Sever's Disease: Heel Pain in Active Kids Aged 8 to 14

Your child comes off the field after practice and walks with a limp. They sit down, they are fine within the hour, and by the next morning they run downstairs normally. Then it happens again after the next game. Nobody remembers a specific injury, no tackle and no twist.

Squeeze the back of the heel between your thumb and fingers, one on each side, and your child pulls the foot away. That squeeze is the single most useful thing a parent can do before booking anything.

In a child between about 8 and 14 who plays sport, that pattern usually points to the growth plate at the back of the heel bone. The medical name is calcaneal apophysitis. Most people know it as Sever's disease, which sounds far more alarming than what it actually is.

What is actually sore, and why it starts during a growth spurt

The heel bone in a growing child has a separate piece of bone at the back of it, joined to the main body of the heel by a layer of cartilage. That cartilage layer is a growth plate. The Achilles tendon attaches directly onto that back piece, so every push-off, every landing, and every sprint pulls on it.

Bone grows first and muscle catches up afterwards. During a growth spurt the leg gets longer over a few months while the calf and Achilles are still the length they were, so they sit under more tension. That tension pulls on a growth plate made of cartilage, at the age when children start playing more organised sport.

The StatPearls chapter on Sever disease by Smith and Varacallo describes the growth plate as typically beginning to close between the ages of 8 and 14. That window explains the age range, because once the growth plate closes this problem cannot happen.

A 2023 systematic review in BMJ Open by Nieto-Gil and colleagues pooled 11 observational studies covering 1,265 participants aged 6 to 15. The mean age was 10.72 years, with a peak in both boys and girls between 10 and 12. It appeared earlier in girls, at around 11 years, than in boys, at around 12. The review reported an incidence of 3.7 per 1000 patients, and noted that the condition accounts for between 2% and 16% of consultations in sports clinics.

The risk factors that same review found are the ones worth acting on. Limited ankle dorsiflexion, meaning how far the knee can travel forward over the foot with the heel down, was the most frequently studied factor across those studies. Peak plantar pressures came second. Foot alignment, including pronated feet, also appeared. Body mass index produced conflicting findings across studies rather than a clear answer. The sports that showed up most were athletics, football, basketball, ballet and tennis.

How the squeeze test tells you what you are dealing with

The 2013 systematic review in the Journal of Foot and Ankle Research by James, Williams and Haines states that diagnosis should be confirmed by medial and lateral compression, known as the calcaneal squeeze test. StatPearls describes the same thing: pain reproduced by manual compression of the back of the heel bone from both sides.

Pressing the sides of the heel bone loads the growth plate while leaving the plantar fascia under the arch and the Achilles above it alone. So when squeezing reproduces the exact pain your child complains about, the growth plate is the likely source.

The rest of the picture usually fits. Pain sits at the back and sides of the heel, is worse during and after activity, and settles with rest. It is often worse on hard surfaces or in flat, worn shoes. Both heels are involved in a large share of cases.

What does not fit that picture matters more. Swelling, redness, warmth, heel pain that wakes a child at night, pain that is present sitting still, fever, or a child who has become unwell needs a physician rather than a rehabilitation appointment. StatPearls notes that raised inflammatory markers on blood work may point to a bone infection rather than Sever's. Those features are uncommon, and they are the reason a clinician asks about them every time.

Telling it apart from three conditions it gets confused with

Plantar fasciitis is an adult diagnosis. The plantar fascia runs under the arch and attaches to the underside of the heel. Its classic story is pain in the first steps out of bed in the morning that eases after walking. Sever's pain is at the back of the heel and is worse after activity rather than first thing. Plantar fasciitis in a child under 14 is uncommon enough that a clinician should look harder before accepting it. If you want the adult version for comparison, we have written about what the first six weeks of plantar fasciitis actually involve.

A calcaneal stress fracture is the one that changes the plan. A stress fracture in the heel bone gives pain that is present with walking rather than only with sport, and it tends to keep getting worse over weeks instead of settling with a few easy days. Pain at rest, night pain, or a child who will not weight-bear points this way. StatPearls lists imaging as appropriate when the presentation is atypical or severe, or when it persists after 4 to 8 weeks of conservative management. That 4 to 8 week marker is a useful thing for a parent to hold onto.

