculoskeletal disorders. doi:10.1186/s12891-018-2184-6 PMID 30053810
8. Belikan P, Färber LC, Abel F, Nowak TE, Drees P, Mattyasovszky SG (2022). Incidence of calcaneal apophysitis (Sever's disease) and return-to-play in adolescent athletes of a German youth soccer academy: a retrospective study of 10 years.. Journal of orthopaedic surgery and research. doi:10.1186/s13018-022-02979-9 PMID 35139872
9. Fares MY, Baydoun H, Khachfe HH, Salhab HA, Fares J, Musharrafieh U (2023). Clinical and Diagnostic Characteristics of Calcaneal Apophysitis: A Systematic Review and Thematic Analysis.. Journal of the American Podiatric Medical Association. doi:10.7547/22-083 PMID 37713414
10. Martinelli N, Spreafico A, Tramacere I, Marcolli D, Valli F, Curci D (2019). Prevalence and Associated Factors of Sever's Disease in an Athletic Population.. Journal of the American Podiatric Medical Association. doi:10.7547/17-105 PMID 31599666
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13. Gao Y, Liu J, Li Y, Liu Q, Xu S (2020). Radiographic study of Sever's disease.. Experimental and therapeutic medicine. doi:10.3892/etm.2020.8796 PMID 32742336
14. Kose O, Celiktas M, Yigit S, Kisin B (2010). Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever's disease)?. Journal of pediatric orthopedics. Part B. doi:10.1097/BPB.0b013e32833a5fa7 PMID 20431490
15. Volpon JB, de Carvalho Filho G (2002). Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center.. Archives of orthopaedic and trauma surgery. doi:10.1007/s00402-002-0410-y PMID 12136298
16. Perhamre S, Lazowska D, Papageorgiou S, Lundin F, Klässbo M, Norlin R (2013). Sever's injury: a clinical diagnosis.. Journal of the American Podiatric Medical Association. PMID 24072363
17. Hernandez-Lucas P, Leirós-Rodríguez R, García-Liñeira J, Diez-Buil H (2024). Conservative Treatment of Sever's Disease: A Systematic Review.. Journal of clinical medicine. doi:10.3390/jcm13051391 PMID 38592198
18. Wiegerinck JI, Zwiers R, Sierevelt IN, van Weert HC, van Dijk CN, Struijs PA (2016). Treatment of Calcaneal Apophysitis. Journal of pediatric orthopedics. doi:10.1097/BPO.0000000000000417 PMID 25985369
19. James AM, Williams CM, Haines TP (2016). Effectiveness of footwear and foot orthoses for calcaneal apophysitis: a 12-month factorial randomised trial.. British journal of sports medicine. doi:10.1136/bjsports-2015-094986 PMID 26917682
20. Alfaro-Santafé J, Gómez-Bernal A, Lanuza-Cerzócimo C, Alfaro-Santafé JV, Pérez-Morcillo A, Almenar-Arasanz AJ (2021). Effectiveness of Custom-Made Foot Orthoses vs. Heel-Lifts in Children with Calcaneal Apophysitis (Sever's Disease): A CONSORT-Compliant Randomized Trial.. Children (Basel, Switzerland). doi:10.3390/children8110963 PMID 34828675
21. Perhamre S, Lundin F, Norlin R, Klässbo M (2011). Sever's injury; treat it with a heel cup: a randomized, crossover study with two insole alternatives.. Scandinavian journal of medicine & science in sports. doi:10.1111/j.1600-0838.2010.01140.x PMID 20673253
22. Kuyucu E, Gülenç B, Biçer H, Erdil M (2017). Assessment of the kinesiotherapy's efficacy in male athletes with calcaneal apophysitis.. Journal of orthopaedic surgery and research. doi:10.1186/s13018-017-0637-5 PMID 28985751
23. Trybulski R, Gałęziok K, Matuszczyk F, Halski T, Muracki J (2025). Problems in Diagnosis and Treatment of Soleus Muscle Injuries-Narrative Review and Case Report.. Journal of Clinical Medicine. doi:10.3390/jcm14061955 PMID 40142763
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Every source the library cites

Changes

• October 5, 2026 First published.