| The following articles report on research completed, | | | | a young soccer player in a negative heel position |
| in whole or in part, under a grant from ACFAOM. | | | | more so than if wearing non-cleated shoes. Soccer is |
| Thanks to all those whose voluntary contributions to | | | | one of if not the most popular sport in the world. |
| ACFAOM's Research Fund make such grants possible. | | | | Currently more children in the U.S. now play soccer |
| Comparing Negative Casting Techniques: Foam versus | | | | than Little League Baseball. 1 Not only has there been |
| Plaster of Paris Richard Berenter, DPM, FACFAOM | | | | an increase of young soccer athletes; there has been |
| Introduction: This study was undertaken to | | | | an increase in the frequency of play. During the |
| determine whether there was any difference in the | | | | 1990's there has been an increasing trend of single |
| clinical outcomes related to the type of negative | | | | sport youth athletes who train year round. Many |
| casting technique utilized in the manufacture of | | | | young soccer players now participate in all four |
| functional foot orthoses. Those practitioners who | | | | seasons of the year playing both indoors and |
| favor foam casting blocks argue that the technique is | | | | outdoors. With the increase in the number of young |
| cleaner, faster, more cost effective and just as | | | | athletes playing soccer and the increase in the |
| reliable a method to produce functional foot orthoses | | | | amount of playing time, there has been, significant |
| versus the plaster of Paris technique. On the other | | | | rise in the incidence of young players presenting with |
| hand, a number of practitioners have argued that the | | | | foot pain such as inflammation of the calcaneal |
| foam block technique is inferior because the foam is | | | | epiphysis, more commonly known as Sever's Disease |
| incapable of capturing the shape of the foot with the | | | | (osteochondritis). Other common names for the |
| subtalar joint in neutral position and the midtarsal joint | | | | calcaneal epiphysis are traction epiphysis or apophysis. |
| maximally pronated thereby leading to an inferior foot | | | | *This study was made possible from a grant from |
| orthosis, which will be less effective at reducing | | | | The American College of Foot and Ankle Orthopedics |
| patient symptoms. Materials and Methods: A total of | | | | and Medicine and a soccer shoe donation from NIKE. |
| 38 patients were enrolled in the study. All of the | | | | Three etiological factors which can lead to the |
| patients presented with lower extremity symptoms | | | | inflammation of the calcaneal epiphysis are: increased |
| associated with abnormal lower extremity function as | | | | pressure, increased pull, and overuse are the factors |
| determined by gait evaluation. At the time of the | | | | that cause an inflammation of the calcaneal |
| initial visit, each patient signed a consent form and | | | | epiphysis.2 A negative heel position would increase |
| completed the top portion of the data sheet which | | | | the direct pressure and tendinous pull, while the |
| included both personal information and the amount of | | | | repetitive nature of soccer would introduce the third |
| pain in each extremity (patients were asked to circle | | | | factor listed, overuse. Thus, the sport of soccer |
| the amount of pain on a scale from 0-10 with 0 being | | | | exposes young participants to three main factors |
| no pain and 10 being the worse pain ever felt). Upon | | | | that can lead to Sever's disease. Soccer shoe design |
| completion of all paper work, both feet of each | | | | has remained relatively unchanged when compared to |
| patient were casted via the semi-weight bearing | | | | other types of athletic shoe gear such as with |
| foam block technique and by the non-weight bearing | | | | running shoes (figure 2). Current designs in soccer |
| supine plaster of Paris method. Both sets of casts | | | | cleats lack pressure absorption and motion control |
| were sent to a professional orthotic laboratory with | | | | which can at times place the foot in an unstable |
| a prescription filled out for an orthotic shell with a | | | | position leading to injuries such as: stress fractures, |
| medium amount of arch fill, average heel cup depth, | | | | sprains, strains, tibial fasciitis (shin splints), exertional |
| normal orthotic width (to the lateral border of the 5th | | | | compartment syndrome, ankle capsulitis/impingement, |
| metatarsal and bisection of the 1st metatarsal shaft) | | | | patelia-femoral dysfunction, and heel pain (figure 3). |