Achilles tendinopathy sits above the heel, not on it. The sore spot is in the tendon itself, roughly 2 to 6 centimetres up from the heel bone, and it is often tender to pinch between two fingers. It is far more common in adults and in older teenagers whose growth plates have closed. Our post on how Achilles tendinopathy responds to loading covers that one in detail.

Bone tumours, tarsal coalition, retrocalcaneal bursitis and heel contusion also appear on the StatPearls differential list. Those are rare, and they are checked by history and examination.

The footwear and heel lift question, answered honestly

Heel lifts and orthoses are the most common things handed to a child with this problem. The evidence behind them deserves a straight answer.

The 2013 review concluded that there is limited evidence to support the use of heel raises and orthoses for children who have heel pain related to calcaneal apophysitis. Orthoses looked better than heel raises for short-term pain relief in the studies available, and the authors advised caution because of methodological problems in that research.

A 2024 systematic review in the Journal of Clinical Medicine by Hernandez-Lucas and colleagues reviewed eight randomised controlled trials and reached a more positive position. Its conclusion: "Conservative interventions, such as the use of insoles, physical therapy, and Kinesio taping, seem to have a positive effect in reducing pain and improving functionality." Insoles came out as the most effective category in that review, with personalised options outperforming generic ones. The review also found that physical therapy including stretching and massage can lead to a decrease in pain.

What that means in practice. A heel lift raises the heel inside the shoe, which reduces how far the Achilles has to stretch and takes some pull off the growth plate. It is cheap and reversible, so a child can try it for two weeks and tell you whether it helped. Both shoes get one, even when only one heel hurts, because raising one side alone changes leg length.

Shoes matter as much as inserts. Flat, worn-out footwear with no heel height makes this worse. Cleats and spikes have little cushioning at the heel, which is often why symptoms are worse at soccer than at basketball. A cushioned heel cup inside a cleat is a practical fix for a season. Before paying for custom devices, our post on what a foot assessment actually looks at before custom orthotics walks through that decision.

Load management across a multi-sport season

This is the part that decides how the season goes, and it is the part most often handled badly in both directions.

Complete rest is a poor plan. Take a child out of sport for six weeks and the heel calms down, because nothing is loading it. Then they return at the same volume, with the same calf tightness, and it comes back within two weeks. Meanwhile they have lost conditioning and missed time with their team. Pushing through unchanged is also a poor plan, because pain that climbs week on week tends to end in a child who cannot walk comfortably at school.

The workable middle is adjusting the dose. A guide most families can follow:

• Use a pain scale out of 10 during activity. Pain up to about 3, settling by the next morning, is usually tolerable to continue with.
• Pain above that, a limp that lasts into the next day, or pain climbing week on week means the load needs to drop for a fortnight.
• Cut the highest-impact elements first. Sprinting, jumping and change of direction load the heel more than steady running or skills work.
• Count everything. School PE, recess, three club practices and two games a week add up to a training load many adults would struggle with.
• Keep the child in the sport in some form. Goalkeeper drills, skills work, swimming or cycling maintain fitness and team membership while the heel settles.

Multi-sport kids in Metro Vancouver often have overlapping seasons, so soccer finishes as basketball starts and there is no off-season. When a schedule has no gap in it, dropping one competition or one weekly practice for six weeks is usually the change that works.

The calf and foot work that reduces the odds of it returning

Since limited ankle dorsiflexion was the most frequently studied risk factor in the 2023 BMJ Open review, and since the 2024 review found stretching and massage can reduce pain, the exercise side of the plan has a reasonable basis.

Calf flexibility targets the two muscles running into the Achilles. One is stretched with a straight back knee, the other with the knee bent, so both positions are needed. During a growth spurt this is maintenance work rather than a two-week fix.

Calf strength matters as much as length, because a growth plate tolerates load better when the muscle above it absorbs some. Heel raises, progressed from two legs to one leg and then to slow lowering, are the usual starting point.

