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The Foot 17 (2007) 178183

Arch taping as a symptomatic treatment in patients with Severs disease: A multiple case seriesGary C. Hunt a,b,e, , Thomas Stowell b , Gregory M. Alnwick c , Shaun Evans b,db a Cox Health Care Systems, 3545 South National Ave., Springeld, MS 65807, USA Franklin Pierce College, Physical Therapy Program, 5 Chenell Drive, Concord, NH 03301, USA c Genesis Rehabilitation Services, 232 Main St., Gorham, NH 03581, USA d Community Health Center, 28 West Main Street, Johnstown, NY 12095, USA e Missouri State University, 901 South National Avenue, Springeld, MO 65804, USA

Received 11 July 2006; accepted 17 April 2007

Abstract Background: Severs disease, is a musculoskeletal condition occurring in adolescence that symptomatically manifests as posterior heel pain during ambulation. Often participation in physical activity is severely limited resulting in frustration for children and parents alike. Conservative treatment options have included rest, abstinence from athletic activity, heel lifts, foot orthotic devices, ice, and calf-stretching exercise. The authors are proposing arch taping as an additional viable treatment option for controlling heel pain during athletic and other weight-bearing activities in patients with Severs disease. Objective: To assess the immediate impact of arch taping in controlling heel pain during ambulation in a group of subjects with Severs disease and to discuss possible biomechanical explanations. Methods and measures: Eleven subjects diagnosed with Severs disease with a history of posterior heel pain were evaluated and treated by three different therapists in three different regions in the USA. Level of perceived pain during ambulation was reported before and immediately after arch tape application. The Wilcoxon Signed Ranks Test was utilized to assess pain reduction with signicance set at p < 0.05 level and effect size was determined with Cliffs delta statistic. Outcomes: Each subject reported an immediate reduction in heel pain during ambulation with arch taping. The median reduction in pain was 5 levels. Wilcoxons statistic was signicant with p = 0.001 and Cliffs delta revealed a value of 0.97 indicating a large pain reduction effect with arch taping. Conclusions: The arch taping technique applied in this case series was effective in the immediate reduction of posterior heel pain during ambulation and allowed an early return to sports activities for those involved in athletics. This technique could be considered an additional treatment option for others with similar clinical presentations. Possible biomechanical explanations may relate to a windlass effect provided through the taping technique. 2007 Elsevier Ltd. All rights reserved.Keywords: Severs disease; Calcaneal apophysitis; Heel pain; Apophyseal injuries; Arch taping; Windlass mechanism

1. Introduction Sever, in 1912 described a clinical entity observed in physically active children which has come to be labeledNo sources of support or grants were involved in this paper. Corresponding author at: 79 Sailboat Lane, Kimberling City, MS 65686, USA. Tel.: +1 417 739 5495. E-mail address: gary.hunt3@att.net (G.C. Hunt).

Severs disease or calcaneal apophysitis [1]. It is one of the most common causes of heel pain in adolescence. Characteristically, the child presents with non-traumatic posterior heel pain, which is often provoked by athletic or repetitive weight-bearing activity and relieved with rest and discontinuance of the specic activity. Onset of the condition can signicantly interfere with sports participation which often frustrates the child and parents alike [27].

0958-2592/$ see front matter 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2007.04.004

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Fig. 1. Pain produced with calcaneal Squeeze test. Fig. 2 Place involved foot on opposite knee. Hold ankle in about 0 . Fig. 3 (a and b) Apply tape strip that will cover metatarsal heads. Fig. 4 (a and b) Apply long tape-strip to wrap around back of calcaneus and onto lateral plantar foot from approximately the 5th to 3rd metatarsal heads. Fig. 5 (a and b) Attach the medial portion of the long tape-strip to approximately the 1st to 3rd metatarsal heads. Fig. 6 Apply short tape strip that will cover the metatarsal heads to anchor the long strip. Fig. 7 Continue to apply short strips proximally to cover the entire plantar foot. Fig. 8 (a and b) Completed arch taping procedure viewed from medial and plantar surfaces.

