Severs skada – paradigmskifte gällande diagnostik och behandling?

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