Foot and ankle control covers how the foot contacts the ground. Balance work on one leg and controlled landing practice fit here. The plantar pressure finding in the 2023 review is why a child's landing gets attention alongside their calf flexibility.

Hip and knee strength is worth including in a child growing fast. Osgood-Schlatter disease at the knee appeared as a co-occurring condition in that review.

None of this is complicated. It runs 10 to 15 minutes, most days, over months rather than weeks. The job of the appointment is choosing the starting dose and adjusting it.

How long an episode lasts, and why it often comes back

The 2024 review states that patients tend to be pain-free after a period ranging from a few weeks to several months, and that full recovery is expected after closure of the calcaneal apophysis. StatPearls describes the same self-limited course, resolving with maturation and closure of the growth plate.

Set expectations from that. An individual episode often settles in a few weeks with load adjustment and a heel lift, though some run for months. The growth plate closes somewhere in the 8 to 14 window and the problem cannot recur after that, with the timing of closure varying between children.

Recurrence in the same season is common and normal. StatPearls puts it directly: recurrence may occur, particularly during periods of increased activity, and it will not persist after apophyseal closure. A heel that settled in October and flares again in February when basketball starts is following the expected pattern rather than signalling that something was missed. Families who know that in advance handle the second episode calmly, because they already know what worked the first time.

There are still good reasons to manage it properly despite it ending on its own. Months of limping change how a child moves. Pain leads to dropping out of sport at the age when sport habits form. A heel that is never assessed also means an uncommon stress fracture or infection goes unchecked.

What a first visit looks like

A first physiotherapy appointment for a child with heel pain starts with questions the parent usually answers. When it started, whether there was an injury, which activities bring it on, whether it wakes them at night, how the shoes look, how many hours a week of sport they do across every sport and school, and whether they have grown quickly in the past year.

The physical part is short. Your child's therapist will squeeze the heel, feel along the Achilles and under the arch, measure ankle dorsiflexion on both sides, watch walking and a few hops, and check calf strength. They will look at the shoes your child wears to sport, so bring them.

Most children leave with a heel lift or footwear change to try, an adjustment to their weekly training load, two or three exercises, and a marker for what should have changed by the next appointment. X-rays are rarely needed at a first visit, because the diagnosis is made from history and examination.

Physiotherapy is a direct-access profession in British Columbia, regulated by the College of Health and Care Professionals of BC, so no physician referral is needed to book an assessment for your child. Some extended-health plans require a referral for reimbursement, so check with your insurer before the first visit.

When to see a physician instead

Book with your child's doctor rather than a rehabilitation clinic if the heel pain comes with fever, if it wakes your child at night, if there is swelling, redness or warmth around the heel, or if the pain is there at rest and not only with activity. A child who refuses to put weight on the foot at all, or whose pain has been climbing steadily for weeks rather than fluctuating with activity, also needs medical assessment first.

Those features point away from a growth plate that is irritated by load and towards something that needs imaging or blood work. They are uncommon. Asking about them takes one minute and is worth the minute.

This article is general information, not personal medical advice. A regulated practitioner can confirm whether the patterns described apply to you.

Frequently asked questions

What is Sever's disease?

Sever's disease, known medically as calcaneal apophysitis, is irritation of the growth plate at the back of the heel bone in a growing child. The Achilles tendon attaches to that area, so running and jumping pull on a growth plate that is still cartilage. StatPearls describes the growth plate as typically beginning to close between the ages of 8 and 14, which is why the condition sits in that age band. It is not a disease in the way the name suggests.

How do I know if my child has it?

Squeeze the back of the heel between your thumb and fingers from both sides. The 2013 review in the Journal of Foot and Ankle Research states that diagnosis should be confirmed by medial and lateral compression, the calcaneal squeeze test, and StatPearls describes pain reproduced by the same manoeuvre. If that reproduces your child's pain, and the pain sits at the back of the heel, is worse after sport and settles with rest, the pattern fits. A clinician confirms it and rules out the less common causes.

What age does Sever's disease affect?

