Health & Recovery

What is Sever’s Disease
Sever’s disease, or calcaneal apophysitis, is a common cause of heel pain in young athletes, particularly footballers. It occurs when repetitive stress from activities such as running and jumping leads to inflammation of the growth plate in the heel bone (calcaneus). This condition typically affects children and adolescents during periods of rapid growth, when the growth plate is most vulnerable to irritation and overload.

Symptoms:
Here are some common symptoms associated with Sever’s disease:

Heel pain: Footballers with Sever’s disease typically experience pain in the back or bottom of the heel. The pain may be described as aching or throbbing and is often worse during or after physical activity, especially running or jumping.
Tenderness and swelling: The affected area may be tender to touch, and there may be localised swelling around the back of the heel. Swelling can vary in severity and may worsen with increased activity.
• Limping or altered gait: Footballers may exhibit a limp or an altered walking pattern to avoid putting excessive pressure on the affected heel. This compensation may be more noticeable after periods of rest or upon resuming physical activity.
Discomfort with pressure: Applying pressure to the heel, such as when wearing tight-fitting shoes or during activities that involve running or jumping, can exacerbate the pain. Footballers may find it uncomfortable to participate fully in training or competitive matches.
Stiffness and reduced range of motion: The heel may feel stiff, and footballers may experience a limited range of motion in the ankle joint. This can affect their ability to perform certain movements, such as dorsiflexion (bringing the foot upward).
Increased symptoms during growth spurts: Sever’s disease commonly occurs during growth spurts when the bones are rapidly growing. Footballers may notice an increase in symptoms during these periods and may have more difficulty participating in football activities.

Causes and Risk Factors

Rapid growth: During growth spurts, bones and soft tissues may grow at different rates, leading to tension and stress at the growth plate.
Overuse and repetitive activity: Football players repeatedly engaging in high-impact activities, such as running and jumping, place increased stress on the heel bone and the attached Achilles tendon.
Muscle imbalances: Weakness or tightness in the calf muscles can contribute to increased stress on the growth plate.
• Lack of recovery time between sessions exacerbates inflammation.
• High Body Mass Index (BMI): Overweight or higher BMI athletes place more load on the calcaneal growth plate.
• Foot Biomechanics Abnormalities: Flatfoot (pes planus) and excessive pronation lead to altered force distribution during running/jumping. These conditions increase tension on the Achilles tendon and stress on the heel.
Hard Playing Surface: Hard artificial turf surfaces or courts can add mechanical stress compared to natural grass if regularly predisposed.

Recovery Time
• Total Recovery can take anywhere from 6-8 18months, in some cases even lasting up to 2 years
• In the study titled “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,” the average return-to-play (RTP) time for athletes diagnosed with Sever’s disease was 4.1 weeks

Treatment Overview for Sever’s Disease
Sever’s disease can be managed effectively with a combination of strategies aimed at relieving pain, supporting healing, and preventing recurrence:
Pain Management: Use ice, rest, and over-the-counter medications (like ibuprofen) as directed to reduce discomfort.
Activity Modification: Limit or avoid high-impact activities (like running and jumping) during flare-ups. Low-impact alternatives like swimming or cycling can help stay active without stressing the heel.
Load Management: Gradually return to sport with a structured plan that increases activity levels in small, pain-free steps.
Strengthening: Focus on exercises that improve foot, calf, and leg strength to support better movement and reduce strain on the heel.
Muscle Release: Gentle stretching and massage techniques, especially for tight calf muscles, can reduce tension on the heel.
Taping Techniques: Supportive taping may help reduce stress on the heel during activity and provide pain relief.
Orthotic Devices: Heel cups or custom orthotics can cushion the heel and improve foot alignment during recovery.
Footwear Modifications: Supportive shoes with good cushioning and a slight heel lift can reduce pressure on the growth plate

Load Management
Recovery is not just about rest; it’s about managing how much and how quickly activity is added back in. This is called load management, and it plays a key role in healing and preventing the pain from coming back.

Why Load Management Matters?
1. Too much too soon can delay healing or cause setbacks.
2. Gradually increasing activity helps the heel adapt without being overloaded.
3. Balancing sport with rest supports healthy growth and long-term performance.

2-4weeks:
– Low Impact / low Volume
– Complete rest from High impact activities such as jumping, sprinting, gist agility.
– Training total 1 hour for the week (30minute training with team x2/week).
– Avoiding sprinting and game like drills/scenarios at training.
– Training: Skills, tactical drills, jogging based drills, light agility.
– 1 hour Rehab with Physio or Strength and Conditioning (30minute rehab x2/week)

4-6 weeks:
– Medium Impact/ Medium Volume
– Start reintroducing drills with sprinting based elements, more aggressive agility work and game like scenarios/drills.
– Not playing games
– Commence Plyometrics in Rehabilitation
– Training total 90 minutes for the week (45 minutes training with team x2/week).
– 1 hour Rehab with Physio or Strength and Conditioning (30minute rehab x2/week)

6-8 weeks:
– High Impact/ High Volume
– Full Spiriting reintroduced
– Completing Game Simulation/ game scenario drills, to onset of symptoms.
– Continue and progress Plyometrics rehabilitation
– Return to play with minutes managed

6-8 weeks +:
– Full return to play and training
– Continue with long-term injury prevention programme given by physio.

References:

1. Hernandez-Lucas, P., Leirós-Rodríguez, R., García-Liñeira, J., & Diez-Buil, H. (2024). Conservative treatment of Sever’s disease: A systematic review. Journal of Clinical Medicine, 13(5), 1391. https://doi.org/10.3390/jcm13051391

2. James, A. M., Williams, C. M., & Haines, T. P. (2013). 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, 6, 16. https://doi.org/10.1186/1757-1146-6-16

3. McSweeney, S. C., Reed, L., & Wearing, S. C. (2018). Foot mobility magnitude and stiffness in children with and without calcaneal apophysitis. Foot & Ankle International, 39(5), 585–590. https://doi.org/10.1177/1071100717750889