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Is Severs Disease a stress fracture?

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  #1  
Old 20th August 2004, 04:41 PM
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Default Is Severs Disease a stress fracture?

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Sever's Injury: A Stress Fracture of the Immature Calcaneal Metaphysis. Journal of Pediatric Orthopedics. 24(5):488-492, September/October 2004.Ogden, John A. MD *; Ganey, Timothy M. PhD ++; Hill, J. David MD +; Jaakkola, Juha I. MD +

Magnetic resonance imaging (MRI) in children with a presumptive diagnosis of Sever's apophysitis and with continuing pain after conservative treatment demonstrated bone bruising within the trabecular bone of the metaphyseal region adjacent to the calcaneal apophysis. Limited portions of the apophyseal secondary ossification center showed similar increased signal changes. MRI studies following treatment with immobilization showed subsidence or disappearance of the metaphyseal but not any apophyseal signal changes commensurate with improvement in symptoms. Accordingly, the disorder commonly referred to as Sever's "apophysitis" may be a metaphyseal trabecular stress fracture, similar to the toddler's calcaneal stress fracture that has minimal or no involvement of the apophyseal ossification center, and thus should not be referred to as an apophysitis. Rather, it appears to be an overuse injury causing microinjury within the developing metaphyseal "equivalent" trabecular bone that has not completely adapted to the changing biologic (biomechanical) requirements of the growing, athletically active child.

What do you think?

Last edited by Craig Payne : 11th October 2004 at 11:47 PM.
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  #2  
Old 1st October 2004, 04:19 AM
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Exclamation Severs disease

Makes sense to me.
Cheers
David H
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  #3  
Old 5th October 2004, 03:07 AM
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Does anyone have any pearls for the management of recalcitrant case of Severs?
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Old 9th October 2004, 07:58 AM
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Default Mr Simiso Ntuli

It could be considered as one if you follow biomechanics princeples on tissue stress.As a result of micro trauma ( overloading i.e shearing & torsional forces in the area) bone stress tolarence level will be reached. As bone reacts to the applied stresses there may be increase in bone cell formation leading to the metioned condition.
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Old 10th October 2004, 01:14 AM
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Hi.

Quote:
Originally Posted by DrPod
Does anyone have any pearls for the management of recalcitrant case of Severs?
I find (and I would think that you do too) that rigid orthoses work well for the majority of cases.
For those cases which do not respond to rigid orthoses on their own (and I am assuming that you cut back the level of activity of the patient, especially if they are playing sport at competition level), good old-fashioned ice therapy is very useful.
In my experience this is best carried out by the patient at home with nothing more than some cold water in a basin, and some ice cubes to lower and maintain the temp . Five times a day for 20 minutes works well, although I supect this is arbitrary and the actual number of footbaths can be tailored for each patient.
Hope this is of use.
Regards,
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  #6  
Old 11th October 2004, 01:52 AM
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Default Recalcitrant Severs

Hi,
For the bad ones also consider the play activities of this age group.
They can be doing things like spending an hour a day bouncing on concrete throwing baskets (and they don't consider this a sporting activity unless asked, or spending free time doing skate board tricks, which is heavy duty use on heels). I always check on activities that may include bouncing. Included in troublesome list are rope skipping and trampoline activities. In the training for many sports are run-throughs done at fast pace with knees being brought up very high. My rule for clients is that they cannot resume these activities until I can squeeze,press, prod heels and elicit no pain. Otherwise management is with foot mobilisations and orthotic therapy. Last point: this group often have tight calves, but too much stretching in the acute stage can be aggravating to the heels, so stop stretching if getting pain in heels when stretching.