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The condition is common amongst ages 8 and 14 with the majority of cases occurring between 10 and 12. Micheli and Ireland [5] reported that this type of heel pain is bilateral 60% of the time. Often the condition develops earlier in females as opposed to males due to gender differences in skeletal development [4,5]. Onset usually manifests during or immediately following the childs growth spurt after the secondary ossication center of the calcaneus appears [5,8]. Complete fusion of this secondary ossication center most often occurs between ages 13 and 15 years and thus the incidence of calcaneal apohysitis is rare in older teens [4,8,9]. The etiology of Severs disease has been related to overuse resulting from a variety of forces generated through the secondary ossication center of the calcaneus [4]. Repetitive traction forces through the calcaneal apophysis by the Achilles tendon and opposing traction force from the plantar fascia have been implicated as a source of injury [9]. The tendon-pull appears to introduce shearing microtrauma to the apophysis at its insertion on the calcaneus [4,5]. Liberson et al. [10] postulated that a traction force, in combination with direct impact force to the plantar calcaneus during initial contact, may cause bending at the mid-part of the apophysis resulting in the condition. During normal skeletal development, linear growth of long bones may exceed the growth of associated muscles and tendons. In Severs disease, it is hypothesized that tibial and bular growth exceeds the corresponding growth of the Achilles tendon and gastrocsoleus musculature. The resulting functionally short Achilles tendon may create excessive traction force on the calcaneal apophysis during stance phase of gait. Other biomechanical abnormalities of the foot such as forefoot varus, hallux valgus, pes cavus or planus and excessive pronation have all been observed and are suggested to contribute to this condition [4,5]. In addition, poor or worn footwear may contribute to the development of symptoms [4,11]. Radiographic ndings are usually unremarkable and are utilized to rule out other potential pathological causes of heel pain in growing children [4,9]. Typical physical examination ndings of Severs disease include an antalgic and guarded gait, a positive calcaneal Squeeze test for pain, as shown in Fig. 1, posterior calcaneal tenderness, and limited ankle joint dorsiexion [2,4,6,9,12,13]. Conservative treatment options have included heel lifts, foot orthotic devices, ice, and calf-stretching exercise [47]. The literature also consistently reports that treatment should include relative rest with complete cessation of sports and strenuous activity until symptoms resolve. This presents a frustrating situation since most of these children are extremely motivated and thrive on intense physical activity. Micheli and Ireland [5] reported that Severs disease may take a few weeks to 2 months to resolve after the initiation of conservative treatment even with relative rest. Despite adhering to an extended period of relative rest, it is quite common for recurrences of heel pain to occur with resumed physical activity [5].

The authors have utilized an arch taping technique as described by Hunt et al. [14] that has been benecial in immediately reducing pain during ambulation and sports activities. Currently, we are unaware of any studies investigating the effectiveness of this arch taping technique in patients with Severs disease. The only study identied that discussed taping was by Szames et al. [6] which mentioned box heel strapping as a means to control heel adipose tissue for better shock absorption. The purpose of presenting this case series is to describe the immediate inuence on posterior heel pain as a result of arch taping in eleven subjects with a diagnosis of Severs disease.

2. Methods 2.1. Subjects Each subject included in this case series was referred to physical therapy with a medical diagnosis of Severs disease. Eleven subjects were evaluated and managed by three different physical therapists in three different regions in the United States of America. Each subject presented with posterior heel pain which limited weight-bearing activity. Nine of the subjects were males and two were females with an age range from 9 to 14 years and an average age of 10 years and 8 months. Seven of the subjects were involved in organized sports prior to clinical examination. Informed consent to evaluate and treat the condition was provided by the parents of each subject. Clinical examination identied that all subjects demonstrated an antalgic and guarded gait, a positive calcaneal Squeeze test, and posterior calcaneal pain to palpation. Six of the eleven subjects measured less than 10 of ankle dorsiexion. 2.2. Research design A single factor one way repeated measures design was utilized with an ordinal pain scale of 010 to identify pain levels during ambulation. Perceived pain levels were compared between without-tape and with-tape conditions for each subject [15]. 2.3. Taping Arch taping as described by Hunt et al. [14] was used in this case series. Multi-purpose polyethylene coated cloth tape (47 mm, Tyco, Norwood, MA) with natural rubber based adhesive was applied with the patient seated and the involved sides ankle resting on the uninvolved knee. The ankle was maintained in 0 dorsiexion during tape application. This taping technique places the main supporting strap across the posterior calcaneus and then in line with the bands of the plantar fascia to anchor just distal to the rst through fth metatarsal heads. Figs. 28b demonstrate the tape application technique.

