Severs skada – paradigmskifte gällande diagnostik och behandling?

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Perhamre et al. Number of patients 25 20 15 10 5 Activity level D E Pre-treatment Treatment Phase Fig. 4. Level of activity measured with Engstrom’s activity index (n 5 33) in the pre-treatment and treatment phase. One person changed from level D (strained to shortness of breath and sweating many times a week) to E (strained to shortness of breath and sweating every day or most days of the week) during treatment, and the others were on the same activity level in both phases. beneficial in the CNS forever (Hanrahan & Carlson, 2006). This period is also crucial to build up the skeleton (Schwinghandl et al., 1999; Linde´n et al., 2006, 2007). Sport activities in general, before and during puberty, are also very important from mental aspects. The joy of being an athlete is of great value (Engstrom, 1999). To lose 1 year or more because of heel pain can be devastating for participation in sports later on. Ogden et al. (2004) challenges the view on this disease as a concept of apophysitis. Instead, he found a traumatic stress fracture of the immature calcaneal trabecular bone, visualized with MRI. Ogden therefore singled out the repeated and intense impact forces as being responsible for the damage of the trabecular bone. Our findings with excellent pain relief during the use of insoles support this concept. The wedge lifting the heel 5 mm probably reduces shear forces on the apophysis and the cup probably reduces heel strike impact forces on the calcaneus due to its effect of fixing the heel pad under the calcaneal tuberosity. The results in this study are valid for several reasons. It is a consecutive study, which includes more than 90% of all boys seeking help for Sever’s injury at our department during the study period. The study design focuses on a single treatment and uses an internal control with a pre- and post-treatment phase. None of the boys used any other type of treatment during the study period, neither drugs, nor physiotherapy, or other orthoses. Pain was possible to quantify from time to time during defined, often 822 performed activities, which excluded recall bias. The self-assessed questionnaire was filled in at home, with no influence from the investigators. There were two dropouts during the study period because of two specific reasons, with no relation to the study design. Because of this, we have analyzed those who completed the study, instead of using the intention-to-treat analysis. From pre-treatment to treatment phase, there was significant pain relief in both activities. After removing the insole, pain returned. This proves that pain reduction is an effect of the treatment and not due to spontaneous healing, as part of the natural course. The results in the non-treatment group also indicate this. The natural course in Sever’s injury, among physically active boys in general, lasts for longer than 8 weeks (Cyriax, 1982; Brukner & Khan, 2007). Recurrence rate is estimated to be 20% (Kvist et al., 1984). Our non-treatment group is small and is not a strict control group because the boys were included separately during a stipulated period. On a group level, they had some characteristics that were different compared with the studied cohorts. The pain at start was worse than in the treatment group (VAS 7 vs VAS 4–4.5), the duration of pain was longer (14 vs 10 weeks) and there were unilateral symptoms in 4/5 of the cases, compared with less than half in the cohort groups, where bilateral pain dominated. It might be considered a weakness that the study has no ‘‘proper’’ control group. From an ethical point of view, we found it questionable to leave a group without any treatment, as a third study group, and have them continue at the same high activity level, with considerable pain. It had also been more troublesome to recruit study patients with this design. Another weakness in the study is that we do not compare the benefit of the two insole alternatives. The number of patients was too small to obtain enough statistical power to answer this question. Treatments suggested previously in Sever’s injury often include a reduction of activity level and physiotherapy (Micheli et al., 1987; Lutter, 1992; Madden & Mellion, 1996; Ishikawa, 2005; Kasser, 2006). Limitation in activity is the dominating recommendation. However, the scientific support for these treatment regimens is lacking. Our study is designed as a single treatment study without any other therapies included. In literature, in general (except in those studies that treat patients with a cast for a stipulated time), there is a number of treatments offered as a mix. This study has therefore no opportunity to discuss whether, for instance, physical therapy provides additional benefit in Sever’s injury or not. The present study shows that two insoles provided significant pain relief in highly active boys with Sever’s injury. This treatment is effective without reducing their level of activity. Further studies are 39
