Heel Pain in Young Athletes: Understanding Calcaneal Apophysitis
What Is Calcaneal Apophysitis?
When a child or adolescent athlete complains of heel pain, the most common diagnosis is calcaneal apophysitis — more commonly known as Sever's disease. Despite the name, it is not a disease in the traditional sense; it is a growth plate injury at the back of the heel bone (calcaneus).
During childhood and early adolescence, bones grow from areas called apophyses — cartilaginous growth plates where tendons and ligaments attach. The Achilles tendon inserts into the growth plate at the back of the heel, and the plantar fascia attaches along the bottom. When a child is growing rapidly and participating in repetitive high-impact activities, these structures pull repeatedly on the still-developing growth plate, causing inflammation, microstress, and pain.
Sever's disease most commonly affects children between ages 8 and 14, with peak incidence around ages 10 to 12. It is more common in boys than girls, and it frequently presents at the start of a new sports season — particularly soccer, basketball, and football — when training intensity increases quickly.
Recognizing the Symptoms
The pain of calcaneal apophysitis is located at the back of the heel, where the Achilles tendon meets the bone. It is typically:
- Worse during or immediately after activity
- Relieved with rest
- Aggravated by running, jumping, or walking on hard surfaces
- Associated with a limp or tendency to walk on the toes to offload the heel
A classic finding on physical examination is the "squeeze test": applying gentle pressure to both sides of the heel simultaneously reproduces the pain. X-rays are often obtained to rule out other causes of heel pain — stress fracture, bone cyst, or infection — but the growth plate fragmentation sometimes visible on imaging is a normal developmental finding, not diagnostic in itself.
Treatment and Return to Activity
The encouraging news is that Sever's disease is self-limiting. It resolves once the growth plate closes, typically in the mid-teens. The goal of treatment is to manage pain and allow continued participation in activity at a tolerable level.
Activity modification — Complete rest is rarely necessary and often counterproductive. Reducing the volume and intensity of the aggravating activity is usually sufficient to allow symptoms to settle.
Heel cushions or cups — Inserting a cushioned heel lift into the shoe reduces impact forces on the growth plate and is one of the simplest and most effective interventions.
Stretching — Regular calf stretching and plantar fascia mobilization reduce the pull of the Achilles tendon on the growth plate. Stretching is most effective when done consistently, not just before and after activity.
Anti-inflammatory medication — Short-term use of ibuprofen or naproxen can help manage pain during flare-ups, but should not be used routinely to allow participation through significant pain.
Footwear assessment — Cleated athletic shoes with minimal heel cushioning, particularly on artificial turf, increase ground reaction forces on the heel. Switching to well-cushioned training shoes for practice, where appropriate, can reduce symptom burden.
In cases where these measures do not adequately control pain, a short period of immobilization in a walking boot may be recommended to allow the growth plate to calm down before a graduated return to activity.
If your child is experiencing heel pain that is affecting their activity, the specialists at Maryland Orthopedic Specialists can help. Call (301) 515-0900 or [schedule an appointment online](https://www.mdorthospecialists.com/contact).