| and a thickness of polypropylene which would | | | | Lack of motion control, improper arch support can |
| behave in a semi-rigid behavior for the patient's | | | | lead to skeletal misalignment leading to postural |
| stated weight. A laboratory technician was instructed | | | | symptomatology such as medial/lateral knee pain, |
| to randomly select one of the two pairs of negative | | | | iliotibial hand syndrome, hip, and lower back pain. |
| casts and keep track of which casts were used | | | | Prepubertal long-bone growth spurts often exceed |
| without the knowledge of the principal investigator. In | | | | the growth of muscles and tendons. Shortening of |
| this way, a double blind study was established since | | | | the triceps surae group, as a result of the rapid |
| neither the principal investigator nor the patient knew | | | | growth of the tibia, may diminish ankle dorsiflexion to |
| which casts were used to construct the foot | | | | less than 10 degrees, possibly creating a strain on the |
| orthotics. Approximately 2-3 weeks following casting, | | | | tendon especially at the area of its insertion (calcaneal |
| the patient was dispensed a pair of functional foot | | | | secondary growth center). 3,4 Negative heel position |
| orthoses and asked to walk around for a minimum of | | | | created by the cleated shoe can increase the amount |
| 10 minutes to gauge the comfort level of the | | | | of heel cord pull on the calcaneal epiphysis, by |
| orthotics. Each participant was asked to use one of 4 | | | | dorsiflexing an ankle joint which may already be |
| descriptive terms (very comfortable, comfortable, | | | | limited due to muscle contracture secondary to |
| slightly uncomfortable or very uncomfortable) to | | | | growth spurts. A combination of repetitive overuse |
| describe the comfort level of 5 different regions on | | | | through soccer practice and games, with the |
| each foot orthosis corresponding to the heel region, | | | | negative heel position created by the use of cleated |
| medial arch, lateral arch, middle of the orthosis and | | | | shoes, place the young athlete at risk for developing |
| distal edge. Patients were then sent home with | | | | not only calcaneal apophysitis but also tendinitis of |
| standardized break-in instructions for the functional | | | | the posterior heel cord (tendo Achilles), and plantar |
| foot orthoses and returned to the clinic at intervals | | | | fasciitis. Very few epidemiology studies to date have |
| of 2 weeks and 4 weeks post-orthotic dispensal. At | | | | been done which look at the relationship between |
| each follow-up visit, patients were asked to fill out a | | | | the use of cleated shoes and foot injuries sustained |
| data sheet gauging the level of symptoms and | | | | by young athletes. Micheli LJ, Fehlandt AF Jr., |
| comfort level of the orthoses. The data was then | | | | reviewed 724 cases of tendinitis or apophysitis that |
| compiled and saved in a spread sheet format and | | | | were diagnosed in 445 patients seen in the Sports |
| upon completion of the study, the laboratory | | | | Medicine Division at Boston Children's Hospital |
| technician was contacted in order to identify which | | | | between 1980 and 1990. Age of the patients ranged |
| patients belonged to which study group, the foam | | | | between 9-19 years. Of the 38 soccer injuries noted |
| box or plaster of Paris casting technique. Results: The | | | | in boys dealing with tendiits or apophysitis, 18(47%) |
| data was compiled and the two study groups | | | | were diagnosed as calcaneal apophysitis, 9(24%) |
| separated by casting technique. An independent | | | | were diagnosed as Aehilles tendinitis, 4(11%) were |
| investigator (non-podiatrist) was contacted and asked | | | | diagnosed with tibialis posterior tendinits. A total of |
| to analyze the data to answer the following | | | | 82% were due to either calcaneal apophysitis or heel |
| questions: 1. Does the negative casting technique | | | | cord tendinitis. Of the 26 soccer injuries noted in girls |
| (foam vs. plaster) make a difference in the ability of | | | | dealing with tendinitis or apophysitis, 8(31%) were |
| the orthotic device to reduce symptoms? 2. Does | | | | diagnosed as calcaneal apophysitis, 6(23%) were |
| the negative casting technique (foam vs. plaster) | | | | diagnosed as tibialis posterior tendinitis, 4(15%) were |
| make a difference in how comfortable the orthotic | | | | diagnosed as Achilles tendinitis. Results totaling 69% |
| device feels to the patient? The data was analyzed | | | | were due to either calcaneal apophysitis or heel cord |
| in a variety of methods such as the mean reduction | | | | tendinitis. According to Micheli and Fehlandt, both |