Most commonly children between about 8 and 14. The 2023 systematic review in BMJ Open pooled 11 studies with 1,265 participants aged 6 to 15 and reported a mean age of 10.72 years, with a peak in both boys and girls between 10 and 12. It appeared earlier in girls, at around 11 years, than in boys, at around 12.

Does my child have to stop playing sport?

In most cases, no. The usual approach is adjusting how much and what type of activity rather than stopping altogether. Pain up to about 3 out of 10 during activity that settles by the next morning is generally tolerable to continue with, while a limp lasting into the next day means the load should drop for a couple of weeks. Cutting sprinting and jumping first, keeping skills work and swimming, maintains fitness and team involvement.

Do heel lifts actually work?

The evidence is mixed and the honest answer reflects that. The 2013 systematic review concluded there is limited evidence to support heel raises and orthoses for this condition, with orthoses looking better than heel raises for short-term pain relief. The 2024 review in the Journal of Clinical Medicine was more favourable, finding insoles the most effective of the interventions studied, with personalised options outperforming generic ones. A heel lift is cheap and reversible, so trying one for two weeks is a reasonable first step.

How is it different from plantar fasciitis?

Plantar fasciitis affects the band under the arch and typically causes pain in the first steps out of bed that eases with walking. It is an adult condition and is uncommon in children under 14. Sever's pain sits at the back and sides of the heel bone and is worse during and after activity rather than first thing in the morning. The squeeze test loads the growth plate and not the plantar fascia, which is what makes it useful for telling the two apart.

Could it be a stress fracture instead?

A calcaneal stress fracture gives pain with ordinary walking rather than only with sport, and it tends to worsen steadily over weeks rather than settle with easier days. Pain at rest, pain that wakes a child at night, or refusal to weight-bear point that way. StatPearls lists imaging as appropriate when the presentation is atypical or severe, or when symptoms persist after 4 to 8 weeks of conservative management.

How long does it take to get better?

The 2024 systematic review states that patients tend to be pain-free after a period ranging from a few weeks to several months. An individual episode often settles within a few weeks once the training load is adjusted, though some run longer. The condition resolves fully once the growth plate closes, which StatPearls describes as beginning somewhere between ages 8 and 14.

Will it come back?

Often, yes, and that is expected. StatPearls states that recurrence may occur, particularly during periods of increased activity, and will not persist after apophyseal closure. A heel that settles during one season and flares when a new sport starts is following the normal pattern. Families who know this in advance tend to manage the second episode themselves, using what worked the first time.

What exercises help?

Calf flexibility work in two positions, one with the back knee straight and one with it bent, targets both muscles running into the Achilles. Calf strength work through heel raises, progressed from two legs to one leg and then to slow lowering, builds tolerance to load. Balance and landing practice addresses how the foot contacts the ground. The 2023 BMJ Open review found limited ankle dorsiflexion the most frequently studied risk factor, and the 2024 review found stretching and massage can reduce pain. Your child's therapist will set the starting dose.

When should I take my child to a doctor instead?

See a physician rather than a rehabilitation clinic if the heel pain comes with fever, night pain that wakes your child, swelling, redness or warmth, or pain present at rest rather than only with activity. A child refusing to weight-bear, or whose pain climbs steadily over weeks, also needs medical assessment first. StatPearls notes that raised inflammatory markers may point to a bone infection instead of Sever's disease.

Do I need a referral to see a physiotherapist in BC?

No. Physiotherapy is a direct-access profession in British Columbia, regulated by the College of Health and Care Professionals of BC, so you can book an assessment for your child without a physician's referral. Some extended-health insurance plans require a referral for reimbursement even though the profession does not, so confirm with your insurer before the first visit.

Sources

• Nieto-Gil et al., "Risk factors and associated factors for calcaneal apophysitis (Sever's disease): a systematic review," BMJ Open, 2023
• Hernandez-Lucas et al., "Conservative Treatment of Sever's Disease: A Systematic Review," Journal of Clinical Medicine, 2024
• James, Williams and Haines, "Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review," Journal of Foot and Ankle Research, 2013
• Smith and Varacallo, "Sever Disease (Calcaneal Apophysitis)," StatPearls, 2024
• College of Health and Care Professionals of BC, physiotherapist scope of practice