Severs skada – paradigmskifte gällande diagnostik och behandling?

Perhamre et al.
Mellion, 1996). Insoles of a molded plastizote orthosis,
a heel cup to align pronation, or a heel wedge to
reduce shear stress to the apophysis, are included in
most recommendations (Micheli et al., 1987; Lutter,
1992; Peck, 1995; Staheli, 1998; Kasser, 2006). Nonweightbearing
with the lower limb immobilized in a
short leg cast or a removable ankle orthosis worn
during daytime is sometimes recommended (Lutter,
1992; Ogden et al., 2004; Kasser, 2006). All studies
are, without exception, observational studies.
The purpose of this study was to find out if insoles,
of two different types, without any other treatments
or recommendations were effective in relieving heel
pain in a group of 35 boys, 9–15 years of age,
attending a Sports Medicine Clinic.
Materials and methods
The design in this experimental study was an intervention phase
(4 weeks) with two randomized insoles, heel cup or heel wedge,
and two non-treatment phases without insoles, one before and
one after treatment, of 2 weeks, respectively (Fig. 1). Thirty-five
boys were consecutively included with a median age of 12
Intervention group, n=33
Inclusion
Nonintervention group, n=5
Inclusion
2 w
4 w
Heel cup
Heel wedge
2 w
Randomisation End of
study
7-8 w
Fig. 1. An experimental study in a group of boys with heel
pain (n 5 33), with randomized types of insoles (heel wedge
n 5 18, heel cup n 5 17). The cohort was followed for 2
weeks in a pre-treatment phase, for 4 weeks in an intervention
phase with insoles and for 2 weeks in a post-treatment
phase, with no insoles. A separate consecutive series of
patients in a ‘‘natural course group’’ was followed in 7–8
weeks without insoles (n 5 5).
820
years (range 9–14 years). The patients were examined at the
Sports Medicine Clinic for heel pain and were recruited during
10 months. All the examinations were performed by the first
author.
Inclusion criteria were male gender, age 9–15 years, and a
diagnosis of Sever’s injury. Findings confirming the diagnosis
were tenderness over the calcaneal tuberosity and a positive
compression test. Additional negative test results from the
Achilles tendon and other parts of the hind foot were
compulsory. Heel pain had to be present for more than 2
weeks, but o26 weeks when examined. All participants were
high-level athletes. Each patient had to specify two physical
activities giving heel pain (here, named activity A and activity
B), where the most painful activity was A. These two activities
must be performed at least three times a week during the study
period. Soccer was the dominating sports activity (n 5 28) in
which the boys registered their pain, followed by running
(n 5 22). In all cases where soccer was one of the choices, it
was reported as the most painful activity. The median duration
of pain on examination was 10 weeks (range 4–20 weeks).
Eighteen of the boys were diagnosed with unilateral Sever’s
injury, and 17 with bilateral. No previous treatment was given.
Three boys fulfilling the inclusion criteria were not willing
to participate in the study. Two boys dropped out of the study,
one of them because he missed filling in the questionnaire, and
the other because of a calf muscle strain (n 5 38).
Borg’s CR-10 scale was used for measuring pain during
activity A and B (Neely et al., 1992). Borg’s CR-10 scale is a
self-assessment visual analog scale (VAS) with anchors of
verbal explanations added to the numbers of the pain scale.
Zero represents absence of pain and 10 represent maximal
pain.
Activity level was measured with Engstrom’s activity index
(Engstrom, 2004) with five levels of activity, A–E. When
included in the study, eight boys reported the second highest
level D (strained to shortness of breath and sweating many
times a week) and 27 boys reported the highest level of
activity, E, (strained to shortness of breath and sweating every
day or most days of the week) (Fig. 4).
To study the natural course, we added a second inclusion
period of 2 months with a consecutive series of patients with
Sever’s injury, not using insoles, with the same inclusion and
exclusion criteria (Fig. 1). The patients were examined at the
Clinic, by the same person, in the same way as those in the
cohort. Self-assessed pain recordings and activity levels were
collected twice, at the start and at the end of the period. This
group included five boys (median age 12 years, range 10–13
years). One boy fulfilling the inclusion criteria was not willing
to participate. Four of the boys were diagnosed with unilateral,
and one with bilateral pain. The median time with
symptoms was 14 weeks (range 6–26 weeks).
In the experimental study, two alternative insoles, a heel
wedge and heel cup, were used (Fig. 2). The heel wedge was a
5-mm-cork wedge covered with a thin elastic surface. The
purpose of the heel wedge was to lift the heel in the loading
phase and thereby limit the shear stresses of the apophysis.
The heel cup was a rigid plastic cup applied directly on the
bare heel, with a moulded long arch support. It encloses the
heel with a 2–3 cm brim. The purpose of the heel cup was to fix
the heel pad directly below the calcaneal tuberosity during heel
strike. Bilateral insoles were always used.
After inclusion in the study, the boys were randomized by
picking one ticket from a concealed box. Randomization
resulted in a heel wedge group (n 5 18) and a heel cup group
(n 5 17). During 2 weeks of pre-treatment, the pain questionnaire
for pain related to the chosen sport activity was filled in
six times for the two chosen activities A and B. No insoles
were used. In the treatment phase of 4 weeks, when the insoles
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