Severs skada – paradigmskifte gällande diagnostik och behandling?

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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 37
Fig. 2. The heel cup, the foot (in the study always supported by a sports shoe) and the heel wedge. were used, the questionnaire was filled in eight times per person for each activity. A post-treatment phase of 2 weeks finally followed, without any insoles, when again the pain questionnaire for pain related to the chosen sport activity was filled in six times each for the two chosen activities A and B (Fig. 1). Activity levels were assessed at the start of the study and in the two phase shifts, three times in total (Fig. 4). Measurement for the non-treatment group (n 5 5) was activity level, median and range for the self-assessed pain at the start and end. The study was approved by the Regional Ethics Board of Uppsala (dnr 2004 M-377). Statistics Median pain for each boy was calculated for each of the three phases, pre-treatment, treatment and post-treatment, separately for activities A and B, and termed the pain variable. Median pain for the whole study group (n 5 33) was thereafter calculated from these pain variables, for each phase and activity. Interquartile range (IQR) (i.e. the numerical difference between the 25th and 75th centiles) was also calculated. To analyze the change over time between the different phases, for activity A and activity B separately, Wilcoxon’s signed-rank test was used. The pain variables for the group for activity A and activity B in the pre-treatment phase were compared with the pain variables in the treatment phase. The pain variables in the treatment phase were also compared with the pain variables in the post-treatment phase, and finally the pain variables in the pre-treatment phase were compared with the variables in the post-treatment phase (Fig. 3). To correct for mass significance, Holm’s sequential Bonferroni’ssss test was used. Results There was a significant reduction in pain level during activity with insoles, when comparing pain levels in the pre-treatment and treatment phase, for both activities A and B (Po0.001) (Fig. 3). Median pain level in the pre-treatment phase was 4.5 in activity A (IQR 2.5) and 4.0 in activity B (IQR 2.5). During treatment, pain was reduced to 2.0 (IQR 3.50) in both activities A and B. After discontinuation of the 38 Median pain values (VAS) 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 Sever’s injury: insole treatment p
Page 1 and 2: Severs skada - paradigmskifte gäll
Page 3 and 4: Rapporten kan beställas från Cent
Page 5 and 6: Innehåll SAMMANFATTNING ..........
Page 7 and 8: Artiklar Denna rapport är baserad
Page 9 and 10: Inledning Idrottshälsan startade
Page 11 and 12: Bakgrund Severs skada, smärta i h
Page 13 and 14: Syfte Syftet med studierna var att
Page 15 and 16: Deltagare delarbete I, IV och V Del
Page 17 and 18: Metod och resultat Alla barn som in
Page 19 and 20: ehandling med antingen hälkopp (n=
Page 21 and 22: I delarbete II beräknades mediansm
Page 23 and 24: Som ett beskrivande komplement till
Page 25 and 26: Dataanalys visade att maximal tryck
Page 27 and 28: Tack Tack för finansiellt stöd ti
Page 29 and 30: Lars Hynsjö, M. Sc at the departme
Page 31 and 32: Referenser 1 Wessmark O. Apofysitis
Page 33 and 34: Bilaga 2 34 Namn: Testnummer: v 1 D
Page 35: Bilaga 4 Scand J Med Sci Sports 201
Page 39 and 40: equired to determine the etiology o
Page 41 and 42: daytime is sometimes recommended (O
Page 43 and 44: and pain history in weeks before th
Page 45 and 46: Brukner P, Khan K. Clinical sports
Page 47 and 48: Perhamre et al. 2010b). More than 7
Page 49 and 50: Perhamre et al. Table 1. Analysis o
Page 51 and 52: Perhamre et al. Table 4. Pain level
Page 53: Stefan Perhamre, specialist i allm

Severs skada – paradigmskifte gällande diagnostik och behandling?

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