equired to determine the etiology of the pain and which insole is the better one. Perspectives Treating Sever’s injury with insoles makes it possible for the boys studied, 9–15 years old, to be active in sports at a high level, instead of being passive, waiting for the symptoms to fade away. Sever’s injury is common in this age, and for many reasons it is important to develop adequate treatments. References Adams JC, Hamblen DL. The leg, ankle and foot. Outline of orthopaedics, 11th edn. Edinburgh: Churchill Livingstone, 1990, 433pp. Brukner P, Khan K. Clinical sports medicine, 3rd edn. North Ryde NWT: McGraw-Hill, 2007, xxxix, 737pp. Cyriax J. The foot. In: Cyriax J, ed. Textbook of orthopaedic medicine vol 1, diagnosis of soft tissue lesions, 8th edn. London: Baillie´ re Tindall, 1982: 435pp. Engstrom L-M. Sports as a social marker [in Swedish]. Stockholm: HLS, 1999, 143pp. Engstrom L-M. School – sports – health: studies of the subject sports and health, and young people’s physical activity, physical capacity and health condition: basis, purposes and methods [in Swedish]. Stockholm: Idrottshogskolan, 2004. Falk B, Tenenbaum G. The effectiveness of resistance training in children. A meta-analysis. Sports Med 1996: 22: 176–186. Hanrahan SJ, Carlson TB. Game skills: a fun approach to learning sport skills. Champaign 2006: 175. Hendrix CL. Calcaneal apophysitis (Sever disease). Clin Podiatr Med Surg 2005: 22: 55–62. Ishikawa SN. Conditions of the calcaneus in skeletally immature patients. Foot Ankle Clin 2005: 10: 503–513. Kasser JR. The foot – acquired conditions. In: Weinstein SL, Lovell WW, Winter RB, Morrissy RT, eds. Lovell and winter’s pediatric orthopaedics 2, 6th edn. Philadelphia: 40 Lippincott Williams & Wilkins, 2006: 1257–1329. Kvist M, Kujala U, Heinonen O, Kolu T. Osgood Schlatter and Sever’s disease in young athletes. Duodecim. 1984: 100: 142–150. [in Finnish]. Linde´ n C, Ahlborg H, Besjakov J, Gardsell P, Karlsson M. A school curriculum-based exercise program increases bone mineral accrual and bone size in prepubertal girls: two-year prospective data from the Pediatric Osteoporosis Prevention (POP) study. J Bone Miner Res 2006: 21: 829–835. Linde´ n C, Alwis G, Ahlborg H, Gardsell P, Valdimarsson Ö, Stenevi-Lundgren S, Besjakov J, Karlsson M. Exercise, bone mass and bone size in prepubertal boys: one-year data from the pediatric osteoporosis prevention study. Scand J Med Sci Sports 2007: 17: 340–347. Lutter LD. Sports related injuries. In: Drennan JC, ed. The child’s foot and ankle. New York: Raven Press, 1992: 407–416. Madden CC, Mellion MB. Sever’s disease and other causes of heel pain in adolescents. Am Fam Physician 1996: 54: 1995–2000. McKenzie DC, Taunton JE, Clement DB, Smart GW, McNicol KL. Calcaneal epiphysitis in adolescent athletes. Can J Appl Sport Sci 1981: 6: 123–125. Micheli LJ, Ireland ML, Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop 1987: 7: 34–38. Neely G, Ljunggren G, Sylén C, Borg G. Comparison between the Visual Sever’s injury: insole treatment Key words: calcaneus, sever’s injury, apophysitis calcanei, insoles, heel cup, heel wedge. Acknowledgements Thanks to Mikael Hasselgren Ph.D. from the Primary Care Research Unit and statistician Katarina Wiberg Hedman and Fredrik Lundin, Centre for Clinical Research, Va¨ rmland County Council, for support. Financial support was provided by the Primary Care Research Unit and by the foundation for Orthopaedic Devices, Va¨ rmland County Council. Analogue Scale (VAS) and the Category Ratio Scale (CR-10) for evaluation of leg exertion. Int J Sports Med 1992: 13: 133–136. Ogden JA, Ganey TM, Hill JD, Jaakkola JI. Sever’s injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop 2004: 24: 488–492. Orava S, Virtanen K. Osteochondroses in athletes. Br J Sports Med 1982: 16: 161–168. Ozmun JC, Mikesky AE, Surburg PR. Neuromuscular adaptations following prepubescent strength training. Med Sci Sports Exerc 1994: 26: 510–514. Peck DM. Apophyseal injuries in the young athlete. Am Fam Physician 1995: 51: 1891–1895. Schwinghandl JK, Sudi B, Eibl B, Wallner S, Borkenstein M. Effects of an individualised training program during weight reduction on body composition. A randomised trial. Arch Dis Child 1999: 81: 426–428. Staheli LT. Sports/foot and ankle. Fundamentals of pediatric orthopedics, 2nd edn. Philadelphia: Lippincott- Raven, 1998: 111–128. Szames SE, Forman WM, Oster J, Eleff JC, Woodward P. Sever’s disease and its relationship to equinus: a statistical analysis. Clin Podiatr Med Surg 1990: 7: 377–384. Volpon JB, de Carvalho Filho G. Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center. Arch Orthop Trauma Surg 2002: 122: 338– 341. 823
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 and 36: Bilaga 4 Scand J Med Sci Sports 201
Page 37: Fig. 2. The heel cup, the foot (in
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

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