"Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review"

Pilot development of diagnostic tools for lower limb apophyseal injuries in children and adolescents

Introduction

Lower limb apophyseal injuries commonly occur in children and adolescents with unknown incidence and prevalence. These conditions are considered benign, but impact children and adolescents quality of life and can lead to sport withdrawal at a crucial time. The primary aim of this research was to develop self-administered tools for two of the most common apophyseal injuries. The secondary aim was to test the sensitivity and specificity of the tools.

Methods

Study 1 used a three round online Delphi panel (n = 8), with expert consensus supported by robust literature. This panel developed a self-administered screening tool for calcaneal (Sever's disease) and tibial tuberosity (Osgood-Schlatter's disease) apophysitis. Study 2 tested the sensitivity and specificity of these developed tools with parents and children (n = 63) with concurrent clinical examination by a health professional. An initial sample size for Study 2 was set at 155 children however this was impacted by COVID-19 and recruitment was halted.

Results

Both tools had excellent diagnostic accuracy with an area under the curve of 83% (95% confidence interval = 0.70 to 0.95) for the posterior heel (calcaneal apophysitis) tool and 93% (95% confidence interval = 0.80 to 1.00) for the anterior of knee (tibial tuberosity apophysitis) tool using the pilot data from the 63 children.

Conclusions

These tools may also enhance opportunities for clinicians and health service providers with pre-clinical screening to reduce wait list time and encourage low cost, self-administered management where indicated. These findings may enable large epidemiological studies to identify populations and calculate incidence and prevalence of these conditions using self report.

Solving the Puzzle: A Compelling Case Study of Calcaneal Apophysitis With Achilles Tendon Calcification in a 14-Year-Old Patient

Calcaneal apophysitis, known as Sever's disease, manifests as heel pain and is prevalent among children and adolescents, particularly during growth spurts and periods of heightened physical activity. Although Sever's disease is well-documented, its co-occurrence with other foot pathologies in pediatric patients is relatively uncommon. We present here a unique case of a 14-year-old female patient who presented with significant heel pain and discomfort associated with flat feet, impacting her daily activities and physical performance. Clinical examination revealed tenderness at the heel consistent with Sever's disease, along with symptoms suggestive of posterior tibial tendinopathy and radiographic evidence of Achilles tendon calcification. The primary diagnoses included Sever's disease, posterior tibial tendinopathy, and calcification of the Achilles tendon. Management involved a thorough assessment comprising physical examination and imaging studies to confirm the diagnoses. Pharmacological and non-pharmacological interventions such as activity modification, stretching exercises, and orthotic devices were implemented to alleviate symptoms and improve foot mechanics. Over the course of treatment, the patient showed gradual improvement in pain levels and functional abilities, indicating a positive response to therapy. Long-term follow-up aimed at preventing recurrence and optimizing foot health was recommended to ensure sustained recovery and overall well-being. In this case study, we aim to elucidate the clinical presentation, diagnostic challenges, and management approach employed in addressing these concurrent foot conditions. By exploring this case, we hope to contribute valuable insights to the understanding and management of pediatric foot pathologies, particularly in cases involving multiple co-existing conditions.

Foot pain in children and adolescents: a problem-based approach in musculoskeletal ultrasonography

Various etiologies and risk factors contribute to foot pain in children and adolescents, including conditions such as Kohler's disease, Sever's disease, Iselin's disease, rigid flat foot, accessory navicular, Freiberg's disease, sesamoiditis, os trigonum syndrome, and more. High-frequency musculoskeletal ultrasonography can show both the bone surface and the surrounding soft tissue clearly from various angles in real-time, thereby providing a higher level of detail that is helpful for identifying the etiology of foot pain and monitoring disease progression compared with other imaging modalities. This review provides an overview of the epidemiology, pathophysiology, clinical manifestations and characteristic ultrasonographic findings of select foot pain conditions in children and adolescents.

