SEVER’S DISEASE – WHAT YOU NEED TO KNOW

Does Your Child Experience Heel Pain When They Run?

Running is supposed to be an enjoyable experience for children of all ages.  The thrill of running faster and faster is exhilarating and rewarding.  However, what happens when that joy of running is replaced with the pain of running?  Could it be Sever’s disease?

Are You Familiar With This Scenario?

Your child is hobbling, limping, and grimacing in pain during or after running.  And in some instances, they are reduced to tears during or after running.  To overstate the obvious, this should not happen.  Children should not experience heel pain when running or jumping.  Avoiding putting full body weight on one leg when walking, standing, or going up and down stairs are strong indicators that your child is experiencing symptoms which are not normal.

Sever's Disease

Heel pain can be used to describe a variety of different diagnoses (Sever’s disease, plantar fasciitis, stress fractures, Achilles tendonopathy, or retrocalcaneal bursitis)1.  The focus of this blog will be discussing Sever’s disease.

What Is Sever’s Disease?

Sever’s disease, also known as calcaneal apophysitis, is the result of repetitive micro trauma to the growth plate (apophysis) of the heel (calcaneus).  Because children are still growing the growth plate is considered “open”.  During running the Achilles tendon pulls at the growth plate. If the repetitive stress is too great from running, the area where the Achilles tendon attaches to the heel, as well as the growth plate become inflamed and painful.  The typical occurrence for Sever’s disease is with children between the ages of 7 to 15 years.

severs disease

First Steps

It is important to improve your understanding with the nature of the child’s symptoms.  These questions will help gather essential information:

  • Where is their pain?
    • Determine the location of their pain (back of the heel, bottom of the heel, arch of the foot)
  • Is there tenderness when the painful area is touched?
  • Does their pain worsen with activity?
  • Are they having difficulty walking / running?
  • Do you notice an usual pattern when walking / running (e.g., limp)?
  • When did their symptoms start?
  • Are their symptoms worsening?
  • Was there a recent growth spurt?
  • Was there a recent and dramatic increase in their activity (running and jumping)?
  • Has a new sport season begun?
  • Are their shoes older than 6 months?
  • Was there another recent (less than 2 months) injury to either leg?

If your child follows a pattern of symptoms based on pain location (heel), worsening symptoms, altered walking or running, new sport season, tenderness, recent growth spurt and increased activity there is concern for Sever’s disease.  This does not mean that a season is lost.  Early treatment is the key.  The earlier the treatment is initiated the sooner the symptoms will go away.

Initial Treatment

The most basic treatment options for Sever’s disease include:

  • Rest from activities that aggravate symptoms
  • Ice the painful area (wrapped in a towel) for 15 minutes or apply an ice massage for 5 minutes
  • Stretching – pain-free
  • Strengthening for the leg – pain-free
  • Balance exercises – pain-free

Management

The above conservative initial treatment should be effective at decreasing symptoms within 7 to 10 days.  However, if the pain persists you should seek medical attention (medical professional).  Remember early treatment is essential to avoid the risk of missing an entire season. You need to avoid the “no pain, no gain” mindset – this will only make the problem worse.

A thorough evaluation by a medical professional includes a detailed patient history and a specific survey for the lower body.  The evaluation is crucial to determine what the actually cause of the injury is and helps develop the treatment plan. 

Evaluation

You should also expect an advanced evaluation to also include:

  • Comprehensive lower body flexibility testing
  • Comprehensive lower body strength testing
  • Hands-on assessment for range of motion and joint mobility
  • Hands-on assessment of the painful area(s)
  • Movement analysis with basic movements (squatting, stepping, walking)
    • If applicable – high speed video analysis with running
  • Discussion and recommendations for age appropriate training and avoiding / preventing overuse
  • Detailed home exercise program
  • Explanation of clinical findings
  • Anticipated recovery period based measurable goals

heel palpation

Recovery

Successful recovery from injuries is criterion-based not time-based. If you are a sports fan you will appreciate the following example because you have heard it countless times.  An elite, professional athlete does not directly return from injury to competition based on a time frame.  They have to pass a collection of tests in order to be cleared for practice and light drills, then another collection of tests to increase the intensity of practice.  This pattern continues until they are able practice at near game conditions, then the athlete is cleared to return to play.

Taking more than 10 to 14 days off from activity to rest while recovering from Sever’s disease requires a plan.  Immediately returning to the same level of training intensity following the period of rest is a recipe of disaster.  This accounts for the high rate of re-aggravation of symptoms and where a season is lost.  It is more safe and effective to determine return to play (running) through a systematic and gradual workout progression. 

what can i do

Expectations

Youth athletes will be frustrated based on their inability to practice and compete.  In order to shorten the recovery period, it is importance that the youth athlete is active.  The crucial point is that the activity is PAIN-FREE.  Once the initial painful symptoms have decreased specific exercises need to be introduced to address their weakness, muscle tightness, coordination, etc.  After these exercise have been mastered (and pain-free) then onto the next phase of their recovery.  This is the basic principle of the criterion-based system.  Once the criteria has been met, the next phase is introduced.  Each individual navigates the phases at different speeds.  The rate of return to play from Sever’s disease varies based on the length of symptoms, severity of aggravation, strength, etc.