Cheers
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  #7  
Old 11th October 2004, 02:01 AM
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Quote:
Last point: this group often have tight calves
Shane - not totally sure I agree . I have seen a number of publications state that; I have seen, what I think are tight calf muscles in recalcitrant cases; but I have also seen OK ankle ROM in other tough cases .... what I am not sure about is how prevalent the tight calf muscles are vs some sort of splinting mechanism due to pain (giving the false impression of tight calf muscles) .... still use heel raises and calf stretching though.
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  #8  
Old 11th October 2004, 02:31 PM
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Smile apophysitis v severs disease

Looking at the brief resume of the paper by Dr Odgen et al I think they may be talking about the recalcitrant version of this type of paediatric heel pain which I see much less commonly than the version that goes away with ICE , relative rest, orthoses, calf stretches and heel raises.
The only way I can add to this discussion on the management of this problem is the use of a Below Knee night splint for a minimum of 3 months .
It may sound extreme but I believe this paper is primarily about recalcitrant heel pain , not our normal garden variety apophysitis.
bets wishes to all
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  #9  
Old 11th October 2004, 03:57 PM
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Default rolf

i agree with 'fleety'. the selection criteria for the subjects in this study were those who had not responded to treatment. there have been previous studies which used MRI and found changes consistent with Apophyseal swelling.[Long G, Cooper JR, Gibbon WW: Magnetic resonance imaging of injuries in the child athlete. Clinical Radiology, 54:781-91, 1999] So due to the small number of cases in this study, maybe should be considered as a variant only at this stage- as suggested by a previous contributor. if it was a stress fracture in all cases, rigid orthoses, modified rest and calf stretching for those with demonstrable equinus would not relieve symptoms fully in 2/52, which is the usual clinical pattern i would see.
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Old 11th October 2004, 08:51 PM
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Default tight calves in recalcitrant severs

Dear Craig,

Obviously each case on it's merits.
I tend to see the more recalcitrant cases because of my work situation and treatment has already been instituted by others. Most have raises w/wout orthoses and have been given stretching and modification of activity.
I find in 'some' of these cases that the stretching is being overdone, i.e. is painful to do and heels are sore after doing stretching and so when I have asked them to reduce stretching and to not go past the point of feeling pain they have resolved fairly quickly. That was the aggravating factor.
My point is that stretching can be added to the list of possible aggravating factors causing the persistence of the problem along with the activities mentioned previously. Kids will be kids and jump out of trees and off walls and limp away and still carry on with play as it is the most important thing they do.
In some cases their existing orthoses need modifying, sometimes they need mobilising, sometimes they need to do more stretching etc

Cheers

Shane
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Old 12th October 2004, 12:50 AM
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Default

Arenateers,
Interesting point made by Rolf regarding symptoms improving after 2/52.
This could happen with a more severe etiology too, depending on how long the condition has been present before you saw them

If I can pull the old "been in practice for years" gambit...........
I really can't recall a case of Severs which did not respond to rigid orthoses and rest, or rigid orthoses, rest and ice.
Obviously I haven't seen every case of Severs going, and I acknowledge there are degrees of damage in every presenting case.
Regards,
David :)
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Old 29th October 2004, 11:46 AM
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Not much of an addition to this thread, but i have recently seen a few cases of the patient becoming 'over excited' with stretching. Even with instruction to parent as is typical. I now dont give a calf stretch routine before the symptoms have resolved, unless there is a big problem with an equinus. But as pointed out what is the 'obviouse' link

I am suprised at how painful the condition appears to be, and how difficult the bargaining of activity reduction, with 12 year old, (almost 22) sports Pro's (Always win at sports day) can be :)

kind regards steven
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Old 23rd April 2005, 04:20 PM
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I am a mom who's son was casted for four weeks for Calcanal apophosystis by an orthoped. After cast removal, his muscles are sore and can not get a straight answer on continued treatment. Is it just patience, ice, less excercise and stretching?

Any help would be great. A very patient 11 year old awaits in pearls you would send this weary mom. I no longer feel like the orthopedist was the best choice to see my son.
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Old 23rd April 2005, 08:02 PM
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Quote:
Originally Posted by Jen Weir
I am a mom who's son was casted for four weeks for Calcanal apophosystis by an orthoped. After cast removal, his muscles are sore and can not get a straight answer on continued treatment. Is it just patience, ice, less excercise and stretching?

