Severs skada – paradigmskifte gällande diagnostik och behandling?

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.
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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
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