Sever’s Disease: Chiropractic Treatment and Management

Apr 1

Reading time: 5 minutes

Sever’s Disease is a painful inflammatory condition affecting the Achilles tendon insertion at the calcaneal apophysis. This condition is a common cause of posterior heel pain in active adolescents. Sever's Disease is often a diagnosis of exclusion dependent on the location of pain, patient age, and clinical presentation. Watch this video before evaluating your next patient with heel pain.

6 Fact’s About Sever’s Disease

1. The mean time to return-to-play of the affected athletes is around two months. (2)

2. Commonly found in athletically active populations between the ages of 8 and 14.

3. There is a slightly higher incidence in males.

4. These patients often present after beginning a new sports season.

5. Activities requiring running and jumping, including soccer, basketball, gymnastics, and track & field, are most closely associated with the development of Sever’s Disease. (3,4)

6. Symptoms are bilateral in 60% of cases. (5).

Why Does Sever’s Disease Affect Children?

In children and adolescents, the epiphyseal growth plate is 2-5 times weaker than in adults. Children are more likely to suffer epiphyseal injuries from stressors that would likely cause sprains and strains in adults (1). The apophysis is most vulnerable during periods of rapid adolescent growth. As bones lengthen rapidly, soft tissues (gastroc/soleus/Achilles tendon) become tighter and produce excessive stress on their bony attachments. Like other traction apophysitis', Sever's Disease is thought to be caused by diminished resistance to shear stress at the apophyseal growth plate. The calcaneal apophysis is subject to significant shear loads due to its vertical orientation and direction of pull from the powerful gastroc/soleus. Severs Disease is the second most common traction apophysitis behind Osgood Schlatters.

How Do I Diagnose Sever's Disease?

Active toe plantar flexion and passive ankle dorsiflexion may often reproduce discomfort. However, the most common clinical findings are based upon symptom location, age of the patient, and one orthopedic test.

1. Peak tenderness is located at the insertion of the Achilles tendon at the calcaneal apophysis.

2. Athletically active populations between the ages of 8 and 14

3. A positive Heel Squeeze Test

Apply simultaneous compression of the medial and lateral calcaneus. The heel squeeze test may help identify calcaneal stress fracture of Sever's Disease depending on the patient's age and presentation.

💡 Clinical Tip: Asking the patient to walk on their toes may provide additional information, as patients with plantar fasciitis report discomfort when shifting weight onto their toes. In contrast, patients with stress fractures or heel spurs find relief in that position.

Will X-ray Evaluation Confirm Sever’s Disease?

The short answer is no. Radiography is not necessary for the diagnosis of Sever's Disease. (6) The calcaneal apophysis is commonly fragmented in children and should not be confused with Sever's Disease. This diagnosis is made based on clinical findings. However, imaging is still useful for recalcitrant cases: plain films to rule out other differential diagnoses, MRI to rule out osteomyelitis or stress fracture, and CT will identify tarsal coalition.

Chiropractic Treatment of Acute Sever’s Disease

1. The clinician’s first goal is to return a patient to pain-free activity. Ice, especially pre- and post-sport, and anti-inflammatory therapies are beneficial initially.

2. Clinicians should address calf hypertonicity with myofascial release and stretching.

3. Evaluate shoes and limit barefoot walking during the acute phases of injury.

4. Orthotics may be required to improve faulty foot biomechanics. The consistent use of ½ inch heel lifts (bilaterally) can ease shear strain from hypertonic calf muscles.

5. Kinesiotaping of the posterior chain or heel may provide symptom relief. (7)

As youth sports become more competitive, adolescent athletes are subject to greater physical demands, and their developing bodies sometimes fail to keep pace with the expectations of parents and coaches. Activity modification is often necessary, including decreasing the frequency and intensity of exercise. Limiting running and jumping may be required during the acute phase of injury recovery. Low-impact cross-training with a stationary bike or in the pool may be beneficial. Reassure patients and parents that calcaneal apophysitis is a self-limiting condition. Avoiding the term 'disease" may limit anxiety.

2 Exercises For Post-Acute Sever’s Disease

When the "squeeze test" is no longer painful, the treatment should shift to strengthening to improve biomechanics and minimize recurrence. Typically, symptoms resolve within 2 to 8 weeks of initiating rest and conservative treatment (8). But now it is time to build our athletes to return to their respective sports. Here are two go-to exercises for balance and ankle/foot strengthening.

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There is limited evidence concerning the diagnosis and treatment of Sever's Disease. Most recommendations are anecdotal evidence. Like so many other musculoskeletal conditions, there is much to be learned regarding the management of Sever's Disease. Evidence-based chiropractors must be able to recognize and treat this often disabling condition. Also, review Heel Pad Syndrome, Achilles Tendinopathy, and Plantar Fasciitis within ChiroUp for other possibilities of heel pain depending on your patient's presentation, age, and location of symptoms.

1. Schwab SA. Epiphyseal injuries in the growing athlete. Canadian Medical Association Journal. 1977 Sep 17;117(6):626.
2. Belikan P, Färber LC, Abel F, Nowak TE, Drees P, Mattyasovszky SG. 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. 2022 Dec;17(1):1-6.
3. Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987 Jan 1;7(1):34-8.
4. McKenzie DC, Taunton JE, Clement DB, Smart GW, McNicol KL. Calcaneal epiphysitis in adolescent athletes. Canadian Journal of applied sport sciences. Journal canadien des sciences appliquees au sport. 1981 Sep;6(3):123-5.
5. Marx J, Walls R, Hockberger R. Rosen's Emergency Medicine-Concepts and Clinical Practice E-Book. Elsevier Health Sciences; 2013 Aug 1.
6. Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, Jaberzadeh S, Cook J. The pain of tendinopathy: physiological or pathophysiological?. Sports medicine. 2014 Jan;44(1):9-23.
7. Fares MY, Salhab HA, Khachfe HH, Fares J, Haidar R, Musharrafieh U. Sever’s Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clinical Medicine & Research. 2021 Sep 1;19(3):132-7.
8. Lee KT, Young KW, Park YU, Park SY, Kim KC. Neglected Sever's Disease as a cause of calcaneal apophyseal avulsion fracture: case report. Foot & ankle international. 2010 Aug;31(8):725-8.

Brandon Steele

Dr. Steele is currently in private practice at Premier Rehab in the greater St. Louis area. He began his career with a post-graduate residency at The Central Institute for Human Performance. During this unique opportunity, he was able to create and implement rehabilitation programs for members of the St. Louis Cardinals, Rams, and Blues. Dr. Steele currently lectures extensively on evidence-based treatment of musculoskeletal disorders for the University of Bridgeport’s diplomate in orthopedics program. He serves on the executive board of the Illinois Chiropractic Society. He is also a Diplomate and Fellow of the Academy of Chiropractic Orthopedists (FACO).