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  • Tim Bushnell

I Have Heel Pain. Is It Sever's?

TBS Physio makes the content of this blog available for general information only. The information in this blog is not a substitute for appropriate clinical advice from your health professional. You should speak to your health professional for personalised clinical advice.


Sever’s Disease is a condition that often affects young athletes, particularly those involved in impact sports like rugby, soccer, and basketball. As we reach the halfway point of the winter season at Joeys, understanding and managing conditions like Sever’s Disease is crucial for staying on the field.


Sever's Disease, also known as calcaneal apophysitis, is characterised by inflammation of the growth plate in the heel. This growth plate, called the calcaneal apophysis, is located at the back of the heel where both the Achilles tendon and plantar fascia attach. The Achilles attaches from the top, while the plantar fascia attaches from the bottom, creating a 'tug of war' at the growth plate. In growing children, this area is weaker than other parts of the bone and therefore more susceptible to stress and overuse, leading to pain and discomfort.




Sever’s Disease is most common during peak growth periods, typically between the ages of 8 and 15, when the bones, muscles, and tendons are rapidly developing and can easily become imbalanced. In some cases, the growth plate can remain open even after age 15, meaning Sever’s can still be prevalent beyond this age.


If the load on the heel is increased beyond the bone’s capacity, pain will occur. We like to explain this using the bucket and water analogy: if the bucket (capacity of the heel bone) is filled with too much water (load), the water spills (pain). To manage this, we first reduce the amount of water (load) in the bucket (heel growth plate) to reduce pain. Then, we work on increasing the size of the bucket (increasing capacity), which we will discuss in more detail below.



Symptoms

  • Pain felt at the back or bottom of the heel, sometimes extending into the Achilles tendon and foot arch, especially during or after physical activity

  • A noticeable limp or tendency to walk on the toes to avoid heel pressure

  • The heel is usually tender to the touch, and pressing on it can cause discomfort

  • Difficulty or inability to push off the toes into a heel raise



Common Causes 

REDUCED CAPACITY:

  • Peak growth spurts reduce the capacity of the heel bone during these periods


INCREASED LOAD:

  • Impact activities like running and jumping done too frequently can exceed the capacity of the heel bone

  • Capacity is reduced during growth spurts, so even normal exercise levels can cause issues

  • Returning to intense physical activity and sport after a holiday period (e.g., school holidays) is especially problematic

  • Rapid weight gain can also be a contributing factor


IMPROPER FOOTWEAR:

  • Shoes that do not provide adequate support or cushioning can exacerbate heel pain.

  • Flat football boots without a gradient are particularly problematic


FOOT BIOMECHANICS:

  • Flat feet or high arches cause altered weight distribution and pressure on the heel


POOR RUNNING TECHNIQUE:

  • Inefficient or improper running techniques can place additional stress on the heel


WEAKNESS:

  • Weakness in the calf and Achilles

  • Weakness in other lower limb muscles, especially the gluteals and core


STIFFNESS:

  • Stiffness in the calf muscles, secondary to significant stretching of the muscles and tendons to accommodate new bone growth



Management Strategies

REDUCE LOAD:

  • Temporarily resting or reducing impact activities (running and jumping)

  • If your Sports Physio decides that you can continue running, taking a day off between each running session will help the bone tolerate the loading better


SUPPORTIVE FOOTWEAR:

  • Wear shoes with good arch support and soft cushioning


STRAPPING:

  • Strapping the foot can help reduce strain and improve shock absorption before the load reaches the heel bone


FOAM ROLLING:

  • Avoid static stretching of the calf, as this increases the force on the growth plate and can worsen pain

  • Use a foam roller or spiky ball to loosen the muscle without increasing strain on the growth plate


ICE:

  • Applying ice to the affected heel for 15-20 minutes several times a day can reduce inflammation and pain


STRENGTHENING:

  • Increase strength in the calf and other lower limb muscles, especially the core and gluteals, so they can better tolerate the loads of exercise and sport. This needs to be programmed specifically according to capacity and pain levels

  • Follow @tbsphysio on Instagram to see our favourite exercises for Sever's


SPORTS PHYSIO:

  • A good Sports Physio can help identify which contributing factors are relevant to you and provide an individualised program to reduce load in the short term and increase capacity in the long term

  • Running assessment to assess and fix any technical issues

  • Evaluation of jumping and landing mechanics, which can be done with our VALD ForceDecks to accurately measure and analyse deficiencies

  • Your Sports Physio should focus on independent management strategies so you can eventually self-manage the condition


CUSHIONED HEEL CUPS AND ORTHOTICS:

  • Cushioned heel cups can relieve pressure on the heel

  • Orthotics may provide extra support if there are underlying foot biomechanical issues




Prevention Strategies 

GRADUAL TRAINING INCREASES:

  • Avoid sudden increases in the intensity, frequency, or duration of physical activity to prevent overloading the heel


PROPER FOOTWEAR:

  • Invest in quality shoes that offer adequate support and cushioning for your feet


FOOT AND ANKLE STRENGTHENING:

  • Strengthen the foot and ankle muscles to increase their capacity to tolerate loads

  • Follow @tbsphysio on Instagram to see our top exercises for preventing Sever's


GENERAL LOWER LIMB STRENGTHENING:

  • Regular strength training of the lower limbs, especially focusing on the core and glutes, to increase overall capacity


SCREENING AND RUNNING ASSESSMENT:

  • Consult with your Sports Physio to identify any underlying risk factors, including evaluating running technique and jumping and landing mechanics

  • Complete performance testing and analysis with tools like our VALD ForceDecks to accurately measure and analyse deficiencies that may increase load on the heel


REGULAR STRETCHING:

  • Encourage regular stretching of the calf muscles to maintain flexibility, only if there are no symptoms present


MONITOR GROWTH SPURTS:

  • Pay extra attention to activity levels during rapid growth phases and adjust as necessary

  • Initially, alternating days of running with rest days may help manage symptoms; otherwise, a short period of rest may be needed



Sever’s can be a painful and frustrating condition for young athletes, but with proper management and preventive measures, it’s possible to minimise its impact. At TBS Physio, we're committed to supporting the Joeys students’ athletic endeavours while prioritising their health and well-being. If you have concerns or need further guidance, don’t hesitate to reach out.


Follow us on Instagram @tbsphysio to see our top exercises for Sever's later this week.

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