Browsing podiatrists’ websites it is not uncommon to see Foot Orthotics recommended for calcaneal apophysitis or Sever’s disease of the heel bone in children. What is the rationale for that? I am not very clear on it. You do see the claim made about “overpronation” and “flat feet” is the reason, but that is not supported by the evidence. Biomechanically, I do not see how a foot orthotic can reduce the load on the growth plate and Achilles tendon. This study showed that a cushioning heel raise worked better than foot orthotics. My unscientific study on Sever’s disease also indicated that of those who got orthotics for it, they did not think they made much if any difference.
To me, this means foot orthotics should not be the initial ‘go to’ treatment for calcaneal apophysitis. I still do occasionally use the foot orthotics in kids with this problem, but typically that there is another reason(s) being present for it to be indicated. For example, a foot that fatigues easily or is very severely “overpronated” – there is some rationale here that they perhaps should be used, but that is done with a full explanation and justification for using them.
The problem with calcaneal apophysitis is that if you take, say, 100 kids with it and do nothing, then by next week x% will be better. If you took that same 100 and did something, then regardless of what that something is, x% will be better. So why did they get better? Was it the ‘something’ or was it just the natural history of the condition. Even if something was a useless intervention, x% will still get better. Then try and convince the parent or child that the ‘something’ might not be the reason that they got better. Can you see the problem? In calcaneal apophysitis that x% is probably quite high which further complicates this even more.
I even got hate email from one mum for the audacity to suggest that Oscon supplements might not be an effective treatment for Sever’s as her daughter was fixed by it. In reality she had no idea if it helped or not. Was it the supplement that helped (that has no mechanism by which it could help) or was it just the natural history? Trying to explain that to a parent can be an exercise in futility.
The solution is to take 200 kids with the problem and then randomize half to getting ‘something’ and do nothing to the other half. Then use the stats to see if there are more in the ‘something’ group go better than the x% in the ‘nothing’ group that will get better anyway.
How then do I treat it?: manage the loads.
I have written before that Sever’s disease treatment is its all about managing loads. Its all about educating them about the nature of the condition, them having the skills to monitor it and have a discussion about that load management and strategies to use to manage the loads and use something like a simple heel pad.
We went into this concept in detail in an episode of PodChatLive with Alicia James:
I know that there will be some who will want to disagree with me, but we do have ethical and legal obligations to be consistent with the evidence.