Pain at the back of the heel in children is a common complaint especially in kids aged between 8 and 12 years old. It is caused by inflammation of the growth plate (apophysis) at the back of the heel bone (calcaneus) where the Achilles tendon attaches to the foot and is best described as Calcaneal Apophysitis.

Calcaneal Apophysitis is a mouthful, so sometimes it is easier to think of it as a growth plate irritation. It can unfortunately,  also be known as "Sever's Disease" (named after Dr Sever who first described the condition back in the early 1900's) which makes it sound terrible.  But it is not a disease and thankfully this term is slowly being phased out.

Causes
  • irritation to the growth plate by repetitive micro-traumas and tractioning of the Achilles tendon at its insertion, that can occur during running and jumping
  • it is not caused by a single injury but is an overuse injury
  • commonly seen in children who play high impact sports like basketball, netball, football and soccer
  • taller children and heavier children seem to be at a higher risk 
  • improper, ill fitting  footwear can further irritate the heel bone
  • not enough recovery time between hard sporting sessions
  • a change of training volume or intensity
  • a change in the playing surface 
Symptoms
  • Pain in the back of the heel 
  • Limping during or after sport. Often your child will avoid putting the heel on the ground and walk on their tip toes
  • As the pain progresses, they may also limp in the morning or have trouble returning to the field after quarter or half time because of the pain 
Treatment
The aim of the game is pain management.

The condition is self-limiting (it will eventually get better by itself) but research shows the longer a child has had heel pain the great the severity of the pain can be.

Growth plate irritation can also negatively impact on a kids quality of life. 

Children usually respond quickly to treatment and early intervention can make a huge difference.

Treatment options include 
  • Non-steroidal anti-inflammatory medication,
  • Relative rest. It's very difficult to ask a kid to stop playing sport or to stop running around at school.  Studies have shown that stopping a kid being physically active can also negatively impact on them socially. A good idea is to avoid activities that make the pain worse 
  • Ice directly post activity can help
  • Taping
  • Heel lifts
  • Footwear advice 
  • Strengthening programs
  • Depending on foot type there are different orthotic designs; all are aimed at decreasing traction or impact at the calcaneal apophysis

What about stretching?
This is a question I get asked all the time. 

And the answer is a firm no to stretching. 

In the old days (and it can still persist even today) the advice would have be to stretch the calf and Achilles to decrease stress at the calcaneal apophysis.  But it makes no sense 

For two reasons
1. Contrary to well held beliefs, recent studies have shown that many kids with calcaneal apophysitis don't have  calf tightness. 
2. The irritation to the growth plate can be caused by traction, or pulling  of the Achilles Tendon. Stretching the calf tractions or pulls the Achilles Tendon on the growth plate.

​So why would you make kids stretch their calf?

If you child does have tightness in the calf then we can look at other mobility options to improve function without  'poking the bear' by stretching 
James, A.M., Williams, C.M. & Haines, T.P. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review. J Foot Ankle Res 6, 16 (2013). https://doi.org/10.1186/1757-1146-6-16

McSweeney, S. C., Reed, L., & Wearing, S. (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

Alicia, J., Cylie, W. & Terry, H. Contributing factors in children who present with calcaneal apophysitis. J Foot Ankle Res 8, O21 (2015). https://doi.org/10.1186/1757-1146-8-S2-O21

Rachel JN, Williams JB, Sawyer JR, Warner WC, Kelly DM. Is Radiographic Evaluation Necessary in Children With a Clinical Diagnosis of Calcaneal Apophysitis (Sever Disease)?. Journal of Pediatric Orthopaedics. 2011;31(5):548–550. doi: 10.1097/BPO.0b013e318219905c.