A parent brings their 11-year-old in because her heel has hurt after every soccer game for three weeks. They've done some reading, and they're worried. Maybe it's plantar fasciitis, the heel problem everyone has heard of. Or maybe a coach or pediatrician has already said the words "Sever's disease," and that word, disease, has them imagining the worst.
I always start by easing that fear, because Sever's isn't a disease at all. Its more accurate name is Sever's apophysitis. When most of us hear "disease," we picture an illness, something that spreads through the body, causes lasting damage, or has to be managed for life. Sever's is nothing like that. "Apophysitis" simply means inflammation of an apophysis, a growth plate where a tendon attaches to bone. A tight calf and Achilles tendon pull on the growth plate at the back of the heel until it becomes irritated and sore. Your child's bone is healthy, the problem is temporary, it responds well to care, and it goes away for good once that growth plate finishes growing.
It's also, by far, the more likely answer. When a child is between about 8 and 14 and plays a running or jumping sport, heel pain is usually Sever's, not plantar fasciitis. The two get mixed up all the time: both cause heel pain, both are tied to tight calves, and both get worse with activity. But they sit in different parts of the heel, show up at different ages, and are handled differently. Knowing which one your child has tells you what's going on and what will actually help.
The Short Answer: It's Usually Sever's
Sever's only happens in kids who are still growing, most often during a growth spurt, and it's the most common cause of heel pain in active children.
Plantar fasciitis is irritation of the thick band of tissue on the bottom of the foot, where it attaches to the heel. It's very common in adults, and it can show up in older teens, but it's much less common in younger kids whose heel growth plate is still open.
The growth plate is simply taking more pull from a tight calf and Achilles tendon than it can comfortably handle. That's good news, because the pull is something we can do something about, and kids usually respond quickly once it eases.
Where It Hurts: Back of the Heel or Bottom?
This is the single most useful clue, and you can check it at home.
Sever's hurts at the back of the heel and along its sides, right where the Achilles tendon attaches and just below. A simple test: gently squeeze both sides of the back of your child's heel between your thumb and fingers. If that squeeze is clearly tender, Sever's is very likely.
Plantar fasciitis hurts on the bottom of the heel, toward the inside, and sometimes along the arch. Pressing up into the bottom of the heel is what's tender, not squeezing the sides.
When It Hurts: During Sports or First Thing in the Morning?
Sever's hurts during and after activity. Running, jumping, and games on hard fields make it worse, and rest usually makes it better. Many kids start limping or walking on their toes after practice to keep weight off the back of the heel. It often affects both heels.
Plantar fasciitis is known for first-step pain. The first few steps out of bed in the morning, or after sitting for a while, are the worst, and it often eases after a few minutes of walking. (I explain why in Why Does Plantar Fasciitis Hurt Worse in the Morning?)
Who Gets It: Growing Kids vs. Older Teens and Adults
Sever's shows up during the growth years, most often around ages 8 to 14, and tends to flare at the start of a new season or right after a growth spurt. Soccer, basketball, running, gymnastics, and any sport played in cleats are the usual triggers. Once the heel's growth plate closes, usually in the mid-teens, Sever's can't happen anymore.
Plantar fasciitis is mostly an adult condition. In teens, it's more likely in older teens whose growth plates have already closed, and in kids with very flat feet or a big jump in running volume.
Side by Side: How to Tell Them Apart
Sever's Disease
- Pain at the back and sides of the heel
- Squeezing the sides of the heel hurts
- Worse during and after sports, better with rest
- Ages about 8 to 14, during growth spurts
- Often both heels; may limp or toe-walk after games
Plantar Fasciitis
- Pain on the bottom of the heel and arch
- Pressing into the bottom of the heel hurts
- Worst with the first steps in the morning
- Older teens and adults
- Often linked to flat feet or a jump in running
Why the Difference Matters
Because the two problems sit in different places, the most helpful care is aimed at different spots. With Sever's, the goal is to take pressure off the growth plate at the back of the heel, mainly by easing the pull from a tight calf and Achilles tendon. With plantar fasciitis, the work focuses more on the tissue on the bottom of the foot and the arch.
Mixing them up usually isn't dangerous, but it can mean weeks of the wrong stretches, the wrong inserts, or the wrong advice about whether to keep playing, while the actual problem keeps flaring.
How We Treat Sever's in Our Office
Every visit starts with a thorough exam, and you're welcome in the room the whole time. For Sever's, treatment is about releasing what's pulling on the heel:
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1Releasing the calves and Achilles tendon Sustained-pressure myofascial therapy and Active Release Technique loosen the tight calf muscles and Achilles tendon that pull on the heel's growth plate. This is usually the biggest single factor in calming the heel down.
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2Working up the leg Tight hamstrings and hips add to the pull through the back of the leg, so we release and stretch those too, including assisted stretching.
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3Stretches and strength work to do at home We teach your child simple calf and hamstring stretches and a few foot and balance exercises, so the tightness doesn't build right back up during the season.
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4Gentle foot and ankle adjusting, if you choose When a stiff ankle or foot joint is adding to the strain, a gentle adjustment can help. It's always optional, and kids still get better without it.
Kids respond quickly. Most feel noticeably better within three or four visits, and many keep playing with a few changes to their practice load while we treat them. You can read more about how we care for young athletes on our Kids & Teens page.
What You Can Do at Home
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1Stretch the calves every day Gentle calf stretches, with the knee straight and then bent, held about 30 seconds each, before and after practice and at bedtime.
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2Ice after activity About 15 minutes on the back of the heel after practice or games can calm a flare.
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3Check the shoes Worn-out shoes and flat cleats with little heel support make it worse. Supportive shoes off the field help.
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4Heel cups can help, but they're a support, not a fix A cushioned heel cup slightly raises the heel and eases the pull on the growth plate, which many kids find more comfortable in cleats. But it doesn't loosen the tight calf causing the problem, so it works best alongside stretching and treatment.
When to See Your Pediatrician First
The heel pain started after a hard fall, jump, or other injury; your child can't put weight on the foot; there's significant swelling, redness, or warmth; the pain wakes them at night or is there even at rest; or they have a fever along with the pain. Those patterns can point to something other than Sever's or plantar fasciitis and deserve a proper medical look first. When in doubt, call us and we'll help you decide.
The Bottom Line
If your child is still growing, plays a running or jumping sport, and the back of the heel hurts after games, it's most likely Sever's, not plantar fasciitis. It's common, it's temporary, and it usually responds quickly once the tight calf and Achilles pulling on the heel are released.
Learn how we help kids and teens with heel, knee, and back pain, book an appointment here, or call or text us at 650-735-1716. If it's you, not your child, with heel pain on the bottom of the foot, our plantar fasciitis page explains how we treat it in adults.