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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Table 3. Peak pressure during standing and running in tested subgroup<br />
Peak pressure, mean (mmHg)<br />
n Shoe<br />
only<br />
Shoe with<br />
cup<br />
Difference<br />
(%)<br />
Standing on heel 10 1407 1056 25<br />
Running 9 1412 1109 21<br />
Fig. 4. Maximal peak pressure during running (three steps)<br />
without cup (upper row) and with cup (lower row) for one<br />
child. Square show area of maximal pressure under forefoot<br />
and hindfoot, respectively. Red color represents the highest<br />
pressure (41385 mmHg).<br />
when using heel cup, with further improvement at<br />
follow-up. The persisting pain with the cup was close<br />
to 0 ( 5 0.5). The reduction in pain level in the non-<br />
A heel cup improves the function of the heel pad<br />
treatment group is thought to reflect the natural<br />
course.<br />
Discussion<br />
This study showed that the use of a heel cup resulted<br />
in increased heel pad thickness and decreased heel<br />
pad peak pressure with corresponding pain relief.<br />
The findings indicate improved heel pad function,<br />
that probably protects the injured heel from further<br />
micro trauma. The very low level of persisting pain<br />
after 4-week treatment with the cup was close to 0<br />
( 5 0.5). These results confirm our results in previous<br />
studies.<br />
The importance of a functional heel box to avoid<br />
overuse injuries in adults was presented by Jo¨ rgensen(1989).<br />
Inspired by the thesis by Jo¨ rgensen, the<br />
former chief at our clinic, Dr. Wessmark, designed<br />
and produced a thermoplastic rigid heel cup with a<br />
2<strong>–</strong>3 cm brim, instead of the traditional cup with its<br />
spoon shape. The ‘‘Wessmark cup’’ has thereafter<br />
been used on this indication. There is no need to<br />
change shoe size because of the added heel cup.<br />
Earlier studies proposing insoles have focused on<br />
the relationship between Sever’s injury, pes equinus<br />
and malalignment. Szames pointed out that equinus<br />
had a definite impact on predisposing a child to<br />
Sever’s disease (Szames et al., 1990). In a retrospective<br />
analysis from his clinic, 482% with Sever’s<br />
injury also had equinus. The primary ambition has<br />
been to normalize the gait/running pattern (Madden<br />
& Mellion, 1996). An excessive pronating foot type is<br />
thought to be associated with poor shock absorption<br />
and therefore contributes to micro trauma of the<br />
heel. This malalignment also may contribute to overactivity<br />
of the calf muscle complex, because of the<br />
necessity to stabilize the talocrural joint and/or to<br />
substitute the eversion of calcaneus. A heel wedge, a<br />
molded plastizote orthosis or a spoon-shaped heel<br />
cup to align the running cycle, have been recommended<br />
from these points of view (Micheli & Ireland<br />
1987; Staheli, 1998; Kasser, 2006). All our children<br />
have been able to walk and stand on their heels with<br />
dorsiflected feet and do not seem to have tight<br />
Achilles tendons, defined as having o101 of dorsiflexion<br />
in the ankle joint, with the knee fully extended.<br />
In an often cited retrospective study by Micheli<br />
and Ireland (1987), the frequency of pronation (without<br />
definition) in a group of 85 patients was 27%.<br />
Almost everyone (98%) was treated with insoles<br />
despite malalignment or not. The insoles used were<br />
soft plastizote orthotic 75%, viscoelastic heel cup<br />
18%, or heel wedge 5%. Approximately 30% in our<br />
studies had unilateral pain. The fact that unilateral<br />
pronation and unilateral short calf muscle seem to be<br />
5<br />
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