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Posterior Calcaneus Apophysitis

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Other Names

  • Sever's Disease


  • This page refers to apophysitis of the calcaneus, a pediatric condition often called 'Sever's Disease'



  • Most common cause of heel pain in active adolescents between 9 and 12 years of age (need citation)


  • General
    • Seen in skeletally immature athletes
    • Traction at the Achilles Tendon insertion site correcting with the secondary ossification center
    • Occurs with growth spurts, increased activity, or repetitive running and jumping
    • Presents as heel pain secondary to overuse
    • Resolves with skeletal maturation and closure of apophysis


  • Repetitive strain and microtrauma
    • Caused by force of the Achilles tendon which inserts at secondary ossification center
    • Results in irritation and potential partial avulsion of the calcaneal apophysis

Risk Factors

  • Sports
    • Running and jumping sports
    • Basketball
    • Soccer
    • Gymnastics
  • Extrinsic
    • Long or year-round activities
    • Poorly fitting or worn-out footwear
    • Poor training mechanics
  • Intrinsic
    • Poor heel cord flexibility
    • pes cavus
    • pes planus
    • genu varum
    • forefoot varus

Differential Diagnosis

Clinical Features

  • History
    • Children are typically 8 to 14 years old
    • Pain over the calcaneal apophysis/calcaneal insertion of Achilles tendon
    • Pain with activity or impact, worse on hard surfaces, wearing cleats
    • Resolution of pain with rest
    • Limping may be present
  • Physical Exam: Physical Exam Ankle
    • May have erythema, swelling, warmth
    • Tender over achilles tendon insertion
    • Pain with passive ankle dorsiflexion
    • Tight Achilles tendon and calf muscles
    • Pes planus or pronated forefoot may be present
  • Special Tests
    • Squeeze Test: Pain over the posterior calcaneus with compression)
    • Sever Sign: Increased pain at calcaneus with standing on tiptoes


  • Clinical diagnosis and imaging is not routinely required


  • Standard Radiographs Ankle or Standard Radiographs Foot
    • Typically normal, especially early in disease process
    • Rule out other pathology including fractures, osteomyelitis, bone cysts
  • Potential findings
    • Sclerosis may be present
    • Fragmentation is frequently present


  • Findings
    • Localize inflammation to apophysis
    • Evaluate for other pathologies stress fracture, lytic lesions, osteomyelitis


  • N/A


  • Indications
    • All patients
  • Activity modification/Rest
    • Discontinue offending activity
  • Physical Therapy
    • Achilles tendon stretches, hamstring stretches
    • Strengthening of dorsiflexors
  • Heel pads/cups
    • Insertion can offload some tenson on achilles
  • Immobilization in severe cases
  • Other
    • Ice
    • NSAIDS
    • Establish proper footwear
  • Prevention
    • Maintain calf flexibility and ankle dorsiflexion
    • Limit use of cleats or time on hard surfaces


  • Indications
    • No role for operative treatment

Rehab and Return to Play


  • Needs to be updated

Return to Play

  • Needs to be updated

Complications & Prognosis


  • General
    • Self-limited usual improvement within 6 to 12 months
    • Symptoms can wax and wane for athlete
    • Complete resolution with apophyseal closure


  • None

See Also


Created by:
John Kiel on 30 June 2019 20:36:32
Last edited:
3 October 2022 23:52:47