Any help would be great. A very patient 11 year old awaits in pearls you would send this weary mom. I no longer feel like the orthopedist was the best choice to see my son.

This isn't a bad idea IF other interventions have failed. Biomechanical correction with (strapping short-term; orthotics long-term) invariably breaks the pain cycle and allows healing. In more recalcitrant cases, rest from aggravating activities may be considered.



Now that you son has endured 4 weeks of immobilisation, there will definitely be many very tight (and weak) structures. These structures will include pathological tissue (severs component) and physiological (neighbouring previously healthy tissue). Vigorous work must now be done, particularly to the latter.
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Old 23rd April 2005, 09:08 PM
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Quote:
Originally Posted by Jen Weir
I am a mom who's son was casted for four weeks for Calcanal apophosystis by an orthoped. After cast removal, his muscles are sore and can not get a straight answer on continued treatment. Is it just patience, ice, less excercise and stretching?

Any help would be great. A very patient 11 year old awaits in pearls you would send this weary mom. I no longer feel like the orthopedist was the best choice to see my son.
Jen: There are not many children with calcaneal apophysitis that require immobilization casting to heal this disease. However, I have had to use casting on a few occasions to heal this painful condition. Here are my treatments for this very common problem:

1. 1/4" heel lifts
2. 20 min icing, 2 times/day
3. Three times/day calf muscle stretching
4. No walking barefoot, no walking around house or at school in flat heel shoes. Walk only in heeled shoes.
5. Possible use of NSAIDS
6. Over the counter foot orthoses.
7. Custom foot orthoses.

(Custom foot orthoses work very well for this condition if made correctly. Both of my sons had this condition from playing soccer and seemed to get better faster once they got foot orthoses.)

I would suggest seeing a sports-podiatrist to get the best treatment for your son's condition.
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Old 23rd April 2005, 09:43 PM
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Dear Kevin,

Thanks for the reply... I am in the Thousand Oaks area of CA. Do you have a recommendation? This sounds like the best idea. I feel really frustrated because his case was not extreme!! I should have known better. My son got his injury from sports, mainly basketball. I will now print up your advice and seek a sports med podiatrist.

I am very greatful for your timely reply... :)
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Old 23rd April 2005, 10:16 PM
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Quote:
Originally Posted by Jen Weir
Dear Kevin,

Thanks for the reply... I am in the Thousand Oaks area of CA. Do you have a recommendation? This sounds like the best idea. I feel really frustrated because his case was not extreme!! I should have known better. My son got his injury from sports, mainly basketball. I will now print up your advice and seek a sports med podiatrist.

I am very greatful for your timely reply... :)
Dr. Michael Zapf practices in Thousand Oaks and is a former student of mine. He is an excellent podiatrist and I'm sure you will like him. Please tell him that I recommended him to you and your son and you may want to print out my posting to you for his information. Dr.Zapf's webpage is http://www.zfootdoc.com/

Good luck.
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Old 23rd April 2005, 10:28 PM
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[quote=Kevin Kirby]
3. Three times/day calf muscle stretching
[quote]




Kevin, I am sure the general consensus includes stretching. And I am sure that you have seen many many more of severs than I have.

But, calf stretching is a dilemma IMO. Severs is a traction apophysitis. The achilles tendon is 'pulling' at the pathology. Calf stretching in the acute/early phase is surely adding to this; hence your sensible advice of heel lifts to reduce the achilles stretch(pull) in terminal stance; and provide more pseudo dorsi-flexion at the ankle joint.

I agree that perhaps a longer gastro-soleal complex will 'pull' less on the calcaneus, but the trick to fixing acute problems is eliminating the pathomechanical forces of the mechanism of injury in the short term early.

A harsh analogy is a mild fibular avulsion involving the lateral ligament complex. Inversion stretching is the "last" thing that this needs.


Ron
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Old 24th April 2005, 03:07 AM
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Have many of you been able to read the article mentioned at the start of this thread? I suggest that you try and get hold of it if you can. They mention that under MRI there is only some pathology to the growth plate and most is actually seen in the trabecular bone beind the plate - suggestive of a stress fracture rather than a traction apophysitis.