International differences and inaccuracies in the public advertising about calcaneal apophysitis: an audit of websites originating in Australia, UK and USA

BACKGROUND

Calcaneal apophysitis is a common condition in childhood. Parents often seek online information for children's' health care concerns prior to seeking care. Therefore, we aimed to evaluate the credibility, readability, and accuracy of calcaneal apophysitis advertising on popular websites in three countries.

METHODS

We used content analysis of publicly accessible data. This involved identifying the top 50 websites in each country from their hit rates. We used elements of validated tools to audit and determine frequencies relevant to credibility (e.g. publisher), readability (e.g. literacy score) and accuracy (e.g. alignment with evidence). Data were analysed quantitatively and reported against each element.

RESULTS

Websites were predominantly hosted by private health services (n = 118, 79%). The mean (SD) SMOG (readability) score was 9.3 (4.5). The majority of websites (n = 140, 93%) provided at least one treatment recommendation, and less than 10% (n = 11) of websites advertised treatments fully aligned with evidence. Use of treatment modalities without evidence and with high risk to children were also found including surgery, extracorporeal shock wave therapy and laser.

CONCLUSIONS

Calcaneal apophysitis online advertising is mostly curated by clinicians. Clinicians should consider revising online advertising to increase understandability and accuracy to reduce health care wastage, risk, and low value care.

Comparison of Braces for Treatment of Sever's Disease (Calcaneal Apophysitis) in Barefoot Athletes: A Randomized Clinical Trial

CONTEXT

Sever's disease (calcaneal apophysitis) is a common condition in youth athletes, including those who participate in barefoot sports. Health care professionals often recommend that young athletes with Sever's disease wear heel cups in their shoes while active, but barefoot athletes are unable to use heel cups.

OBJECTIVE

To compare the efficacy of 2 braces used by barefoot athletes with Sever's disease.

DESIGN

Randomized controlled clinical trial.

SETTING

Pediatric sports medicine clinic.

PATIENTS OR OTHER PARTICIPANTS

A total of 43 barefoot athletes aged 7 to 14 years were enrolled, and 32 completed the study (age = 10.3 ± 1.6 years; 29 girls, 3 boys).

INTERVENTION(S)

Participants were randomized to the Tuli's Cheetah heel cup (n = 16) or Tuli's The X Brace (n = 16) group for use during barefoot sports over the 3-month study period.

MAIN OUTCOME MEASURE(S)

Participants completed self-reported assessments after diagnosis (baseline) and 1, 2, and 3 months later. The primary outcome was the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) physical score (3 months postenrollment). The secondary outcomes were OxAFQ-C school or play and emotional scores and the visual analog scale pain score.

RESULTS

The percentage of time wearing the brace during barefoot sports was not different between the Cheetah heel cup and The X Brace groups (82% versus 64% of the time in sports; P = .08). At 3 months, we observed no differences for the OxAFQ-C physical (0.79 versus 0.71; P = .80; Hedges g = 0.06), school or play (0.94 versus 1.00; P = .58; Hedges g = 0.26), or emotional (1.00 versus 1.00; P = .85; Hedges g = 0.21) score. Visual analog scale pain scores during activities of daily living and sports were lower (better) at the 2- and 3-month time points than at baseline (P < .001).

CONCLUSIONS

Both groups demonstrated improvements in ankle and foot function across time, but no between-groups differences were seen at 3 months. Given these results, barefoot athletes with Sever's disease may consider using either brace with barefoot activity to help improve pain and functional status.

Characteristics of Pressure on the Apophysis in the Course of Paediatric Heel Pain-Preliminary Report

Increased pressure on the heel apophysis is often implicated as a cause of paediatric heel pain. However, there are few reports on the causes of the increased pressure and its origin. Therefore, the aim of this study was to analyse the distribution of pressure on the feet in children with heel pain. The study included 33 paediatric patients with non-traumatic heel pain, i.e., 24 boys (73%) and 9 girls (27%), aged on average 11.2 years (±3 years). Pedobarographic diagnostics proved a decrease in the pressure on the heels in relation to the ground and the transfer of the projection of the centre of gravity to the forefoot. While standing, the average contribution of the pressure on the heel was 0.52, SD = 0.14 in children with normal and reduced weight. In overweight children, the average pressure on the heel was higher (0.60, SD = 0.08), but the small number of children with this characteristic (n = 4) did not allow conclusions to be drawn in this area. Heel underload was also demonstrated during gait. However, the assessment of this aspect requires additional observational analyses in the field of propulsion and gait phases. The reduced pressure on the heel promotes apophysis traction, causing intracanal compression. Studies have shown that the causes of apophysis traction may be postural defects (in particular, forward inclination of body posture) and overpronation of the foot, or defects in the metatarsal area.