| of pain, Fischer exact test and Chi-square with | | | | Sever's disease and heel cord tendinitis make up the |
| T-tests. A simple comparison of the average | | | | majority of youth soccer injuries resulting from either |
| reduction of pain after four weeks of orthotic | | | | tendinitis or apophysitis (boys=42% girls=69%). |
| therapy indicates that the plaster of Paris orthoses | | | | Methodology Frame by frame video analysis of 36 |
| achieved a mean decrease of 82.43% of pain versus | | | | male test subjects was performed on soccer fields, |
| 61.14% reduction in pain with foam box cast | | | | to study the length of time for the test subjects to |
| orthoses, with a level of significance p< 0.01. | | | | move from heel strike to heel lift while running in |
| However, further analysis of the data demonstrated | | | | both cleated and non-cleated shoes. Freeze frame |
| that casting technique had no statistical difference in | | | | comparisons were also made of the same video to |
| the reduction of pain in patients presenting with high | | | | evaluate the dorsifiexed foot position in cleated |
| levels of pain, but a significant advantage for plaster | | | | shoes. Video was obtained of test subjects that ran |
| of Paris orthotics in reducing moderate amounts of | | | | past at a moderate running pace commonly seen in |
| pain. The difference between the comfort levels of | | | | soccer play. F-scan pressures vs. time |
| the orthoses from different casting techniques was | | | | pedobaragraphs were taken of both cleated and |
| also extremely interesting. No statistical difference | | | | non-cleated shoes (running shoes) to note pressure |
| was noted in the comfort level of any of the five | | | | distribution while running. All test subjects were |
| regions studied (the heel, medial arch, lateral arch, | | | | between the ages of eight and eleven, weighing |
| middle of orthosis and distal edge) at the time the | | | | from 75 to 110 lbs, and had standard biomechanical, |
| orthotic was dispensed. However, after one month | | | | gait, and postural exams performed. Results Of the |
| of orthotic wear, the orthoses manufactured from | | | | 36 test subjects, 11 were determined to have cavus |
| plaster of Paris casts were statistically more | | | | or high arched foot types, 14 with rectus or normal |
| comfortable in the medial longitudinal arch and the | | | | foot types, and the remaining 11 with pes planus or |
| distal edge regions. Another analysis performed on | | | | low arched foot types. All test subjects had |
| comfort level of the orthotic devices compared | | | | adequate ranges of motion at the subtalar joint (STh, |
| improvement of comfort level between the orthoses | | | | midtarsal joint (MTJ), first metatarsal phalangeal joint, |
| from the two casting techniques. In this analysis, only | | | | and ankle joint with the exception of 5 subjects who |
| the medial longitudinal arch was statistically more | | | | had limited ankle joint dorsiflexion. All testing was |
| improved in the plaster of Paris technique versus the | | | | performed on outdoor soccer fields. For consistency |
| foam box method. Final Thoughts: The analysis of | | | | the same researcher performed the biomechanical |
| the data was fascinating in that both casting | | | | exams. 187 questionnaires were gathered noting foot |
| techniques were able to show some marked | | | | and leg pain among young soccer players between |
| reduction in symptoms and reasonably comfortable | | | | the ages of eight to thirteen years old. (figure 4) |
| orthoses. However, there were some statistical | | | | When compared to non cleated shoes, frame by |
| advantages of the plaster of Paris orthoses over the | | | | frame video analysis revealed that 23 test subjects |
| foam box devices. Further research needs to be | | | | took a longer period of time to move from heel |
| encouraged and might include studying the | | | | strike to heel lift while running in cleated shoes. |
| differences between orthotic devices from plaster | | | | (Figure 5). Freeze frame analysis demonstrated a |
| casts versus over-the-counter pre-fabricated devices | | | | more dorsiflexed foot position during full foot contact |
| and also against orthotics constructed from | | | | (an average of 7 degrees) during stance phase while |
| computer-digitized images of the foot. The Evaluation | | | | running in cleated shoes in 26 subjects (figures 6a, |
| of Cleated Shoes with the Adolescent Athlete in | | | | 6b). F-scan sensor data was able to capture a |
| Soccer John H. Walter Jr. DPM, MS, Temple University | | | | characteristic plantar pressure "foot print" of very |