Could we suggest that there be a grading of Severs with this in mind?
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Old 24th April 2005, 07:38 AM
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Quote:
Originally Posted by Atlas

Kevin, I am sure the general consensus includes stretching. And I am sure that you have seen many many more of severs than I have.

But, calf stretching is a dilemma IMO. Severs is a traction apophysitis. The achilles tendon is 'pulling' at the pathology. Calf stretching in the acute/early phase is surely adding to this; hence your sensible advice of heel lifts to reduce the achilles stretch(pull) in terminal stance; and provide more pseudo dorsi-flexion at the ankle joint.

I agree that perhaps a longer gastro-soleal complex will 'pull' less on the calcaneus, but the trick to fixing acute problems is eliminating the pathomechanical forces of the mechanism of injury in the short term early.

A harsh analogy is a mild fibular avulsion involving the lateral ligament complex. Inversion stretching is the "last" thing that this needs.


Ron
The list of recommendations for treatment of calcaneal aphophysitis that I provided are not necessarily all used for all patients, but are a general set of treatment guidelines I use for most of my patients with this disorder.

The stretching exercises I recommend are gradual gastrocnemius-soleus stretching exercises which are intended to decrease the passive tension of the gastrocnemius-soleus complex (GSC) during weightbearing activities. The patients are instructed to not stretch so "hard" that it makes their heel hurt. I am certain that the tensile forces on the Achilles tendon are similar if not greater in walking than they are when my patients perform their GSC stretching exercises. In running, the Achilles tendon tensile forces are probably much larger.

Your analogy of an inversion ankle sprain injuring the lateral ankle ligaments is not a good one. The lateral ankle ligaments are not subjected to much tensile force during normal gait like the Achilles tendon is. The lateral ankle ligaments are placed under increased tensile force with subtalar joint supination and with ankle joint inversion with their passive tensile force causing a subtalar joint pronation moment and an ankle joint eversion moment.

The Achilles tendon, on the other hand, is placed under considerable tensile loading forces with each step. These repetitive tensile loading forces on the Achilles tendon are transmitted to the calcaneal apophysis and create a shearing force in the area of the apophysis. Gradual stretching of the GSC should help most patients reduce the Achillles tendon tensile loading forces during their weightbearing activities and enable them to have more rapid symptomatic improvement.
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Old 24th April 2005, 07:25 PM
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"A harsh analogy is a mild fibular avulsion involving the lateral ligament complex. Inversion stretching is the "last" thing that this needs."




I stand by it Kevin, for the simple reason that if this presents acutely, the "last" thing it needs is inversion stretching. However, months down the track, after a lengthy period of immobilisation in a neutral/everted position, the time now has come to regain total mobility (including inversion). At this stage, after adequate osseous healing, the clinician is certain that inversion tensile stress will not threaten the original cardinal pathology, yet permit restoration of length in active and passive tissue.



I am just pushing the timing factor. As clinicians we have this lovely full knapsack of techniques. The trouble is which is relevant, and when is it the appropriate time to use it?


Giving a patient a heel lift is virtually the antithesis of giving them a calf stretch. Both are integral in the management of severs/achilles tendinopathy/gastro-soleal tear. But one is given early in the acute protective stage, whilst the other is given later when the red light turns to orange and later green.


Ron
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Old 24th April 2005, 07:46 PM
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Quote:
Originally Posted by Atlas
Giving a patient a heel lift is virtually the antithesis of giving them a calf stretch.
Ron:

The heel lift acts by reducing the passive tensile loading force on the Achilles tendon during the late midstance phase of gait. The calf stretch, by elongating the serial and parallel passive elastic elements in the gastrocnemius-soleus muscle, also acts by reducing the passive tensile loading force on the Achilles tendon during the late midstance phase of gait. How are these two therapies "virtually the antithesis" of each other??
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Old 24th April 2005, 08:35 PM
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Quote:
Originally Posted by Kevin Kirby
Ron:

The heel lift acts by reducing the passive tensile loading force on the Achilles tendon during the late midstance phase of gait.
Agree. What you are also doing is actually reducing the (tensile stresses) stretch of the achilles/gastroc in this phase of gait and other activities such as descending stairs.