G.C. Hunt et al. / The Foot 17 (2007) 178183 Table 1 Comparison of immediate pain reduction utilizing tape (pain scale, 010) Subject 1 2 3 4 5 6 7 8 9 10 11 Without-tape pain level 8 5 5 7 8 8 5 3 6 9 7 With-tape pain level 3 0 0 2 2 4 1 0 0 3 0 Pain level reduction 5 5 5 5 6 4 4 3 6 6 7

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2.4. Procedure Each subject received an initial examination that included musculoskeletal tests and measurements for posture, motion, strength, pain, and gait. The gait assessment required that each subject rate perceived pain during normal paced ambulation. Pain intensity was recorded using an eleven-point ordinal scale with 0 representing absolutely no pain, and 10 representing the worst imaginable pain. The tape was then applied and the subject was asked again to rate the pain during ambulation. Each subject had a without-tape ambulation pain score compared to a with-tape ambulation pain score. 2.5. Data analysis Pain scores for both without-tape and with-tape conditions were entered into Microsoft Excel and analyzed using Analyse-it 1.73 (Analyse-it Software Ltd., England, UK). Since this pain scale included ordinal data, the median score for the difference between the two conditions was noted. Wilcoxon Signed Rank test was used to test for treatment signicance at the 0.05 level, and the Cliffs delta statistic was used to assess treatment effect size [1517].

3. Results Each subject reported an immediate reduction in posterior heel pain during ambulation with arch taping. The median pain reduction score was 5. Table 1 demonstrates the impact of taping on pain reduction for all subjects. A 2-tailed Wilcoxon Signed Rank Test statistic revealed a signicant p-value of 0.001. The Cliff delta statistic of 0.97 indicated a large difference between without-tape and with-tape conditions.

4. Discussion The explanation for pain reduction with taping may relate to its potential effect on the biomechanics of the foot dur-

ing weight-bearing activities. The biomechanical events that may be responsible for producing various stresses through the secondary ossication center of the calcaneus relate to the opposing traction forces of the Achilles tendon and plantar fascia. This interplay of forces seems signicant during (1) subtalar and midtarsal joint pronation during the rst part of stance [1820]; (2) forward progression of the leg over the ankle through eccentric contraction of the gastrocsoleus musculature [21]; (3) the windlass mechanism through the plantar fascia occurring during terminal stance when the heel is off the ground [22,23]; and (4) the physical growth of the calcaneal apophysis during adolescent growth spurts [10,13]. During the rst part of stance the arch lowers as a result of coupled motion of leg internal rotation associated with subtalar and midtarsal joint pronation. If this motion occurs too rapidly, or is excessive in magnitude or frequency, abnormal tension in the plantar fascia may develop [18,20,24]. Simultaneously, tension increases through the Achilles tendon as the arch lowers and the ankle begins to progress into dorsiexion [21]. As forward progression proceeds over the forefoot, additional tension develops through the lengthening Achilles tendon as the soleus and gastrocnemius prepare to contract at near maximum capacity to produce heel lift and forward progression [21]. The forceful contraction of the gastrocsoleus musculature generates traction forces through the Achilles tendons attachment site on the calcaneal apophysis and results in pulling the calcaneus posteriorly and superiorly. During a growth spurt, the imbalance between the gastrocsoleus musculature and the linear bone growth creates a functionally short Achilles tendon, which in turn, would seem to intensify the tensions generated through the Achilles tendon during stance phase [4,5]. A main restraining tissue opposing the forces generated by the Achilles tendon on the calcaneus is the plantar fascia [9]. The windlass effect acting through the metatarsophalangeal joints with particular contribution from the rst metatarsophalangeal joint is responsible for increasing tension in the plantar fascia [8,22,23,25]. As the soleus and gastrocnemius muscles contract vigorously to produce heel off during terminal stance, passive extension occurs at the metatarsophalangeal joints. As a result, the plantar fascia wraps around the convex surface of the metatarsal heads and produces a windlass mechanism which increases tension in the plantar fascia, raises the longitudinal arch, and resists the posterior and superior rotation of the calcaneus [25]. The opposing tensile forces generated by the Achilles tendon and the plantar fascia may produce excessive traction stress through the secondary ossication center of the calcaneus [6,9,19,26]. In addition to these traction forces, shearing and bending forces are produced directly through the calcaneal apophysis [10]. Specically, Liberson et al. [10] proposed that the combination of repetitive traction force produced by contraction of the gastrocsoleus coupled with impact loading of the calcaneus produce a bending force at