[Juvenile osteochondrosis and osteonecrosis]

BACKGROUND

Juvenile osteonecrosis is an important topic in orthopedics. A wide variety of body regions of the growing patient are affected, predominantly during adolescence. All are characterized by a usually unknown aetiology as well as a stadium-like course. The main problem is a local osseous circulatory disorder, which causes osteonecrosis.

RISK FACTORS

Mechanical overloading due to increased body weight, axial misalignment, and sports activity is discussed as a risk factor. Healing depends on the localization and extent of the osseous necrosis.

DIAGNOSTICS

Diagnostically, radiologic imaging is used, in which the typical bony remodeling can be followed.

THERAPY

The therapeutic procedure depends on the affected region but is usually accompanied by a reduction of mechanical loading. If the clinical and radiological findings worsen, surgical treatment must be considered. The recognition and treatment of juvenile osteonecrosis is important and significantly influences the further development of the patient.

Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol

Calcaneal apophysitis and Achilles tendinopathy are common overuse injuries characterised by insidious posterior heel pain with activity. Calcaneal apophysitis is commonly diagnosed in adolescents, although Achilles tendinopathy is understudied in the adolescent population and is therefore rarely considered until adulthood. Exercise therapy and activity modification have the highest level of evidence for treating Achilles tendinopathy, while calcaneal apophysitis is treated with anecdotal and passive treatment or complete rest. It remains unknown whether exercise therapy is effective for adolescents with heel pain related to either diagnosis.

This is a pilot and feasibility study. Thirty participants between the ages of 7 years and 17 years with posterior heel pain will be recruited from the local community and club sports team and local physicians, school nurses, and athletic trainers through flyers and social media. Participants will be asked to complete evaluations and treatment sessions every 4 weeks with three virtual visits every 2 weeks in between for 12 weeks. All participants will receive standardised treatment consisting of daily Achilles tendon loading exercises and education on pain-guided activity modification. Feasibility outcomes will include recruitment, enrolment, retention and compliance. Clinical outcomes will include the measures of symptom severity, quality of life, tendon morphology and lower extremity function.

This protocol will provide preliminary data to inform a larger clinical trial based on the feasibility of the proposed intervention and methodology. Additionally, the results will provide preliminary evidence on whether Achilles tendon injury occurs in the adolescent population.

The trial is registered with clinicaltrials.gov (ID:1652996).

Describing Frequencies of Lower-Limb Apophyseal Injuries in Children and Adolescents: A Systematic Review

OBJECTIVE

To describe the frequency with which children are affected by lower-limb apophyseal injuries, and subgroups at greater risk.

DESIGN

Systematic review.

SETTING

N/A.

PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Systematic review of Medline OVID, PsycINFO, Cinahl, and PubMed from inception until February 21st, 2020. Articles reporting prevalence and/or incidence of an apophyseal injury (eg, calcaneal apophysitis) or its eponym (Severs or Sever disease). Per person data relating to the incidence or prevalence. Subgroup comparisons were made between sex groups and between activity participant groups.

RESULTS

There was wide variation in measurement approaches and follow-up timeframes with the majority of studies reporting on traction apophysitis of the tibial tubercle (Osgood-Schlatter disease). This condition had a point prevalence of 10% in the general population of children between the ages of 12 and 15 years, whereas the lifetime incidence has been reported as 13%. Point prevalence was higher among those who participated in sport compared with those who did not {relative risk [95% confidence interval (CI): 1.98 (1.31-2.99)]}, whereas lifetime incidence was higher among those who participated in sport at the age of 13 years compared with those who did not [relative risk (95% CI): 4.63 (2.31-9.26)]. Other apophyseal injuries did not report enough data to permit comparisons.

