Severs skada – paradigmskifte gällande diagnostik och behandling?

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Perhamre et al. ing adults), found that a tight heel box in the sports shoe in order to minimize the deformation of the heel pad, gave less overuse injuries from foot, lower leg and knee compared with optimal external shockabsorbing material that was put under the heel without the box support. The rigid heel cup with its brim, produced unloaded, directly on the bare heel that was used in our study, appears to be optimal to minimize the deformation of the heel pad. This cup is different from the other insoles that are described as heel cups, where the ‘‘cups’’ are made like spoons without the brim, often in flexible material. The present study showed that the heel cup fixating the heel pad provided better pain relief in young boys with Sever’s injury compared with the traditional heel wedge. This indicates that the reduction of impact forces, rather than reduction of shear stresses, is crucial for optimal pain relief. We agree with the demand to change the terminology from Sever’s disease and apophysitis calcanei to Sever’s injury, as proposed by Ogden et al. (2004). This is supported by a histological analysis of the region that corroborates a primary compression, rather than a tension cytoarchitecture (Ogden, 2000). Cortical bone (80% of the total bone mass) is primarily found in the diaphyses of the long bones. Trabecular bone is mainly found in the metaphyseal regions, the vertebral bones and pelvic bones (Alfredson, 1997). In adulthood, 95% of calcaneus is built up with trabecular bone, the biggest part among all body bones (Apurva et al., 1997). There was an 80% reduction of the odds score for pain when using a heel cup compared with a wedge. The cup was also preferred by 475% in the second part of the study. It although appears obvious that both insoles offered pain relief, supported by the pain relapses when the insoles were removed in every following baseline phase for both activities (Table 2, Fig. 3). After 26 weeks, when the intervention was concluded the pain level in general was very low (median 5 0), but at 1-year follow-up half of the boys still used insoles in their physical activities where half of the group used it for pain relief (n 5 12) and half of the group for prevention (n 5 10). The chosen insole still offered adequate pain relief, and appeared to protect the heel from repetitive traumatic stress, but did not in all cases appear to improve healing of the injury. The inconvenience with the cup (n 5 5) that first occurred after the study, can possibly be ex- References Adams JC, Hamblen DL, eds. The leg, ankle and foot. In: Outline of orthopaedics, 11th edn. Edinburgh: Churchill Livingstone, 1990: 359–402. e46 Alfredson H. Exercise and bone in females and in athletes with chronic Achilles tendinosis. Umea˚ : Umea˚ University, 1997. plained by the fact that they can be grown out within a period of 18 months. The small group (n 5 10) who preferred the wedge had as good effect on pain with their choice, during the study period and at followup, as the cup group. A hypothesis is that there can be more than one morphologic origin in Sever’s injury. Another interesting finding was that 43% of the boys in the study had only unilateral pain, and were symptom free in the other foot. This big number of boys with unilateral pain is also earlier presented (Micheli & Ireland, 1987; Perhamre et al., 2009). This indicates that there may be internal unknown factors involved. Perspectives Heel pain is a common condition in an important period of development, between 8 and 15 years of age, and should be named Sever’s injury, not Sever’s disease. An individually made molded rigid heel cup with a fixating brim should primarily be offered in Sever’s injury, in order to protect the heel from a continuing overload with repetitive stress. If this does not work the next offer, with respect to the minor group in this study, can be a pair of 5 mm wedges. Sport activities in general, before and during puberty, are very important especially from physiological, neuromuscular and mental aspects. To lose a long period of time because of heel pain can be devastating for participation in sports later on, and is according to the results in this study, not necessary. Key words: calcaneus, Sever’s injury, apophysitis calcanei, insoles, heel cup, heel wedge. Acknowledgements Thanks to Ingemar Hansson, who made the insoles, Mikael Hasselgren PhD medical chief Centre for Clinical Science, Eva Stjernstro¨ m RPT, division chief Va¨ rmland County Council and Staffan Janson professor, Department of Paediatrics, University of O¨ rebro, and professor Department of Public Health, Karlstad University, for support. Financial support was provided by the Primary Care Research Unit, by the division Health, Habilitation and Rehabilitation and by the foundation for Orthopaedic Devices, Va¨ rmland County Council. Apurva S, Vliet E, Lewiecki M, Maricic M, Abdelmalek A, Gluck O, Baylink D. Bone density measurement – a systematic review. JIM 1997: 241: 12–22. 45
Brukner P, Khan K. Clinical sports medicine, 3rd edn. North Ryde: McGraw-Hill, 2007, p. 737. 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: 435. Engstro¨ m 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: Idrottsho¨ gskolan, 2004: 142. 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. Jo¨ rgensen U. Implication of heel strike: an anatomical, biomechanical, physiological and clinical study with focus on the heel pad. Link o¨ ping: Linko¨ ping University, 1989. Kasser JR. The Foot – Aquired conditions. In: Weinstein SL, Lovell WW, Winter RB, Morrissy RT, eds. Lovell and winter’s pediatric orthopaedics 2, 6th edn. Philadelphia: 46 Lippincott Williams & Wilkins, 2006: 1257–1329. 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. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop 1987: 7: 34–38. Neely GL, Sylén G, Borg CG. Comparison between the Visual 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. Foot. In: Ogden JA, ed. Skeletal injury in the child, 3rd edn. New York: Springer, 2000: 1091–1159. 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. Sever’s injury; treat it with heel cup Orava S, Virtanen K. Osteochondroses in athletes. Br J Sports Med 1982: 16: 161–168. Peck DM. Apophyseal injuries in the young athlete. Am Fam Physician 1995: 51: 1891–1895. Perhamre S, Janson S, Norlin R, Klässbo M. Sever’s injury: treatment with insoles provides effective pain relief. Scand J Med Sci Sports 2009, in press. Rabe-Hesketh S, Skrondal A, Pickles A. Reliable estimation of generalized linear mixed models using adaptive quadrature. The Stata Journal 2002: 2: 1–21. Staheli LT, ed. Sports/Foot and ankle. In: Fundamentals of pediatric orthopedics, 2nd edn. Philadelphia: Lippincott- Raven, 1998: 111–128. Stata P. STATA/IC release 10 user manual [XT] – longitudinal/panel data. College Station: Stata Press, 2007. 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. e47
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 and 40: equired to determine the etiology o
Page 41 and 42: daytime is sometimes recommended (O
Page 43: and pain history in weeks before th
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

Severs skada – paradigmskifte gällande diagnostik och behandling?

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