Sever's disease running

Properly managed Sever’s disease can be treated efficiently provided you are pro-active based on your newfound awareness and education related to this injury.  If you have concerns or questions talk to a coach or medical professional who has experience with youth athletes.

  1. Malanga GA, Ramirez-Del Toro JA. Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am. 2008; 19:347-371.

Matt Weissbach is originally from Canada, and graduated from Queen’s University (2002) and the University of St. Augustine (2017).  He has over 16 years of working as a physical therapist, coach, teacher, and consultant.  Currently, he is co-owner of Evolve Physical Therapy in Sherwood, Oregon.

Matt is a United States of America Track and Field (USATF) Level 1 Coach, and has spoken at track and field coaches clinics, universities, and international conferences on running, footwear, long-term athlete development, and ACL rehabilitation.

Your First Physical Therapy Visit For Knee Pain

WILL PHYSICAL THERAPY HELP YOUR KNEE PAIN?

If you are unsure if you will benefit from physical therapy for you knee you can follow these guidelines.

If you are experiencing:

  • Pain
  • Stiffness
  • Swelling
  • Weakness
  • Poor balance
  • Loss of muscle mass

If you have difficulty with:

  • Walking
  • Going up and down stairs or curbs
  • Running or jumping
  • Squatting
  • Getting into or out of a chair or car

If you answered YES to any of the above questions, you are a candidate for physical therapy.

CANDIDATES:

Physical Therapy is essential for you to achieve your goals following an injection or surgical procedure, as well as with overuse injuries or degenerative changes (osteoarthritis). When you have knee pain, the body modifies how you move and is often referred to as compensation. This could mean that you are limping while walking, going up or down the stairs one leg at a time, shifting weight to the “good leg” when you are getting out of a chair, or when you are standing. This abnormal movement will not correct itself magically following a medical procedure or if you take time off from your sport. This is WHY you need physical therapy!

Our experience assisting people re-learn how to move pain-free is the combination of hands-on techniques for your knee, as well as the entire leg. Treatment will include strengthening and balance exercises to address weakness and poor joint stability. We will also spend time educating you on how treatment does not end once you leave the clinic. You will be given an individualized home exercise program to maximize your success of returning to the activities that you love.

EXPECTATIONS:

Come Prepared:

Have a list of questions you would like to ask. Don’t be afraid to ask for more clarity with the answers you are provided.

Please bring a personal identification card with picture (your drivers license works best), your insurance card, and a detailed list of your medications.

In addition you filling out relevant medical history, you will also complete a functional outcome test for the legs, the Lower Extremity Functional Scale. The survey helps us determine your biggest limitations with your daily life. It also helps us objectively track your success in physical therapy.

Please wear or bring a pair of loose fitting shorts. We need to see the structure of your legs and how you move as you complete basic functional tasks such as: walking, standing, getting out of a chair, and negotiating stairs.

You should bring in your most common footwear choice, as well as your current workout shoes. This will provide insight with how your body moves and if footwear changes are needed.

YOUR VISIT IN THE CLINIC:

A thorough initial physical therapy appointment will take 40 to 60 minutes. This involves us asking you questions for the most relevant information prior to the physical examination. Remember YOUR story is important because there is not a diagnosis, or treatment, which works best for everybody.

The Physical Therapy Knee Exam:

Once a detailed patient history has been given the next phase of the visit is the physical examination. We will address the symptoms, while performing additional tests to determine the cause(s) of your complaints in a thorough assessment.

The following tests will be conducted:

  • Range of Motion (ROM) – the available movement for a joint
  • Hands-on joint mobility and soft tissue assessment
  • Muscle length, strength, and endurance
  • Balance assessment
  • Functional movement
  • Neurological screening

To perform these tests you will have to change your body position, for example lying on your back or front, sitting, and standing. If any positions make you feel unsafe or cause an increased level of pain, please let us know. Also, an informed patient is essential, which means we will explain what we are doing prior to testing. Your understanding of our intentions, interpretations, and the expectations of the test are vital to developing an effective treatment approach for you.

The Goals of the Initial Visit:

Based on the findings from the above tests an individualized treatment plan will be developed and discussed with you. We will work with you to develop strategies to help you improve how you walk, negotiate stairs and any other immediate limitations with your daily activities.

crutch knee

Findings of your clinical tests will be discussed and how those findings affect your functional independence. Your understanding of the WHY behind your pain and limitations is important to us. We believe the more you know and understand allows you to be more involved and successful with your physical therapy experience.

COMMITMENT:

Your Commitment:

Ask questions to understand the goal of treatment
Perform the home exercises
Attend your appointments

Our Commitment:

We strive to clearly explain:

  • WHY physical therapy is needed
  • HOW physical therapy will help
  • WHAT treatment, both in the clinic and at home, is vital for your success

We will also provide you will resources for performing your exercises at home and the gym.

trust knee

ACCOUNTABILITY:

To ensure our shared commitments, we will hold each other accountable to achieving the best possible results from physical therapy. We believe effective physical therapy is a partnership between individuals.

We will work together to

MOVE BETTER

FEEL BETTER

LIVE BETTER

Matt is originally from Canada, and graduated from Queen’s University in 2002. His areas of clinical interest are pre and post-surgical rehabilitation, aquatic rehabilitation, and return to play testing. He has more than 15 years of experience working with active people across the lifespan, and athletes from grade school to professional level.