| School of Podiatric Medicine, Philadelphia, PA Chairman | | | | highly focused pressures in the rearfoot as well as a |
| and Professor, Department of Orthopedics and | | | | rough transition from rearfoot to forefoot while |
| Medicine 8th and Race Streets, Philadelphia, PA 19107 | | | | running in cleated shoes (figures 7a, 7b). A |
| Gregory K. NG DPM 2nd yr. Podiatric Surgical | | | | characteristic footprint was reproducible in 21 of the |
| Resident, Parkview/City Ave Hospitals, Tenet Health | | | | 36 test subjects. It should be noted that the "foot |
| Systems Philadelphia, PA 19124 Abstract Thirty-six | | | | print" was most reproducible in test subjects who |
| children between the ages of eight and eleven were | | | | had pes planus foot types with limited ankle |
| tested to determine if soccer cleats placed their feet | | | | dorsiflexion. The "foot print" was least reproducible in |
| in a dorsiflexed or "negative heel" position at | | | | test subjects with cavus foot types. The average |
| midstance while running in cleated shoes. A | | | | plantar pressure was noted to be in the |
| comparison was made between non-cleated shoes | | | | 3O-psi(pounds per square inch) range in non-cleated |
| and cleated shoes using both F-scan in-shoe sensor | | | | shoes, and in the 70 psi range wearing cleated shoes. |
| system (Tekscan INC., Boston MA), and videotape | | | | See also figures 8a, 8b. Discussion Data gathered |
| analysis. Negative heel position is afoot that is in a | | | | from both the video and F-scan analysis between |
| dorsiflexed position, relative to the lateral aspect of | | | | running shoes and soccer cleats confirms the |
| the heel and forefoot greater than ninety degrees | | | | negative heel hypothesis. It is this negative heel that |
| during the stance phase of running while wearing | | | | plays a crucial role in the high percentages of young |
| cleated shoes. It is this dorsiflexed foot position that | | | | soccer players who develop Sever's disease, by not |
| is responsible for increases in the amount of pressure | | | | only increasing the direct pressure placed on the |
| placed upon the calcaneal epiphysis or secondary | | | | calcaneal epiphysis, but by also increasing the traction |
| growth center of the calcaneus. In addition to the | | | | on the epiphysis primarily via the tendo achilles. In |
| increased pressures placed on the calcaneal epiphysis | | | | addition to the increased pull and pressure on the |
| a dorsiflexed foot position during the stance phase | | | | calcaneal epiphysis, the repetitive nature of the sport, |
| increases the amount of pull from the soft tissue | | | | constant running in cleated shoes, must also be |
| attachments which is primarily from the tendo achilles | | | | considered as a factor. If one is able to decrease the |
| and secondarily from the plantar fascia The study | | | | amount of negative heel (via. Heel lifts, orthotic |
| attempts to link the negative heel position to the high | | | | management, soccer shoe redesign, etc...), then one |
| incidence of inflammation of the calcaneal growth | | | | can decrease the tendency for young soccer players |
| center, or calcaneal apophysitis commonly found in | | | | to develop heel pain and or posterior heel cord |
| the youth soccer population. Treatment options for | | | | tendinitis. Treatment options for mild heel pain or |
| calcaneal apophysitis are also discussed Introduction | | | | calcaneal apophysitis should include 1/8" to ΒΌ" heel |
| A comparison was made between non-cleated shoes | | | | lifts in both shoes, elastic ankle bracing, ice massage |
| and cleated shoes using both F-scan in-shoe sensor | | | | before, during and after play, and warm up stretching |
| system (Tekscan INC., Boston MA), and videotape | | | | exercises. If the pain persists or increases than turf |
| analysis. When the foot is positioned in a dorsiflexed | | | | or non-cleated shoes should be worn with heel lifts, |
| position greater than ninety degrees to the | | | | bracing, and a reduction in both playing and training |
| supporting surface during the stance phase of | | | | time should be implemented. When the symptoms |
| running, a negative heel position is created (figure 1). | | | | persist and the player is noticeably limping from the |
| Thirty-six male test subjects between the ages of | | | | pain, discontinuation of play is recommended with |
| eight and eleven were tested in an effort to prove | | | | immobilization of the foot and anide in a short leg |
| that the wearing of cleated shoes placed the foot of | | | | walking cast, cast boot, or soft cast. |