Quote:
Originally Posted by Kevin Kirby
The calf stretch, by elongating the serial and parallel passive elastic elements in the gastrocnemius-soleus muscle, also acts by reducing the passive tensile loading force on the Achilles tendon during the late midstance phase of gait. How are these two therapies "virtually the antithesis" of each other??
No doubt in my mind that a heel lift and stretching are at 2 ends of the spectrum. The former wants to minimise elongation; the latter wants to maximise it.

Your physics makes sense in that, a stretched or elongated (past tense) unit will reduce the p.t.l.f. on the tendon. This has clinical implications on prevention or later-stage or chronic rehab.

While you are stretching however, you must surely increase passive tensile forces within the achilles tendon. Imagine a rubber band with a 50% tear within it. How can you elongate/stretch it without making the tear worse?



IMO, the worst thing a clincian can do in the acute stage after tensile-stress induced pathology (ie. lateral ankle sprain; pf tear; hamstring strain) is stretch it.
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Old 24th April 2005, 10:10 PM
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Quote:
Originally Posted by Atlas
While you are stretching however, you must surely increase passive tensile forces within the achilles tendon. Imagine a rubber band with a 50% tear within it. How can you elongate/stretch it without making the tear worse?

IMO, the worst thing a clincian can do in the acute stage after tensile-stress induced pathology (ie. lateral ankle sprain; pf tear; hamstring strain) is stretch it.
One must always consider the viscoelastic nature of tendon/muscle and ligament when one is trying to determine how an injury occurs and how best to treat an injury. Factors such as strain rate, duration of loading force (i.e. creep response and stress-relaxation response), temperature (i.e. temperature effect on Young's modulus of elasticity), and magnitude of loading force are very important in determining whether a loading force will cause sufficient magnitude of stress within the tissue to initiate or propogate a tear or fracture in a biological structure.

A slow, gradual stretch of the gastrocnemius-soleus-Achilles tendon is unlikely to either initiate a tear or further propogate an existing small tear in Achilles tendon and is equally as unlikely to cause damage to the inflamed calcaneal apopysis or the trabecular bone of the metaphyseal region adjacent to the calcaneal apophysis. Not stretching at all will cause gradual shortening of the muscle-tendon complex that may induce increased magnitudes of tissue stress and increased strain rates during ambulation that may be more likely to prevent normal healing than doing no stretching at all.

By the way, how many days must a child have calcaneal aphopysitis before it is no longer considered acute??
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Old 25th April 2005, 04:49 AM
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Originally Posted by Kevin Kirby
One must always consider the viscoelastic nature of tendon/muscle and ligament when one is trying to determine how an injury occurs and how best to treat an injury. Factors such as strain rate, duration of loading force (i.e. creep response and stress-relaxation response), temperature (i.e. temperature effect on Young's modulus of elasticity), and magnitude of loading force are very important in determining whether a loading force will cause sufficient magnitude of stress within the tissue to initiate or propogate a tear or fracture in a biological structure.
IMO much of that is icing on the cake. The cake itself is all about working out stretch versus compressive pattern; which can lead one to the mechanism of injury and vice-versa. A new patient complaining of lateral ankle pain is treated entirely differently depending on what motion reproduces symptoms. Where passive eversion is the main provocative clinical finding, a compressive impingement type pathology heads possible diagnoses; and hence avoiding compression (end-range eversion) is vital in early management.

Where passive inversion is the main provocative clinical finding, ...stretch/strain pattern.............stretch (end-range inversion).....


