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Patient Education Articles

Wednesday, August 1, 2018

Heel Cracks

heel fissures

Sever's Disease

Sever’s disease (also known as calcaneal apophysitis) is one of the most common causes of heel pain in growing children and adolescents. It is an inflammation of the growth plate in the calcaneus (heel).

Sever’s disease is caused by repetitive stress to the heel, and most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Children and adolescents who participate in athletics—especially running and jumping sports—are at an increased risk for this condition. However, less active adolescents may also experience this problem, especially if they wear very flat shoes.

In most cases of Sever’s disease, simple measures like rest, over-the-counter medication, a change in footwear, and stretching and strengthening exercises will relieve pain and allow a return to daily activities.


The bones of children and adolescents possess a special area where the bone is growing called the growth plate. Growth plates are areas of cartilage located near the ends of bones.

When a child is fully grown, the growth plates close and are replaced by solid bone. Until this occurs, the growth plates are weaker than the nearby tendons and ligaments and are vulnerable to trauma.

Growth plate in heel

An x-ray of an adolescent foot shows the open growth plate of the calcaneus. The x-ray appearance of Sever’s disease looks similar to those without symptoms.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Sever’s disease affects the part of the growth plate at the back of the heel where bone growth occurs. This growth area serves as the attachment point for the Achilles tendon—the strong band of tissue that connects the calf muscles at the back of the leg to the heel bone.

Repetitive stress from running, jumping, and other high-impact activities can cause pain and inflammation in this growth area of the heel. Additional stress from the pulling of the Achilles tendon at its attachment point can sometimes further irritate the area.

Insertion point for Achilles tendon

Illustration shows the area where the Achilles tendon attaches (inserts) into the heel bone.


Painful symptoms are often brought on by running, jumping, and other sports-related activities. In some cases, both heels have symptoms, although one heel may be worse than the other. Symptoms may include:

  • Heel pain and tenderness underneath the heel
  • Mild swelling at the heel
Areas of pain from Sever's disease

The red shading shows the typical areas of pain from Sever’s disease.  

Doctor Examination

During the appointment, your doctor will discuss your child's symptoms and general health. He or she will conduct a thorough examination of the foot and ankle to determine the cause of the pain. This will include applying pressure to the heel bone on both the bottom of the bone and along the sides, which should be tender or painful for a child with Sever’s disease. In addition, your doctor may ask your child to walk, run, jump, or walk on his or her heels to see if the movements bring on painful symptoms.


Treatment for Sever’s disease focuses on reducing pain and swelling. This typically requires limiting exercise activity until your child can enjoy activity without discomfort or significant pain afterwards. In some cases, rest from activity is required for several months, followed by a strength conditioning program. However, if your child does not have a large amount of pain or a limp, participation in sports may be safe to continue.

Your doctor may recommend additional treatment methods, including:

  • Heel pads. Heel cushions inserted in sports shoes can help absorb impact and relieve stress on the heel and ankle.
  • Wearing shoes with a slightly elevated heel. Elevating the heel may relieve some of the pressure on the growth plate.
  • Stretching exercises. Stretches for the Achilles tendon can reduce stress on the heel, help relieve pain, and hopefully prevent the disease from returning.
  • Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen can help reduce pain and swelling.

In cases where the pain is bad enough to interfere with walking, a “walker boot” might be required to immobilize the foot while it heals.

Heel cord stretch

Heel cord stretch. You should feel this stretch in your calf and into your heel.


It is not unusual for Sever’s disease to recur. This typically happens when a child once again increases sports activities. Wearing sports shoes that provide good support to the foot and heel may help prevent recurrence.

Sever’s disease will not return once a child is fully grown and the growth plate in the heel has matured into solid bone.

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