Combating chronic heel and ankle pain in adolescents

It is not always the most complex solution that is best. A study shows that even a small amount of support might have a significant impact: enabling adolescents to continue to be physically active.

Sever’s disease, also known as calcaneal apophysitis, is a common form of chronic heel and ankle pain affecting especially children and adolescents. The condition causes inflammation at the site of the attachment of the Achilles tendon to the calcaneus (heel bone). Other forms of chronic heel and ankle pain include heel spur and achillodynia (Achilles tendon pain). Sever’s disease (named after James Warren Sever, an American orthopedic surgeon, 1878–1964) mainly occurs during adolescence. Typical symptoms include pressure pain on the calcaneal tuberosity, often combined with swelling and redness of skin, generally on both feet. Symptoms usually resolve after adolescence. Causes might include factors such as obesity as well as excessive strain on the calcaneal apophysis, the base of the Achilles tendon, during intense exercise. Seeing as the pain intensifies during exercise, many physically active young individuals feel unable to continue with their sporting activities. Considering the fact that joy of movement and enthusiasm for exercise is usually developed and consolidated at an early age, this is especially unfortunate.

Three different therapeutic approaches

Dr. Jan Joost Wiegerinck, an orthopedic specialist at the Academic Medical Center in Amsterdam, recently conducted a study involving over a hundred adolescents affected by Sever’s disease. The study examined a variety of treatment options in terms of their effectiveness and practicability. The study focused on three nonsurgical therapeutic approaches. The first approach was called “modification of activity levels” or “wait and see.” This involved test subjects being asked to simply avoid painful movements. The second approach was entitled “heel raise.” This approach involved the use of the Bauerfeind viscoelastic heel cushion ViscoHeel. Test subjects were asked to wear the heel cushion in their shoes as often as possible. The third group of test subjects underwent a “physiotherapeutic stretching and strengthening program:” This involved performing specialized targeted exercises to stretch and strengthen specific muscle groups at the clinic and at home. All three treatments were aimed at relieving the adolescents’ chronic heel and ankle pain.
“We knew in advance that all three methods would be valid,” explains Dr. Wiegerinck. “They are all methods that are also applied at our clinic in Amsterdam.” This means that the Dutch researchers were able to gather additional retrospective data on different treatments for Sever’s disease. Now, conducting a prospective study, their aim was to find out which of these three approaches would be the most effective “based on strict EBM  guidelines,” emphasizes the orthopedic specialist. Until now, no standard scientific guidelines for treating the disease had been compiled. Consequently, to paraphrase literature, treatment often turned out to be a “guessing game.” Neither is there any prevalent scientific consensus as to the causes of the disease. It is assumed that an imbalance between the muscle-tendon structure and the development of the skeleton in adolescents is responsible for the painful inflammation to the site of the attachment of the Achilles tendon to the apophysis of the heel. It has also been suggested that the disease might be caused by circulatory disorders due to excessive strain or growth, as well as injuries caused by repeated microtraumas. “Nevertheless, the clinical conditions and the type of patient remain very specific,” explains Dr. Wiegerinck. “Thus, using pressure testing to the attachment of the Achilles tendon to the apophysis of the heel , it is relatively easy to diagnose the condition – while imaging techniques can only help exclude other conditions. They are unable to explicitly identify Sever’s disease.”

ViscoHeel – very popular with the patients

Scientists were also unable to clearly identify which of the three treatments might offer a clear therapeutic advantage. No significant differences could be seen between using “wait and see,” “heel raise with Viscoheel ,” or the “physiotherapeutic stretching and strengthening program.” The good news is that all three succeeded in relieving the pain. In other words: Anything goes. While this might seem arbitrary at first glance, it also means that patients are offered a choice: Adolescents will be able to continue being physically active with only minor adjustments. All it takes to reduce their heel pain is to wear a heel cushion in their shoe. Whereas, for instance, the physical therapy approach involves time-consuming appointments and consultations, the patient using the “heel raise” treatment would simply need to get a ViscoHeel cushion. “It appears that the heel cushion provides exactly the right degree of shock absorption,” explains Dr. Wiegerinck. “It is the simplest way to treat Sever’s disease,” he continues. “Furthermore, ViscoHeel is very popular with the patients, who are finally able to continue playing football , hockey or volleyball.” But does it not sadden the scientist to come to the conclusion that there is no clear winner amongst the different treatments? “Why should I be sad?” the physician asks in surprise. “We are able to offer patients three different options to suit their needs, a perceived winner among them. What other study is able to achieve as much? And – what physician?”

Bilder: picture-alliance/Oliver Killig, Astrid Mulder, Bauerfeind