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Originally Posted by Kevin Kirby
A slow, gradual stretch of the gastrocnemius-soleus-Achilles tendon is unlikely to either initiate a tear or further propogate an existing small tear in Achilles tendon and is equally as unlikely to cause damage to the inflamed calcaneal apopysis or the trabecular bone of the metaphyseal region adjacent to the calcaneal apophysis.
You have referred to speed (slow) and tempo (gradual), but not force. Surely force of the tensile stress is the main issue here. You will be able to better explain why failure of the healthy tissue resulted (External tensile forces > Internal tensile stress capacity????). Now post-tear you have a reduced cross sectional area of tissue. Reduced CSA means a reduced capacity to withstand tensile stresses. How can the fibres adjacent to the tear appreciate tensile stress until the void can be filled with something capable of sharing such stresses.


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Originally Posted by Kevin Kirby
Not stretching at all will cause gradual shortening of the muscle-tendon complex that may induce increased magnitudes of tissue stress and increased strain rates during ambulation that may be more likely to prevent normal healing than doing no stretching at all.
Short-term musculo-skeletal goals are rarely congruous with long-term. What do we say to an old lady with osteopaenia and a calcaneal or met fracture? On the one hand we want weightbearing to prevent osteoporosis, but on the other, we want the fracture to heal.

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Originally Posted by Kevin Kirby
By the way, how many days must a child have calcaneal aphopysitis before it is no longer considered acute??
I cannot answer that. In the main, minimising/removing the mechanism-of-injury forces and some decent management (self and/or clinical) will soon facilitate an acute injury to resolution. Failure to remove provocative forces will allow this acute injury to persist until it becomes chronic (removal of original provocative factors will no longer allow resolution (ie. secondary problems...recalcitrance of original injury).

How long does it take for a 1 cm clean primary suture wound to heal on the dorsum of the foot? A very very long time if the patient stetches it open every day.
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Old 26th April 2005, 02:29 PM
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Kevin Kirby Kevin Kirby is offline
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Originally Posted by Atlas
A new patient complaining of lateral ankle pain is treated entirely differently depending on what motion reproduces symptoms. Where passive eversion is the main provocative clinical finding, a compressive impingement type pathology heads possible diagnoses; and hence avoiding compression (end-range eversion) is vital in early management.

Where passive inversion is the main provocative clinical finding, ...stretch/strain pattern.............stretch (end-range inversion).....
Sinus tarsi syndrome often times hurts more for the patient when the subtalar joint (STJ) is maximally supinated than maximally pronated by the examiner. I have seen this quite consistently for the past 20 years of practice in well over a 1,000 cases of this condition I have treated. However, the patient responds best to increasing the STJ supination moment with an orthosis that reduces the interosseous compression force between the floor of the sinus tarsi of the calcaneus and the lateral process of the talus (Kirby, KA.: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989). How then, Ron, do you explain these somewhat contradictory findings with your treatment protocol you suggest above?



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Originally Posted by Atlas
You have referred to speed (slow) and tempo (gradual), but not force. Surely force of the tensile stress is the main issue here. You will be able to better explain why failure of the healthy tissue resulted (External tensile forces > Internal tensile stress capacity????). Now post-tear you have a reduced cross sectional area of tissue. Reduced CSA means a reduced capacity to withstand tensile stresses. How can the fibres adjacent to the tear appreciate tensile stress until the void can be filled with something capable of sharing such stresses.)
Of course, reducing the cross sectional area of a ligament or tendon with a partial tear will tend to reduce the maximum amount of force the ligament or tendon can withstand due to the resultant increase in stress on the remaining fibers adjacent to the tear and the shift in the stresses in this area of partial tear upward on the stress-strain curve toward ultimate failure. However, at lower levels of "stretch" of a ligament or tendon, there are physiological loading forces and motions that need to occur on the ligaments and tendons of the joint to allow more normal healing to occur. This is exactly why internal fixation of fractures and early range of motion are advocated to speed the recovery of the joint to physiologic strength and mobility. I realize that you are saying, Ron, that an acute tear should be immoblized, which I agree with. However, the current treatment model for many athletic injuries is now early range of motion and gradual stretching of the injured structure to allow more normal healing to occur, versus six weeks of plaster/fiberglass immobilization casting that had been advocated in the past.

