Severs skada – paradigmskifte gällande diagnostik och behandling?

and pain history in weeks before the randomization
between the two groups, starting with either heel
wedges or heel cups (Table 1). All boys continued
their high levels of physical activity during the study
(Engstro¨ m’s activity index level E n 5 38, and D
n 5 6).
Pain was significantly lower in the heel cup group
compared with the wedge group. For activity A and
B, the effect of the cup was OR 5 0.22 (Po0.001
[0.15, 0.34]) and OR 5 0.18 (Po0.001 [0.12, 0.27]),
respectively, thus reducing the odds score for pain to
a fifth compared with the wedge (ordinal data). There
was also a significant effect of time for activity A
OR 5 0.93 (P 5 0.001) and for activity B OR 5 0.93
(P 5 0.002), which means that pain was reduced with
time as an independent variable (Table 2). We did
check duration of pain at baseline and age as
explanatory variables, but none of them had any
significant effect in the model.
When able to freely choose in the final second part
(intervention 3), 34 boys (77%) chose the heel cup
and 10 (23%) chose the heel wedge (Fig. 2). No one
preferred to stop using insoles.
There was a continuous reduction of pain between
the three intervention phases for both groups. After
each intervention phase, the pain reoccurred in the
next baseline phase (Fig. 3). During the prolonged
phase with the free choice of insole (8 weeks compared
with 4 weeks), the median pain was 0.5. After
26 weeks when the study was concluded, the median
value for pain was 0 (IQR 1).
The 1-year follow-up questionnaire showed that
pain relief during the study period was good or
excellent in 40 answers (n 5 41) for the chosen insole,
and in 14 (n 5 40) for the non-chosen alternative.
During the following year, 14 were pain free throughout,
12 still had pain when being active on their level
and 14 had pain that disappeared in 3 months
(median), where six boys had relapses thereafter
(n 5 40). The number of boys that used insoles after
1 year was 22. Nineteen of the boys assessed its effect
on pain as excellent or good. Five boys found the
insoles (all cups) inconvenient in the post-study
phase.
Discussion
This study shows that treatment with heel cup was
superior to treatment with heel wedge for relieving
pain during sport activities in Sever’s injury without
reducing physical activity, indicating that the reduction
of repetitive impact forces in heel strike is the
most important factor for pain relief.
The result is valid for several reasons. Our randomized
study was focused on a single treatment regime
for heel pain: insole treatment (Figs 1 and 2). There
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Sever’s injury; treat it with heel cup
was no advertisement or active recruitment made and
the boys were included in the same season during 3
following years. There were two parallel groups with
the same overall experiences during the randomized
first half of the study with baseline phases and
crossover treatment (Fig. 2). All pain recordings
were self–assessed with no influence from the investigators.
All boys continued being physically active at
the same high level throughout the study period. The
studied group appears to be typical for physically
active boys, 9–15 years old, seeking Health Care for
heel pain (Table 1). We put the upper inclusion limit
in pain history before start to 26 weeks to avoid the
most refractory cases, where 14% had a pain history
between 4 and 6 months at start. No one had a pain
history shorter than 4 weeks (mean 11 weeks). At the
end of phase B2, 39 boys still had pain (n 5 44) (Fig.
3). Less than 10% (n 5 3) of all the boys fulfilling the
inclusion criteria at our clinic did not want to
participate. Hence, missing cases were few and the
reasons for dropping out were not related to the
study design.
We chose to include only boys with Sever’s injury,
because boys totally have dominated in frequency,
probably due to different gender preferences and
training patterns (Lutter, 1992).
Previous guidelines for treating Sever’s injury are
built on principles for adults suffering from heel pain
(Micheli & Ireland, 1987; Ishikawa, 2005; Kasser,
2006). Scientific evidence for the effect of these
treatment regimens are lacking. Insole treatment
together with limitations in activity are the most
frequent advice, and the wedge is the most frequent
insole advice in the literature (Peck, 1995; Staheli,
1998; Kasser, 2006). The approach is to limit the
stress to the apophysis – Achilles tendon complex by
placing the foot in slight equinus. It points out the
apophysis and its growth plate, the physis, as the
morphologic origin of pain. The second proposed
alternative in the literature is to correct malalignment
particularly pronation or flat-footed running, by a
molded plastizote orthosis or a heel cup (Micheli &
Ireland, 1987; Madden & Mellion, 1996).
Ogden et al. (2004) questioned the 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 responsible for
the damage of the trabecular bone close to the physis,
the metaphysis and not to the apophysis. His arguments
are supported by the fact that sports like ice
hockey and cross country skiing, with very little
impact forces compared with soccer and running,
but with great shear stresses to the apophysis in pull
off, are very uncommon as exacerbating sports for
heel pain (Orava & Virtanen, 1982; Micheli & Ireland,
1987). The thesis by Jo¨ rgensen (1989) (includ-
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