CONCLUSION

Sports participation is likely to substantially increase the frequency of traction apophysitis of the tibial tubercle. Further research is required with standardized approaches to compare frequencies between different apophyseal injuries and subgroups of interest.

Incidence of calcaneal apophysitis (Sever's disease) and return-to-play in adolescent athletes of a German youth soccer academy: a retrospective study of 10 years

Background

Calcaneal apophysitis, or Sever's disease, is the most common cause of heel pain in childhood and adolescence. It is regarded as an overuse syndrome. Studies on the incidence of calcaneal apophysitis in young athletes and their associated return-to-play time are lacking in the current literature. The aim of our current study was to identify the incidence of calcaneal apophysitis in professional youth soccer, the associated time to return-to-play, predisposing factors and their impact on time to return-to-play.

Methods

Retrospective evaluation of injury data gathered from a German youth soccer academy in the years 2009–2018. In total, 4326 injury cases in 612 players were included in the study. The diagnosis and the follow-up visits were carried out in a weekly consultation hour at the youth academy.

Results

During the observation period of 10 years, 22 cases of calcaneal apophysitis were detected. The incidence of calcaneal apophysitis per 100 athletes per year was found to be 0.36. The mean age of the affected athletes at the time of diagnosis was 11.8 ± 2.1 years (MW ± SD). The complaints were unilateral in 20 and bilateral in two cases. Three of the 22 detected cases of calcaneal apophysitis (13.6%) were recurrent injuries. The mean time to return-to-play of the affected athletes was 60.7 ± 64.9 days (MW ± SD). Athletes with recurrent complaints showed longer recovery time and time to return-to-play when compared to players with primary diagnosed disease. Our results could show that neither age nor body mass index at the time of diagnosis had an impact on time to return-to-play.

Conclusions

This is the first study investigating the incidence of calcaneal apophysitis and the associated time to return-to-play in youth elite soccer. Calcaneal apophysitis results in substantial time loss for the athletes. Further prospective clinical studies are required to fully understand the etiology and risk factors for calcaneal apophysitis and therefore develop preventive strategies.

Apophysitis Among Male Youth Soccer Players at an Elite Soccer Academy Over 7 Seasons

Background:

Apophyseal injuries are common in children and adolescent athletes. These injuries are believed to be caused by repetitive overloading, which can create inflammatory and degenerative conditions in growing bone prominences. However, their prevalence, diagnosis, and treatment in young soccer players have been understudied.

Purpose:

To evaluate characteristics of apophyseal injuries in adolescent athletes at an elite soccer academy.

Study Design:

Case series; Level of evidence, 4.

Methods:

All apophyseal injuries between July 2008 and June 2015 were evaluated. For each injury, the authors recorded the type and location, age of the player, injury date, imaging modalities, and time absent from training/competition.

Results:

Over the 7 seasons of this study, 210 apophyseal injuries were documented, including 172 simple apophyseal injuries and 38 apophyseal avulsion fractures. The rate of apophyseal injuries was 0.35 per 1000 hours of training exposure. A total of 196 (93.3%) cases were primary injuries, and the rest (6.7%) were reinjuries. Ultrasonography was the most commonly used imaging modality for diagnosis (172 cases; 81.9%). The most common location of apophyseal injuries was the anterior inferior iliac spine (AIIS). Return to sport was faster in athletes with apophyseal injury at the ischiopubic ramus, those with simple apophyseal injuries, and younger athletes.

Conclusion:

The most common location for apophyseal injury among soccer players was the AIIS. Return to training and competition differed according to injury location, type of apophyseal injury, and age.

Effects of custom-made insoles on foot pressure redistribution, gait parameters, and pain in calcaneal apophysitis-a pretest and posttest study

BACKGROUND

Calcaneal apophysitis is a self-limiting disorder that often affects adolescents with a high level of activity and leads to increased pain severity, impairments in gait parameters, and poor health-related quality of life.

