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