Severs skada – paradigmskifte gällande diagnostik och behandling?

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Scand J Med Sci Sports 2011: 21: e42–e47 doi: 10.1111/j.1600-0838.2010.01140.x Sever’s injury; treat it with a heel cup: a randomized, crossover study with two insole alternatives S. Perhamre 1{ , F. Lundin 2 , R. Norlin 3 , M. Kla¨ ssbo 2 1 2 3 Centre of Sports Medicine in Va¨rmland, Karlstad, Sweden, Centre for Clinical Research, Karlstad, Sweden, Department of Orthopaedics, University Hospital, O¨rebro University, O¨rebro, Sweden Corresponding author: Rolf Norlin MD, Department of Orthopaedic Surgery, University Hospital, 70185 O¨rebro, Sweden. Tel: 146 19 60 25 366, Fax: 146 19 60 25 337 E-mail: rolf.norlin@orebroll.se { Deceased. Accepted for publication 24 March 2010 Sever’s injury (apophysitis calcanei) is considered to be the dominant cause of heel pain among children. Common advice is to reduce physical activity. However, our previous study showed that application of insoles reduced pain in Sever’s injury without having to reduce physical activity. The purpose of this study was to test which of the two insoles, the heel wedge or the heel cup, provided best pain relief during sport activity in boys with Sever’s injury (n 5 51). There was a crossover design in the first rando- 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 (Staheli, 1998; Ogden et al., 2004; Hendrix, 2005). The heel complaint is benign, but includes a wide spectrum of pain intensity, and duration. It disappears without exception after puberty (Cyriax, 1982; Brukner & Khan, 2007). Boys constitute two-thirds of the patients, probably due to different physical activity preferences compared with girls at the same age (Lutter, 1992). The physical activity that produces the highest levels of pain includes frequent running and jumping, and the sport that tends to dominate is soccer (Madden & Mellion, 1996). Outdoor winter sports are represented at a low frequency (Orava & Virtanen, 1982; Micheli & Ireland, 1987). The average age at onset is 11–12 years (Lutter, 1992). In 35–40% of the cases, only one heel is affected (Micheli & Ireland, 1987; Perhamre et al., 2009) Sever’s injury is in modern literature described as induced by mechanical overuse with repetitive microtrauma to the calcaneal apophysis and its growth plate – the physis. The injury is reported to be related to forces from the Achilles tendon and calf complex due to shear stresses that compromise the apophysis (Peck, 1995; Volpon & de Carvalho Filho, 2002). Some authors suggest the repetitive impact forces at e42 Bilaga 5 & 2010 John Wiley & Sons A/S mized part of the study. In the second part, the boys, 9–14 years, chose which insole they preferred. There was a reduction in odds score for pain to a fifth (a reduction of 80%) for the cup compared with the wedge (Po0.001). When an active choice was made, the heel cup was preferred by 475% of the boys. All boys maintained their high level of physical activity throughout. At 1-year follow-up, 22 boys still used an insole and 19 of them reported its effect on pain as excellent or good (n 5 41). heel strike as an alternative or a complementary explanation (McKenzie et al., 1981; Orava & Virtanen, 1982), including a microtraumatically induced calcaneal stress fracture of trabecular bone in refractory cases (Ogden et al., 2004). The clinical findings include tenderness over the lower part of the tubercle of calcanei and a positive calcaneal compression test, the squeeze test (Adams & Hamblen, 1990; Madden & Mellion, 1996; Kasser, 2006). The traditional advice is to diminish or eliminate provoking activities for a prescribed period of time. This is similar to the recommendations for Mb Osgood Schlatter (Hendrix, 2005). The proposed treatment consists of a traditional concept for adults with Achilles tendon pain, most frequently including stretching, strengthening exercises for calf and extensor muscles, ice and NSAID treatment (Ishikawa, 2005; Kasser, 2006). The importance of correcting malalignment, dominated by pronation, is stressed (Madden & Mellion, 1996) as well as the relation between pain and a tight heel cord (Szames et al., 1990). Insoles, either a molded plastizote orthosis to align pronation, or a heel wedge to directly reduce shear stresses to the apophysis, are the major insole proposals (Staheli, 1998; Kasser, 2006). Non-weightbearing with the lower limb immobilized in a short leg cast or a removable ankle orthosis worn during 41