OBJECTIVE

To investigate the combination of custom-made insoles and exercise on foot pressure distribution, spatial-temporal gait parameters, and pain intensity in patients with calcaneal apophysitis.

STUDY DESIGN

A one-group pretest-posttest design.

METHODS

Forty patients, aged between 8 and 15 years, diagnosed with calcaneal apophysitis, were included in this study. Patients were asked to use the custom-made insoles and to perform a home exercise program for 3 days a week. The duration of treatment was 4 weeks. The pain severity was evaluated with the Visual Analog Scale. The spatial-temporal gait parameters and foot pressure distribution were assessed with the Zebris FDM-THM-S treadmill system before and after the treatment.

RESULTS

At posttreatment assessment, there were significant changes in step length, stance phase percentage, swing phase percentage, and gait speed (P < 0.05), except step width and cadence (P > 0.05). Moreover, significant differences were found in forefoot, midfoot, and rearfoot pressure distribution (P < 0.05). There was also a significant decrease in pain intensity during activity compared to the pretreatment (P < 0.05).

CONCLUSION

Our study results suggest that the combination of the custom-made insoles and exercise program created improvements in spatial-temporal gait parameters and foot pressure distribution by reducing the pain severity.

Effectiveness of Custom-Made Foot Orthoses vs. Heel-Lifts in Children with Calcaneal Apophysitis (Sever’s Disease): A CONSORT-Compliant Randomized Trial

The aim of the present research was to determine the effectiveness of relieving calcaneal apophysitis pain using “off-the-shelf” heel-lifts and custom-made orthotics. Two intervention modalities were evaluated and compared in a 12-week follow-up trial. Inclusion criteria included 9- to 12-year-old children diagnosed with calcaneal apophysitis. Children were randomly stratified into treatment A (custom-made polypropylene foot orthoses) and treatment B (“off-the-shelf” heel-lifts) groups. Treatment effectiveness was measured by algometry and the visual analogical scale (VAS). A total of 208 patients were included. The treatment A group showed an increase in threshold algometry of 53.4% (95% CI 47.1% to 59.7%) and a decrease in VAS of −68.6% (95% CI −74.5% to −62.7%) compared with the treatment B group (p < 0.001). Calcaneal apophysitis pain perception was improved in both groups, but children who used custom-made foot orthoses showed a greater improvement.

Sever's Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations

Sever's disease is an underreported prevalent pediatric condition that causes heel pain in children worldwide. It is often described as an overuse injury that can present with either unilateral or bilateral heel pain. Even though the exact mechanism of injury is unknown, it is often thought it involves repetitive stress and pressure on the calcaneal growth plate. Diagnosing Sever's disease mainly relies on a thorough clinical investigation and physical examination, with a positive squeeze test usually sufficient to establish diagnosis. Nevertheless, radiographic imaging can help exclude other differential diagnoses. Therapeutic options of Sever's disease are mostly conservative, and these include rest, physical therapy, kinesiotherapy, and orthoses. Educating parents and coaches on the symptomatology and presentation of Sever's disease is pivotal for the establishment of efficient preventive interventions and earlier diagnoses. This study presents a case of a pediatric patient with Sever's disease and offers medical insight into the diagnostic, clinical, pathologic, and therapeutic characteristics of this condition, in light of the current existing literature.

Eponyms in Pediatric Sports Medicine: A Historical Review

The use of eponyms in the orthopedics literature has come under scrutiny, and there is a growing body of literature evaluating the utility of these terms in modern healthcare delivery. Although the field of pediatric orthopedic sports medicine is a relatively modern subspecialty, it is built on a foundation of over 100 years of pediatric musculoskeletal medicine. As a result, eponyms account for a significant portion of the vernacular used in the field. The purpose of this review is to summarize and describe the history of common eponyms relevant to pediatric sports pathology, examination maneuvers, classification systems, and surgical procedures. Use of eponyms in medicine is flawed. However, an improved understanding of these terms allows for informed use in future scientific discourse, patient care and medical education and may encourage future innovation and research into understanding pediatric orthopedic pathologies.

