Severs skada – paradigmskifte gällande diagnostik och behandling?

Bilaga 4
Scand J Med Sci Sports 2011: 21: 819–823
doi: 10.1111/j.1600-0838.2010.01051.x
Sever’s injury: treatment with insoles provides effective pain relief
S. Perhamre 1 , S. Janson 2,3 , R. Norlin 4 , M. Kla¨ ssbo 5
1 Centre of Sports Medicine in Va¨rmland, Va¨rmland County Council, Karlstad, Sweden, 2 Department of Paediatrics, Va¨rmland
County Council, Karlstad, Sweden, 3 Department of Public Health, Karlstad University, Karlstad, Sweden, 4 Department of
Orthopaedics, University Hospital, O¨rebro University, O¨rebro, Sweden, 5 Centre for Clinical Research, Va¨rmland County Council,
Karlstad, Sweden
Corresponding author: Stefan Perhamre, Idrottsha¨lsan i Va¨rmland, Kolvgatan 1 B, S-653 41 Karlstad, Sweden. Tel: 146 54 15 34 12,
Fax: 146 54 15 58 98, E-mail: stefan.perhamre@liv.se
Accepted for publication 7 October 2009
Sever’s injury (apophysitis calcanei) is considered to be the
dominant cause of heel pain among children between 8 and
15 years. The traditional advice is to reduce and modify the
level of physical activity. Recommended treatment in general
is the same as for adults with Achilles tendon pain. The
purpose of the study was to find out if insoles, of two
different types, were effective in relieving heel pain in a
group of boys (n 5 38) attending a Sports Medicine Clinic
for heel pain diagnosed as Sever’s injury. The type of insole
was randomized, and self-assessed pain during physical
activity in the treatment phase with insoles was compared
Sever’s injury (apophysitis calcanei, Sever’s disease)
is considered to be the dominant cause of heel pain
among growing children between 8 and 15 years of
age, but epidemiologic data on its incidence are still
lacking (McKenzie et al., 1981; Orava & Virtanen,
1982; Staheli, 1998; Ogden et al., 2004; Hendrix,
2005). The complaint is benign, and disappears without
exception after puberty when the apophyseal
growth plate is closed. The natural course is poorly
studied, but the condition appears to settle within 6–
12 months. Occasionally, symptoms will persist for 2
years (Cyriax, 1982; Brukner & Khan, 2007).
The condition includes a spectrum of pain from
recurrent light pain to strong pain. Boys constitute
two-thirds of the patients, probably due to different
physical activity preferences compared with girls of
the same age (Lutter, 1992). The physical activity
that appears to produce the highest levels of pain
includes frequent running and jumping, and the sport
that tends to dominate is soccer (Micheli et al., 1987;
Madden & Mellion, 1996). Winter sports are only
represented in low frequencies (Orava & Virtanen,
1982; Micheli et al., 1987). The average age at onset is
11–12 years (Micheli et al., 1987; Lutter, 1992).
Modern literature describes Sever’s injury in terms
of mechanical overuse with repetitive microtrauma
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& 2010 John Wiley & Sons A/S
with pain in the corresponding pre- and post-treatment
phases without insoles. There were no other treatments
added and the recommendations were to stay on the same
activity level. All patients maintained their high level of
physical activity throughout the study period. Significant
pain reduction during physical activity when using insoles
was found. Application of two different types of insoles
without any immobilization, other treatment, or modification
of sport activities results in significant pain relief in boys
with Sever’s injury.
to the calcaneal apophysis and its growth plate. Some
authors relate the injury to forces from the Achilles
tendon and the calf muscle complex, causing shear
stress that compromises the apophysis (Adams &
Hamblen, 1990; Volpon & de Carvalho Filho, 2002;
Hendrix, 2005). Others suggest the repetitive impact
force at heel strike as an alternative or complementary
explanation (McKenzie et al., 1981; Orava &
Virtanen, 1982; Ogden et al., 2004).
The clinical findings are tenderness over the calcaneal
tubercle and a positive calcaneus compression test
(Micheli et al., 1987; Adams & Hamblen, 1990; Madden
& Mellion, 1996; Kasser, 2006). In 40% of the
cases, only one heel is affected (Micheli et al., 1987).
The traditional advice is to diminish or eliminate
provoking activities for a period of time. This is
similar to the recommendations for treating Mb
Osgood Schlatter (Hendrix, 2005). In addition, patients
are recommended treatment similar to that
for adults with Achilles tendon pain, most frequently
including stretching, strengthening exercises for
calf and extensor muscles and also NSAID treatment
(Micheli et al., 1987; Lutter, 1992; Ishikawa,
2005; Kasser, 2006). The importance of correcting
malalignment, dominated by pronation, is stressed
by some authors (Szames et al., 1990; Madden &
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