daytime is sometimes recommended (Ogden et al., 2004; Kasser, 2006). Our previous study showed that two specific types of insoles, with different approaches to microtraumatic stress, were effective in relieving pain among physically active boys (Perhamre et al., 2009). By lifting the heel 5 mm with the wedge, the tension forces are expected to be reduced in mid stance and in push off. The heel cup is thought to act as an internal tight box in the shoe, fixating the heel pad in order to reduce the direct impact force in heel strike. The purpose of this study was to test which of the two insoles, the heel wedge or the heel cup provided best pain relief in boys with Sever’s injury, without reducing their level of physical activity. Materials and methods The study was a prospective crossover designed, with alternation between baseline phases and intervention phases with the two different insole alternatives (Fig. 1). The first randomized part of the study period included 12 weeks. In the second nonrandomized part of the study (14 weeks), each boy chose one treatment alternative (Fig. 2). Inclusion criteria were male between 9 and 15 years with a history of Sever’s injury, and heel pain present for 42 weeks, but o26 weeks when examined. Findings confirming the diagnosis were tenderness over the calcaneal tubercle, and a positive compression test (Kasser, 2006). Additional negative test results from the Achilles tendon were compulsory. The level of physical activity must be high, at least the second highest level of sport activity (D 5 strained to shortness of breath and sweating many times a week or E 5 strained to Fig. 1. The heel wedge used in the study, lifting the heel 5 mm and the heel cup (of 3 mm. thickness) fixating the heel pad. The cup offers no wedge effect, due to equal lift of the rear and fore foot. 42 shortness of breath and sweating every day or most days of the week) according to Engstro¨ m’s activity index (Engstro¨ m, 2004). Two alternative insoles, the heel wedge and the heel cup, were used (Fig. 1). Bilateral treatment was always performed. The heel wedge was a 5 mm cork wedge covered with a thin elastic surface. It lifted the heel 5 mm in mid stance and push off. The heel cup was a rigid thermoplastic cup (of 3 mm height but with no wedge effect) molded directly on the bare heel with a three-fourth length arch support. It enclosed the heel with a 2–3 cm high brim in order to stop the heel pad from excessive deformation. The high brim made it different from earlier described molded heel insoles with their purpose to align the foot in running. There are some similar rigid alternatives, like the prefabricated Whitman–Roberts and the semi-molded Lange insoles in hard plaster. All boys were examined by the first author at the Sports Medicine Clinic for heel pain and recruited during February– June during 3 following years, totally 15 months. A total of 51 boys were invited of which four did not accept. During the study, three boys dropped out, one due to social complications, one due to difficulties filling in the questionnaire and one due to a calf muscle strain injury, leaving 44 boys. The analyses below were performed on data supplied by these 44 boys who completed the study. Nineteen (43%) of the boys were diagnosed with unilateral Sever’s injury (10 right foot, nine left foot) and 25 with bilateral. After inclusion, the boys were randomized into two groups with tickets concealed in a box. No stratification was made. Thereafter, the pain questionnaire was filled in for the chosen activities during the baseline phase (weeks 1–2) preceding the interventions, including six registrations for each of the two activities. During the first intervention phase (weeks 3–6), the boys were using either heel cup (n 5 20, group I) or heel wedge (n 5 24, group II) including eight pain registrations for each of the two activities A and B. A second baseline phase (wash-out) followed (weeks 7–8) without any treatment. During the second intervention phase (weeks 9–12), there was a shift between insoles (crossover). In the second and final part of the study (after 12 weeks), the boys started with another baseline phase (wash-out) of 2 weeks without insoles followed by a last intervention period of 12 weeks. Here every boy, instead of being randomized, chose a treatment alternative with respect to his overall preferences, and was asked to focus on pain relief. He could also stay active without the insole. The intervention phases were concluded after 26 weeks (Fig. 2). There was a follow-up questionnaire added 1 year later concerning pain relief during the study period. The continuing need of insoles and pain relief with their used insoles the Following Randomisation Cross-over Choice choice: Group 1 n=20 Cup Cup 19 Cup n=34 Group 2 n=24 Wedge Wedge Wedge 5 Time line: 0w 2w 6w 8w 12w 14w Period: B1 I1 B2 I2 B3 Sever’s injury; treat it with heel cup Fig. 2. Study design with alternating periods of baseline ( 5 no treatment, B1, B2 and B3) and intervention phases ( 5 treatment with insoles, I1, I2 and I3). The first part, including intervention phases (I1 and I2) were randomized with a crossover design, and the second part (I3) represented each boy’s personal choice (n 5 44). I3 26w n=10 e43
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 and 38: Fig. 2. The heel cup, the foot (in
Page 39: equired to determine the etiology 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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