Managing the patient with heel pain

Heel pain presents frequently to primary care, commonly affecting athletic and elderly patients. Its presentation can be a common source of confusion for clinicians given the wide variety of differential diagnoses and the similarities in presenting symptoms and signs. This review classifies heel pain according to site of pain and explores the common pathologies clinicians may encounter. A brief summary of common imaging modalities used is provided. The literature is reviewed to guide evidence-based practice and to provide a framework to help clinicians investigate and manage heel pain before onward referral for specialist intervention. A linked article detailing the imaging of heel pain is included in this issue ( https://doi.org/10.12968/hmed.2019.80.4.192 ).

Prevalence and Associated Factors of Sever's Disease in an Athletic Population

BACKGROUND

Sever's disease is a common cause of pain in growing kids. Many papers reported in the literature discuss this pathologic condition, but no consensus regarding its etiology has been found among researchers. The aim of the present study was to describe the epidemiologic profile and associated factors of 430 athletic children in a population-based sample of soccer (29.5%), basketball (48.1%), and volleyball (22.3%) players aged 6 to 14 years.

METHODS

Every athlete was evaluated through physical examination, the Foot Posture Index (FPI), the Oxford Ankle Foot Questionnaire, and a custom-made sports questionnaire.

RESULTS

These data show that body mass index, sex, terrain type, sports discipline, and FPI should not be considered as risk factors for calcaneal apophysitis, whereas a significantly higher risk has been found in younger individuals (P < .01), in those with fewer training sessions per week (P = .02), and in those with shorter training sessions (P < .01).

CONCLUSIONS

The prevalence of Sever's disease in the athletic children evaluated in the present study was higher in younger and less active patients, whereas no differences were registered by sex, FPI, body mass index, terrain type, or sports discipline.

Incidence of calcaneal apophysitis in Northwest Istanbul

Background

Calcaneal apophysitis is a common clinical entity affecting children and adolescents. It is also known as Sever’s disease. Heel pain without a recent trauma is the primary manifestation. There are limited studies on the incidence of this disease. In this study, we aimed to report the regional incidence in Istanbul.

Methods

This retrospective audit of health records of all paediatric patients aged 6–17 years between January 1, 2014, and December 15, 2017 was undertaken. During this period, data were extracted from health records that recorded calcaneal apophysitis as the primary diagnosis.

Results

The 4-year incidence of calcaneal apophysitis was found to be 0.35% (74 of 20,967 paediatric patients). It commonly affected males, and bilateral cases were more common than unilateral cases. There were more admissions during the spring season, which may indicate a possible association with physical activity.

Conclusion

Although calcaneal apophysitis is a relatively common paediatric foot problem, due to its benign course and spontaneous healing capacity, most physicians are not interested in this topic. However, increased awareness of this diagnosis is important for reducing the rates of unnecessary radiological examinations and orthopaedic referrals. With increased knowledge, most cases may be diagnosed at the family physician level, which may decrease the economic burden on the health system. Incidence reports from various countries and regions may be published in the future.

Assessment of the kinesiotherapy's efficacy in male athletes with calcaneal apophysitis

BACKGROUND

The aim of the present study was to assess the efficacy of kinesiotherapy used for treating various disorders in athletes on pain and pedal functions in patients with calcaneal apophysitis.

METHODS

This prospective randomized controlled study included 22 patients with calcaneal apophysitis aged 8 to 16 years presenting with heel pain among junior athletes of a professional football club. The patients were randomly grouped into two groups, with one group receiving sham tape only and the other kinesio tape. American Orthopedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scores were recorded before and after the treatment.

RESULTS

The preoperative VAS score of the kinesio tape was 7, and AOFAS score was 62.4; the corresponding figures of the sham group were 6.81 and 70.5, respectively. The kinesio-tape group had a better AOFAS scores at 1st and 3rd month (p < 0.05). Posttreatment AOFAS score was 99.7 ± 0.9 for the kinesio-tape group and 97.4 ± 3.9 for the sham-tape group. Posttreatment VAS score was 0.1 ± 0.3 for the kinesio-tape group and 0.4 ± 0.5 for the sham-tape group (p > 0.05).