One final question, Ron. Do you advocate treatment of Achilles tendinitis or tendinosis in the adult with heel lifts and stretching of the Achilles tendon? Nearly all the sports podiatrists here in the States that I lecture with on sports injuries use both heel lifts and Achilles tendon stretching for treating this condition. I don't see that the mechanism of injury in Achilles tendinitis in the adult is that much different from the mechanism of injury in retrocalcaneal apophysitis in the pre-adolescent. How do you explain this?

By the way, great discussion!
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Old 27th April 2005, 04:15 AM
Atlas Atlas is offline
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Quote:
Originally Posted by Kevin Kirby
Sinus tarsi syndrome often times hurts more for the patient when the subtalar joint (STJ) is maximally supinated than maximally pronated by the examiner. I have seen this quite consistently for the past 20 years of practice in well over a 1,000 cases of this condition I have treated. However, the patient responds best to increasing the STJ supination moment with an orthosis that reduces the interosseous compression force between the floor of the sinus tarsi of the calcaneus and the lateral process of the talus (Kirby, KA.: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989). How then, Ron, do you explain these somewhat contradictory findings with your treatment protocol you suggest above?


For me, a sinus-tarsi novice, I would love to know how one distinctly diagnoses sinus tarsi syndrome? What is the exact structure in the tunnel that is producing pain? (Extensor retinaculum? I/O talocalcaneal ligament? Cervical ligament? Fat? Post-tib artery branch? I have managed to read Klausner & McKeigue's view on it in The Phsyicain and Sportsmedicine of May 2000.

They state, "...with inversion trauma, the ligaments are usually injured in the following order: ATFL, calcaneofibular ligament, cervical ligament, and interosseous talocalcaneal ligament....". If this is indeed the order (which may or may not be true), how can the ankle ligaments tolerate passive inversion in the acute stage, let alone the ligaments within the sinus tarsi. Note that they also stated that the I/O TC ligament is taut when the foot is supinated; while the "cervical ligament helps resist hindfoot varus".


In my humble opinion, STS is a black hole with a lot of ifs, buts and maybe's. A bit like "non-specific back pain". It's not specific because us clinicians have failed to detect what is specifically wrong. Diagnostic injection for STS isn't enough for me, unless it can be guaranteed that no other potential pain producing tissue in the vicinity has also been exposed.

The other issue is the unparallelled congruency of the STJ. IMO, partial ligament tears within the tunnel would be very well splinted in the acute phase, unless the patient was 'trying to walk on the outside of their foot as a special rehab strength exercise'. Klausner quoted that severing the tunnel ligaments in cadavers showed no greater than 2.6 degree increase in motion in any plane. Compare this to severing the lateral ligament complex of the ankle and its subsequent hypermobility sequale.


My knowledge of this sinus tarsi syndrome is below par. But all I can say is that basic concepts tell me that acute tensile pathology lateral to the STJ axis within the tunnel would enjoy pronation/eversion. Whereas compressive pathology lateral to the STJ axis within the tunnel would enjoy supination/inversion.

When the pathology crosses the STJ, and exist on both sides of the STJ, then you will have paradoxical mixed confusing results; as you would also with mulitple pathology. I would find it difficult to believe, particularly after trauma, that only one pathological problem exists.



Quote:
Originally Posted by Kevin Kirby
Of course, reducing the cross sectional area of a ligament or tendon with a partial tear will tend to reduce the maximum amount of force the ligament or tendon can withstand due to the resultant increase in stress on the remaining fibers adjacent to the tear and the shift in the stresses in this area of partial tear upward on the stress-strain curve toward ultimate failure. However, at lower levels of "stretch" of a ligament or tendon, there are physiological loading forces and motions that need to occur on the ligaments and tendons of the joint to allow more normal healing to occur. This is exactly why internal fixation of fractures and early range of motion are advocated to speed the recovery of the joint to physiologic strength and mobility.
But the pathology here is the fracture. Early ROM is advocated to the adjacent physiological tissue, not the pathological region. Notwithstanding differences in healing time, why do we treat soft-tissue tears different to bone fractures? IMO, if you don't facilitate early protection/immobilisation of both, quality of healing suffers and long-term function is threatened.



