Severs skada – paradigmskifte gällande diagnostik och behandling?

Perhamre et al.
2010b). More than 75% of the boys preferred the
heel cup (Fig. 1).
The purpose of this study was to analyze if thickness
and function of the heel pad was affected by the
use of a heel cup. Our two main research questions:
Does the thickness of the heel pad differ between
standing bare feet, in the sport shoe, and in the same
sport shoe but with the heel cup?
Is there a difference in local peak pressure in standing
and running with vs without the heel cup in the shoe?
Materials and methods
Design
The study included a pilot study (n 5 5) and a prospective
intervention study (n 5 30). Children attending our clinic and
diagnosed with Sever’s injury were randomized to either group
I, heel cup treatment or to group II, without heel cup or other
insole treatment during the study period of 4 weeks (Fig. 2). A
third matched group of painless children (n 5 15) were included
as a control group.
Sample
A total of 53 children fulfilling the inclusion criteria were
offered to participate in the study. Three children (all girls) did
not accept. No one dropped out of the study, leaving 50 who
finished the study. Forty were boys and 10 were girls. Thirtyfive
children with Sever’s injury were consecutively included,
seeking for heel pain at a Sports Medicine Clinic. The median
Fig. 1. The individually made molded rigid ‘‘Wessmark’’
cup, which was used in the study.
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Pilot group
n = 5
Untreated patients
n = 15
Randomised group
n = 30
Heel cup treated patients
n = 15
age was 11 years (range 9–14 years). Twenty-four children had
bilateral pain and 11 children had unilateral heel pain (eight
boys, three girls, five with pain in the right and six in the left
foot). The painless children (n 5 15) were individually matched
(same gender, age, activity level and playing in the same sports
team) as the children in group I (Fig. 2). The children were
recruited during a 6-month period.
Inclusion and exclusion criteria
Inclusion criteria were both gender, age 9–15 years, and the
diagnosis of Sever’s injury, except for the children without
symptoms who did not suffer from Sever’s injury. Findings
confirming the diagnosis were tenderness over the lower onethird
of the posterior calcaneus and a positive calcaneus
compression test, the squeeze test, where all participants
were examined by the first author. Heel pain had to be present
for more than 2 weeks when examined. The most painful
activity had to be a ball sport of some kind (soccer, floor ball,
handball, etc.) with a pain level of 4 or more on the Borg CR-
10 scale during the last week activities. The Borg scale is a self
assessment VAS scale with anchors of verbal explanations
added to the numbers in the pain scale (Neely et al., 1992).
Zero represents absence of pain and 10 represents maximal
pain. All participants had to be high-level athletes, measured
with Engstrom’s five level activity score index (Engstro¨ m,
2004). They had to master Swedish, and together with their
parents they had to agree to participate.
Exclusion criteria were intermittent pain, specified disease
that could interfere with the heel pain, dominant pain from the
Achilles tendon, earlier fracture in the area, a poorly defined
ache in the lower extremities and participation in another
study including any kind of treatment for pain.
Radiographic examination – heel pad thickness
The pilot group was only recruited to test the radiographic
examination. In the true radiographic examination the thickness
of the heel pad was measured (n 5 45) not including the
pilot group, and the examinations were analyzed by the last
author. The lower vertex of calcaneus was the bone reference
mark, and a steel band fixated on the skin under the center
portion of the heel was the skin reference mark. A 5 mm steel
bullet marker was fixed on the medial side of the ankle as a
reference, in order to calibrate each radiograph for each child.
The heel pad thickness is defined as the distance between the
lower vertex of the calcaneus and the steel band fixed under
the heel. The measured error within the computer analysis was
estimated to 0.2 mm. The radiographic investigator was partly
blinded. The reliability test for heel pad thickness measure-
Matched control group
n = 15
Fig. 2. Study design with two randomized groups with Sever’s injury. There was a 4 weeks intervention with heel cup in the
treated group (group I). The untreated randomized control group (group II) is supposed to represent the natural course.
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