DISCUSSION

Conservative treatment modalities are preferentially used for its treatment. Kinesiotherapy is one of the treatment methods for the apophysitis. In the literature, our study is the first prospective randomized trial on the efficacy of kinesio taping in calcaneal apophysitis.

CONCLUSIONS

Although kinesio taping can be effectively used for the restoration of ankle functions of athletes with calcaneal apophysitis, its role in pain is limited. Since it lacks serious side effects, it can be used in combination with or as an alternative to pharmacological treatment in this patient group.

Injected corticosteroids for treating plantar heel pain in adults

BACKGROUND

Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach.

MAIN RESULTS

We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality.

AUTHORS' CONCLUSIONS

We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.

Effectiveness of footwear and foot orthoses for calcaneal apophysitis: a 12-month factorial randomised trial

OBJECTIVE

Calcaneal apophysitis, is a relatively common cause of heel pain in children. Very few randomised studies have evaluated treatment options. This trial compared the effectiveness of currently employed treatment options for the relief of pain and disability associated with calcaneal apophysitis.

DESIGN

Factorial 2×2 randomised comparative effectiveness trial with 1, 2, 6 and 12-month follow-up.

SETTING

Participants were recruited from the caseload of podiatrists at Monash health and Peninsula Health.

PARTICIPANTS

Children aged 8-14 years with clinically diagnosed calcaneal apophysitis.

INTERVENTIONS

Treatment factor 1: two different types of in-shoe orthoses: a heel raise or prefabricated orthoses. Treatment factor 2: footwear replacement or no footwear replacement.

OUTCOMES

Our primary outcome was functional disability, the secondary outcomes were pain and ankle dorsiflexion range.

RESULTS

A total of 133 children and their parents responded to the recruitment advertisement, 124 participated in the trial.At the 1 and 2-month follow-up points, there was a main effect of the shoe insert (heel raise) in only the physical domain for the Oxford ankle foot questionnaire (p=0.04). At the 6 and 12-month follow-up points, there was no main effect or interaction effect for any outcome measure.

CONCLUSION

This trial indicates at the 2-month time point there is a relative advantage in the use of heel raises over prefabricated orthoses for the treatment for calcaneal apophysitis. At 12 months there was no relative advantage to any one of the investigated treatment choices over another. Therefore, if a physical impact is experienced for greater than 2 months, the selection of treatment choice may defer to clinical judgement, cost-minimisation and or patient preference.

TRIAL REGISTRATION NUMBER

ACTRN12609000696291.

Effectiveness of orthotic devices in the treatment of Achilles tendinopathy: a systematic review

Orthotic devices such as foot orthoses, splints, taping and bracing are recommended for Achilles tendinopathy (AT). This systematic review was conducted to review the current evidence for the effectiveness of orthotic devices for the treatment of mid-portion or insertional AT. Electronic bibliographic databases (MEDLINE, EMBASE, Current Contents, CINAHL and SPORTDiscus) were searched in May 2014. The methodological quality of included studies was evaluated using the Quality Index. Where possible, effects were determined using standardised mean differences. The strength of evidence for each intervention was determined according to the quality and number of studies. Twelve studies satisfied the inclusion criteria; nine studies investigated mid-portion AT, whilst three studies did not distinguish between mid-portion and insertional pathology. Weak evidence showed that foot orthoses were equivalent to physical therapy, and equivalent to no treatment. Very weak evidence supported the use of adhesive taping alone or when combined with foot orthoses. Moderate evidence showed that the AirHeel™ brace was as effective as a calf muscle eccentric exercise programme, and weak evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. Weak evidence showed that an ankle joint dorsiflexion night splint was equally effective to a calf muscle eccentric exercise programme, and strong evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. These findings may aid clinical decision making in the context of AT, however further high-quality studies are required.