in such as inflammation of the calcaneal epiphysis, mor.commonly known as Sever's Disease (osteochondritis). Othe.common names for the calcaneal epiphysis are traction epiphysis or apophysis. =This study was made possible from a grant from The American College of Foot and Ankle Orthopedics and Medicine and a
soccer shoe donation from NIKE. Three etiological factors which can lead to the inflammation of the calcaneal epiphysis are: increased pressure, increased pull, and overuse are the factors that cause an inflammation of the calcaneal epiphysis.2 A negative heel position would increase the direct pressure and tendinous pull, while the repetitive nature of soccer would introduce the third factor listed, overuse. Thus, the sport of soccer exposes young participants to three main factors that can lead to Sever's disease. Soccer shoe design has remained relatively unchanged whe.compared to other types of athletic shoe gear such as with running shoes (figure
2). Current designs in soccer cleats lack pressure absorption and motion control which can at times place the foot in an unstable position leading to injuries such as: stress fractures, sprains, strains, tibial fasciitis (shin splints), exertiona.compartment syndrome, ankle capsulitis/impingement, patelia-femoral dysfunction, and heel pain (figure
3). Lack of motion control, improper arch support can lead to skeletal misalignment leading to postural symptomatology such as medial/lateral knee pain, iliotibial hand syndrome, hip, and lower back pain. Prepubertal long-bone growth spurts often exceed the growth of muscles and tendons. Shortening of the triceps surae group, as a result of the rapid growth of the tibia, may diminish ankle dorsiflexion to less than 10 degrees, possibly creating a strain on the tendon especially at the area of its insertion (calcaneal secondary growth center). 3,4 Negative heel position created by the cleated shoe can increase the amount of heel cord pull on the calcaneal epiphysis, by dorsiflexing an ankle joint which may already be limited due to muscle contracture secondary to growth spurts. .combination of repetitive overuse through soccer practice and games, with the negative heel position created by the use of cleated shoes, place the young athlete at risk for developing not only calcaneal apophysitis but also tendinitis of the posterior heel cord (tendo Achilles), and plantar fasciitis. Very few epidemiology studies to date have been done which look at the relationship between the use of cleated shoes and foot injuries sustained by young athletes. Micheli LJ, Fehlandt AF Jr., reviewed 724 cases of tendinitis or apophysitis that were diagnosed in 445 patients seen in the Sports Medicine Division at Boston Children's Hospital between 1980 and 1990. Age of the patients ranged between 9-19 years. Of the 38 soccer injuries noted in boys dealing with tendiits or apophysitis, 18(47%) were diagnosed as calcaneal apophysitis, 9(24%) were diagnosed as Aehilles tendinitis, 4(11%) were diagnosed with tibialis posterior tendinits. A total of 82% were due to either calcaneal apophysitis or heel cord tendinitis. Of the 26 soccer injuries noted in girls dealing with tendinitis or apophysitis, 8(31%) were diagnosed as calcaneal apophysitis, 6(23%) were diagnosed as tibialis posterior tendinitis, 4(15%) were diagnosed as Achilles tendinitis. Results totaling 69% were due to either calcaneal apophysitis or heel cord tendinitis. According to Micheli and Fehlandt, both Sever's disease and heel cord tendinitis make up the majority of youth soccer injuries resulting from either tendinitis or apophysitis (boys=42% girls=69%). Methodology Frame by frame video analysis of 36 male test subjects was performed on soccer fields, to study the length of time for the test subjects to move from heel strike to heel lift while running in both cleated and non-cleated shoes. Freeze fram.comparisons were also made of the same video to evaluate the dorsifiexed foot position in cleated shoes. Video was obtained of test subjects that ran past at a moderate running pac.commonly seen in soccer play. F-scan pressures vs. time pedobaragraphs were taken of both cleated and non-cleated shoes (running shoes) to note pressure distribution while running. All test subjects were between the ages of eight and eleven, weighing from 75 to 110 lbs, and had standard biomechanical, gait, and postural exams performed. Results Of the 36 test subjects, 11 were determined to have cavus or high arched foot types, 14 with rectus or normal foot types, and the remaining 11 with pes planus or low arched foot types. All test subjects had adequate ranges of motion at the subtalar joint (STh, midtarsal joint (MTJ), first metatarsal phalangeal joint, and ankle joint with the exception of 5 subjects who had limited ankle joint dorsiflexion. All testing was performed on outdoor soccer fields. For consistency the same researcher performed the biomechanical exams. 187 questionnaires were gathered noting foot and leg pain among young soccer players between the ages of eight to thirteen years old. (figure
4) Whe.compared to non cleated shoes, frame by frame video analysis revealed that 23 test subjects took a longer period of time to move from heel strike to heel lift while running in cleated shoes. (Figure
5). Freeze frame analysis demonstrated a more dorsiflexed foot position during full foot contact (an average of 7 degrees) during stance phase while running in cleated shoes in 26 subjects (figures 6a, 6b). F-scan sensor data was able to capture a characteristic plantar pressure "foot print" of very highly focused pressures in the rearfoot as well as a rough transition from rearfoot to forefoot while running in cleated shoes (figures 7a, 7b). A characteristic footprint was reproducible in 21 of the 36 test subjects. It should be noted that the "foot print" was most reproducible in test subjects who had pes planus foot types with limited ankle dorsiflexion. The "foot print" was least reproducible in test subjects with cavus foot types. The average plantar pressure was noted to be in the 3O-psi(pounds per square inch) range in non-cleated shoes, and in the 70 psi range wearing cleated shoes. See also figures 8a, 8b. Discussion Data gathered from both the video and F-scan analysis between running shoes and soccer cleats confirms the negative heel hypothesis. It is this negative heel that plays a crucial role in the high percentages of young soccer players who develop Sever's disease, by not only increasing the direct pressure placed on the calcaneal epiphysis, but by also increasing the traction on the epiphysis primarily via the tendo achilles. In addition to the increased pull and pressure on the calcaneal epiphysis, the repetitive nature of the sport, constant running in cleated shoes, must also be considered as a factor. If one is able to decrease the amount of negative heel (via. Heel lifts, orthotic management, soccer shoe redesign, etc...), then one can decrease the tendency for young soccer players to develop heel pain and or posterior heel cord tendinitis. Treatment options for mild heel pain or calcaneal apophysitis should include 1/8" to ¼" heel lifts in both shoes, elastic ankle bracing, ice massage before, during and after play, and warm up stretching exercises. If the pain persists or increases than turf or non-cleated shoes should be worn with heel lifts, bracing, and a reduction in both playing and training time should be implemented. When the symptoms persist and the player is noticeably limping from the pain, discontinuation of play is recommended with immobilization of the foot and anide in a short leg walking cast, cast boot, or soft cast. For more information visit
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