Severs skada – paradigmskifte gällande diagnostik och behandling?

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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 5 51
Perhamre et al. Table 4. Pain level measured with Borgs CR-10 scale unusual, are two reasons to question these treatment strategies in Sever’s injury. The golden age of tissue development peaks at 11–12 years. The physiological remodelling to develop strong and lasting tissues with enough capacity to resist injuries (Wolff’s law) requires physical activity with repeated impact force to the hind foot. This relation between stimulating load and developing capacity seems to be disturbed in Sever’s injury. Histological analysis of the region shows a primary compression, rather than a tension cytoarchitecture (Ogden, 2000). The heel pad with its sum of cooperating compartments provides cushioning, and thereby reduces the impact force on calcaneus in heel strike (Ogden, 2000). An effective support to the heel pad therefore seems to be crucial, and this is supported by the findings in our previous study were the heel cup was shown to be superior to the wedge in giving pain relief (Perhamre et al., 2010a). Soccer is the predominating sport among our patients. Walter & Ng(2002) showed that the studded soccer shoe placed the foot in a dorsiflexed position, increasing the amount of pull from the Achilles tendon, exceeding the pressure placed upon the calcaneal apophysis. The conclusions from our previous studies are that pain in Sever’s injury primarily is an effect of impact, not shear forces. The reason why soccer dominates is probably simply because it is the dominating sport in this age, including both genders. It includes much running and jumping and the shoes offer little heel support. Our two previous studies have shown immediate and lasting pain relief with the heel cup, confirmed in the present study (Perhamre et al., 2010a, b). The purpose with this study was to assess the possible mechanisms behind the rapid and impressive pain relief. There was a significant increase of heel cup thickness from barefoot to shoe and from shoe to heel cup (Table 1, Fig. 3). There was also a significant reduction of the heel peak pressure using heel cups (Fig. 4). We believe that both these effects strongly support Ogden’s theory that Sever’s injury is a traumatic condition due to repetitive impact forces during heel strike with corresponding pathology in 52 Pain at start (median values) Pain at 4 weeks (median values) Shoes only With cup Shoes only With cup Group I (treatment) 7.0 2.0 3.0 0.5 Group II (no treatment) 7.0 – 5.0 – 6 the rear foot (Ogden et al., 2004). An effective treatment seems to reduce these forces. The cup seems to protect the heel, significantly reducing pain, compared with our non-treatment group (Table 3). The sample in the peak pressure test was small (n 5 10) with one child missing in the running trials. This reduces the power of our conclusions. An interesting finding was that children with Sever’s injury show a tendency toward thinner heel pads compared with the painless control group (Table 2). This could possibly be a predisposing factor to Sever’s injury. Perspectives Sever’s injury seems to be a result of high impact forces during an intense puberty period with an immature heel. The traditional recommendation to stop or diminish the sports activity for an unspecified period of time seems inappropriate and we suggest that this should be replaced by the general advice to use heel cups and continue with the activities. The effect of using the rigid heel cup can be explained both by less deformation, preserving the heel pad thickness when loaded, and by the reduction of heel pad peak pressure during heel strike. Key words: Sever’s injury, apophysitis calcanei, insoles, heel cup, heel pad thickness, heel peak pressure. Acknowledgements Thanks to Ingemar Hansson, who made the heel cups, Klara Perhamre for help with the figure layout, Mikael Hasselgren, PhD, medical chief Centre for Clinical Science, Eva Stjernstro¨ m RPT, division chief Va¨ rmland County Council for support and Ola Wessmark, former chief doctor at our Clinic, who made the prototype of this heel cup. Financial support was provided by the Primary Care Research Unit, by the division Health, Habilitation and Rehabilitation, the foundation for Orthopaedic Devices, Va¨ rmland County Council, O¨ rebro University Hospital Research Committee and Swedish National Centre for Research in Sports.
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 44: and pain history in weeks before th
Page 45 and 46: Brukner P, Khan K. Clinical sports
Page 47 and 48: Perhamre et al. 2010b). More than 7
Page 49: Perhamre et al. Table 1. Analysis o
Page 53: Stefan Perhamre, specialist i allm

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