Back Pain Doctor
Sever's Disease (Calcaneal Apophysitis)
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Sever’s disease is irritation of the growth area at the back of the heel bone, where the Achilles tendon attaches. During growth spurts the heel bone and the calf muscle-tendon unit grow at different rates, and running and jumping concentrate load on a growth plate that is not yet mature. It is typically seen in active children of about 7 to 14 years, either heel can be affected, and it does not indicate serious damage.
Assessment focuses on the history of activity-related heel pain and tenderness at the heel. The diagnosis is clinical. X-rays do not confirm it and are used only to exclude other problems when the picture is atypical, for example with night pain, swelling, fever, an injury or a child outside the usual age range.
First-line care is a temporary reduction in running and jumping, with swimming or cycling to stay active, well-fitting sports shoes, heel pads and gentle calf stretching once the acute pain eases. The research on specific treatments is limited, with small and varied trials, so results vary and cannot be guaranteed. Clinic procedures such as injections or shockwave are not used for children with this condition. See your GP if heel pain is stopping sport or play, or if there is night pain, swelling or a fever.
This page is general information, not a substitute for individual medical advice.
Common symptoms
- Pain at the back or sides of the heel
- Pain during or after running and jumping
- Tenderness when the heel is squeezed from the sides
- Limping or walking on tiptoes, in one or both feet
Commonly seen in
Evidence for twelve treatment options in sever's disease (calcaneal apophysitis)
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. The treatment
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
A 2024 systematic review of eight randomised trials found insoles, heel cups and orthoses, physiotherapy and Kinesio taping generally reduced pain and improved function, but the trials were small and varied, no meta-analysis was possible, and sham taping reduced pain as much as real taping (Hernandez-Lucas, J Clin Med 2024). An earlier review found rest, ice and stretching were given as a bundle and never tested separately (James, J Foot Ankle Res 2013). The Perth Children's Hospital guideline advises short-term limitation of running and jumping, heel pads, well-fitting shoes and gentle Achilles stretching once the acute episode settles.
Pairing reviewed 2026-11-07.
Where it fits
The mainstay of care is activity adjustment, footwear and heel pads, and calf stretching, alongside reassurance. The evidence is limited, from small and varied trials, and benefit cannot be guaranteed.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Not offered to children
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Not offered to children
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Not offered to children
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Not offered to children
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Not offered to children
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Not offered to children
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Not offered to children
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Not offered to children
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not offered to children
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Not offered to children
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Not offered to children
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.
Pairing reviewed 2026-11-07.
Where it fits
Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other foot, ankle & lower leg conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
Does my child need an X-ray?
What helps?
How long does it last?
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