summary Sever's Disease is a common idiopathic condition caused by overuse injury of the calcaneal apophysis in a growing child that presents with posterior heel pain. Diagnosis is made clinically with tenderness over the calcaneal apophysis with foot radiographs showing sclerosis and fragmentation of the calcaneal apophysis. Treatment is usually activity modifications, stretching of the heel cord and NSAIDs as the condition typically resolves over time. Epidemiology Demographics commonly seen in immature athletes participating in running & jumping sports frequently seen just before or during peak growth Etiology Mechanism exact etiology is unknown thought to be due to traction apophysitis and repetitive microtrauma experienced during gait (similar to Osgood Schlatter's Disease) anatomy The calcaneal apophysis experience significant force from combination of both direct impact onto the heel during the heel strike phase of gait opposing tension forces generated by the plantar fascia and the pull of the gastrocsoleus complex Presentation Symptoms pain in the area of the calcaneal apophysis in an immature athlete pain increased with activity or impact stretch of the triceps surae exacerbates heel pain can display warmth, erythema, & swelling Physical exam tight Achilles tendon positive squeeze test (pain with medial-lateral compression over the tuberosity of the calcaneus) pain over the calcaneal apophysis Imaging Radiographs diagnosis is clinical as there is no established diagnostic criteria sclerosis can be present in both patients with and without calcaneal apophysitis fragmentation is more frequently seen in patients with Sever's disease helpful to rule out other causes of heel pain (osteomyelitis, calcaneal bone cysts) MRI can help localize inflammation to apophysis can rule out disorders of the body of the os calcis (stress fracture, lytic lesion, osteomyelitis) Other bone scan can show increase uptake at the apophysis, but is typically not helpful in diagnosis Treatment Nonoperative symptomatic treatment modalities include activity modification Achilles tendon stretches (can help decrease recurrence) ice application before and after athletic endeavors use of heel cups or heel pads NSAIDs short leg cast immobilization of persistent pain outcomes recurrence is common Operative there is no role for operative treatment Prognosis Natural history self-limiting entity that resolves with maturation and the closure of the apophysis