Sever disease

Case contributed by Dinesh Brand


Posterolateral heel pain

Patient Data

Age: 13 years
Gender: Male

There is increased density of the calcaneal apophysis, typical for ages between 7 and 14 years. There is loss of fat/soft tissue planes in the region of the retrocalcaneal bursa in keeping with acute inflammation. This may be seen in the context of the clinical diagnosis of Sever disease

Ultrasound may be clinically indicated.


There is an increase of vascularity on Doppler interrogation while scanning at this site. The appearances are suggestive of Sever disease. There is no focal mass lesion or abnormal fluid collection identified.

Case Discussion

Calcaneal apophysitis also known as Sever disease is mostly seen in physically active children. It is usually self-limiting. 

Fragmentation of the secondary nucleus may play an important factor in the diagnosis of Sever disease, although this remains controversial in radiographic studies 1. Children may show considerable variation in the radiographic appearance of the secondary ossification center of the calcaneus at different ages 2.

One study showed that symptomatic heels of 14 children showed fragmentation of the secondary nucleus on both conventional radiographs and sonograms proving that ultrasonography may be valuable in the diagnosis of Sever disease with clinical correlation 1.  

Another study showed that the difference in a normal cohort and apophysitis cohort was the degree of fragmentation of the secondary nucleus on conventional radiographs, which was greater in the apophysitis group 2. This suggests that a mechanical etiology contributes to the condition. 

Both radiography and ultrasonography may prove valuable in the clinical diagnosis of calcaneal apophysitis also known as Sever disease, eponymously named after, an American orthopedic surgeon, James Sever in 1912 2.

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