Quote:
Originally Posted by Kevin Kirby
I realize that you are saying, Ron, that an acute tear should be immoblized, which I agree with. However, the current treatment model for many athletic injuries is now early range of motion and gradual stretching of the injured structure to allow more normal healing to occur, versus six weeks of plaster/fiberglass immobilization casting that had been advocated in the past.

One final question, Ron. Do you advocate treatment of Achilles tendinitis or tendinosis in the adult with heel lifts and stretching of the Achilles tendon? Nearly all the sports podiatrists here in the States that I lecture with on sports injuries use both heel lifts and Achilles tendon stretching for treating this condition. I don't see that the mechanism of injury in Achilles tendinitis in the adult is that much different from the mechanism of injury in retrocalcaneal apophysitis in the pre-adolescent. How do you explain this?

By the way, great discussion!
Ditto.

Stretch an acute achilles tendinitis and pain will be provoked. A basic philosophy of mine is that healing rarely occurs if acute pain is not interrrupted. (The only exception may be a chronic stiffness/hypomobility). Hence, despite what the majority of well respected clinicians do, I advocate minimising/avoiding stretching ie. heel-lifts early, and as the heel-lifts are weaned as the cotton-wool stage gradually passes, the introduction of gradual stretching. Stretching should be a pulling sensation; not a painful one. (Of course, biomechanical issues must be considered, but in my experience, biomechanics takes on a greater significance if one side of the tendon (usually) the medial side of the tendon is affected.)

Just because most sports podiatrists and sports physio/physical-therapists use heel lifts and tendon stretching in the early acute phase, doesn't mean it is right. Try to find physcial therapist or orthopaedic surgeon who advocates back braces (or traction to a lesser extent); yet IMO there is a place for them in certain circumstances. If one isn't prepared to walk against the herd, how can one help conditions that others cannot?

Many elite sports physical therapists are handed an MRI-plus-report prior to a initial/decent assessment. Over time, how can these elite practitioners be elite at musculo-skeletal assessment? Compare this to the unknown rural hands-on practitioner that is forced to work from the ground-up all the way on his/her own. Even the local mechanic surprises me of his conceptual understanding of mechanical injury; and he left school at 16?
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Old 22nd March 2006, 03:15 AM
Megan Megan is offline
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Hi,

Just a question, a classmate of mine recently treated a 10 year old boy with severs and a podiatrist suggested heel raises as a treatment. Ok, agree with that but he also said that on each return visit +/- every 3 weeks that one inch is to be taken off the heel raise? Any reasoning behind that?

Thank you

Megan

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Old 22nd March 2006, 04:35 AM
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Donna Donna is offline
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Hi Megan,

If the patient came into my practice with Sever's, I would use a heel lift of between 3 and 5 mm inside shoes with a good heel (leather school shoes or runners) combined with stretching and ice therapy.

I am assuming you meant mm not inches in your post?

I usually review the patient after 2 weeks initially to determine how the heel raises are working, if not responding well I would look at using functional orthoses (haven't had to do this yet)...

I don't normally wean the patient off their 3mm heel raises once the Sever's has resolved, as long as they are wearing good supportive footwear and continuing their stretches I find that all goes happily ever after. I'm sure if they went from wearing nice shoes with heel raises to suddenly wearing no shoes or thongs , it would be a different story!

I'm sure there are others out there who have seen millions more Sever's patients than I, but that's my 2 cents worth anyways... Hope it hasn't been entirely useless! :)

Regards

Donna
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Old 22nd March 2006, 04:45 AM
Megan Megan is offline
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Hi Donna,

Thank you, yes I meant mm, sorry for the confusion :P

I will pass this on, it has been very helpful, thanks again

Regards
Megan
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