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the mid-portion of the apophysis. When the sum of these forces exceeds the structural tolerance of the developing apophysis in the posterior heel, Severs disease may develop in these active children. Histological hypotheses also contribute and support the biomechanical explanation of the development of Severs disease. It has been suggested that the normal increased chondrocyte proliferation of the apophyseal plate observed during the growth spurt, diminishes the ability of the calcaneal apophysis to tolerate these shearing forces [10,13]. The development of posterior heel pain associated with Severs disease appears related to the inability of the growth plate to handle shearing and bending forces generated during weight-bearing activities. When these forces exceed the plates strength capability, microtears or microfractures occur resulting in an inammatory process and pain. This inammatory state may develop into chondroid metaplasia if inadequate control of forces continues through the growth plate [10]. It would seem that if forces during weight-bearing could be controlled to more tissue-tolerant levels, then the normal growth process could occur with minimal negative impact on weight-bearing activities. The more common treatments for Severs disease reported in the literature have included rest, heel lifts, foot orthotics, ice, and calf-stretching exercises. Rest and cessation from sports activity seems logical since the condition appears to be secondary to overuse. The clinical challenge is that most of these children want to continue participation in their sports. Heel lifts seem to be helpful if a plantar exion contracture exists but would not seem to effectively reduce forces generated through the Achilles tendon during the terminal part of stance when the gastrocsoleus complex contracts near maximum capacity. Foot orthotic devices may have some benet to control excessive pronation, but again their inuence might be more evident during the rst part of stance and not during terminal stance when the heel is off the ground. Ice application seems appropriate in that it provides a numbing effect which decreases pain. Calf-stretching seems to make sense since associated limited ankle dorsiexion is often, but not always, present with Severs disease. Theoretically, tension might be reduced if the gastrocnemius complex had more extensibility. However, it seems that arch taping, as described in this case series, may have a more immediate and direct stabilizing effect on a somewhat vulnerable calcaneal apophysis throughout the gait cycle. In fact, all subjects involved in sports and their parents commented that the arch taping allowed earlier return to sports compared to the other conservative treatments previously attempted. The taping technique may simulate the windlass effect normally produced by the plantar fascia. The tape wraps around the posterior heel and anchors just distal to the plantar surface of the metatarsal heads, which seems to impose increased pressure on the posterior heel particularly during terminal stance. We suggest that the windlass effect produced by the tape might help to stabilize the apophysis against the body of the calcaneus and thus reduce pain.

5. Conclusions The clinical outcomes in this multiple case series suggest that the referenced arch taping technique can be immediately effective in minimizing posterior heel pain during ambulation in patients with Severs disease and may allow an early return to sports activities. Arch taping is cost effective since patients and parents can be instructed on the proper technique and can apply it themselves. This treatment option should be considered in similar cases of patients who present with Severs disease. Future randomized clinical trials with larger numbers will help determine how well one can generalize the effectiveness of this treatment option for posterior heel pain associated with Severs disease. Additional research designed to objectively measure forces exerted on the calcaneus during gait in adolescent subjects might also contribute to a better understanding of how arch taping can be effective in the symptomatic treatment of Severs disease.

Acknowledgements We wish to thank Reggie Coulombe, PT, Stacey Turmel, Matt Marallo, PT, and Heather Alnwick, DPT for their assistance in reviewing this manuscript. Conict of interest statement: No nancial or personal relationships with any entity were involved in this work.

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