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Overuse injuries of the anterior leg in military personnel; literature and Dutch experiences

Overuse injuries of the anterior leg in military personnel; literature and Dutch experiences. Lt.col Wes Zimmermann MD Royal Dutch Army May 2012, USU/Walter Reed, Washington DC, 60 minutes. contents. 1. Introduction 2. Literature 3. Organization of care 4. Complex cases

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Overuse injuries of the anterior leg in military personnel; literature and Dutch experiences

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  1. Overuse injuries of the anterior leg in military personnel;literature and Dutch experiences Lt.col Wes Zimmermann MD Royal Dutch Army May 2012, USU/Walter Reed, Washington DC, 60 minutes

  2. contents • 1. Introduction • 2. Literature • 3. Organization of care • 4. Complex cases • 5. Future directions • 6. Take home messages

  3. 1. introduction

  4. Introduction: your speaker • Undergraduate degree: University of Nebraska (1987) • Medical degree: University of Leiden (1995) • Sports medicine: University of Utrecht (2000) • Occupational medicine: University of Nijmegen (2005) • Work: primary care physician in sports medicine, • Royal Dutch Army • Other: former international diver and age group diving coach

  5. Introduction: The Netherlands

  6. Introduction: professional armed forces • Army • Navy • Air force • Military police • personnel: • 40.000 military • 20.000 civilians

  7. Introduction: Training and placing recruits • pre-employment: • military training in civilian schools ( 75% of soldiers !) • 2. employment: • Selection procedure + medicalscreening • Basic military training 4 months (or 3 months) • Secondary military training • Placement in firstposition • 3. Fitness during the career • Fitness whenleaving the forces • P.m.: Injuredrecruits do notgetfired!

  8. Introduction: Sportsmedicine department • one central location • Cure: 2 physicians, • 2 therapists • 1 p.e. instructor / running expert • Orthopedic problems • Exercise testing • Patients: at least 4-6 weeks problems, referred by other physicians • Prevention: 4 scientists

  9. 2.Literature

  10. Literature, pubmed (2012) • Medial tibial stress syndrome 1975 90 items • Shin splints 1963 198 items • Chronic exertional compartment syndrome 1978 157 items • Compare: • Anterior knee pain 1973 2235 items • Anterior cruciate ligament injuries 1954 7324 items

  11. Basic Military Training (BMT)

  12. Local epidemiology • Basic Military Training (BMT) • 4 months training • 85% boys; 15% girls • 90% succesfull first time; 10% to remedial platoon • Top 3 overuse injuries: • 1. knee 2. back 3. lower legs (anterior) • Lower legs = MTSS and/or CECS: • 18% of remedial platoon population • Girls > boys • Average duration of rehab training: 23 weeks • Return to training / active duty 50% (Zimmermann, NMGT, march 2005, no 2, pp 47-56)

  13. Basic Infantry Training

  14. Local epidemiology • Basic Infantry training • 11 weeks training, boys only • 46% succesfull first time • 33% to remedial platoon • 21% dismissed • Top 3 overuse injuries: • 1. lower legs (anterior) 2. knee 3. back • Lower legs = MTSS and/or CECS: • 35% of remedial platoon population • No girls, only boys • Duration of rehab training: 20 weeks • Return to training / active duty 57% (Zimmermann, NMGT, january 2008, no 1, pp 21-24)

  15. Local epidemiology, summary • Royal Dutch Army (2005-2008) • (anterior) leg injuries are in the top 3 of overuse injuries • Relative Risk (RR) girls > boys, but many more boys active (90% boys) • Significantly longer duration of rehab (longer stay in remedial platoon) than other injuries • poor prognosis, 50% does not return to the original training course / duty • Substantial time loss, money loss, frustrating injury for patient and physician.

  16. Literature: differential diagnosis • Bone MTSS, shin splints, periostitis tibiae • Bone stress fracture • Bone tibiofibular syndrome • Bone tumor • Soft tissue chronic exertional compartment synrome (CECS) • Soft tissue fascial hernia • Soft tissue tendinopathy • Soft tissue muscular rupture • Soft tissue nerbe entrapment • Soft tissue acute compartment syndrome • Soft tissue muscular hypertension • Neuro spinal stenosis • Neuro lumbar disc herniation • Neuro diabetic neuropathy • Vascular popliteal artery syndrome • Vascular claudication • Vascular chronic venous insufficiency • Vascular endofibrosis (intima hyperplasia) • Vascular sympathetic hyperfunction (arterial flow reduction)

  17. Differential diagnosis: short list • Anterior leg injuries in Dutcharmyrecruits • MTSS = medialtibial stress syndrome • CECS = chronicexerciseinducedcompartmentsyndrome • Combined MTSS and anteriorcompartment pain • (in ourpopulation 44%) • 4.Fascial hernia • ----------------------------------------- • very rare: • Stress fracture of the tibia • Peronealnerveentrapment

  18. Literature: Surface anatomy

  19. Literature: 4 compartments of the lower leg

  20. Diagnosis: Fascial hernia, common presentation

  21. Literature: fascial hernia • Definition: focal thinning or defect of the fascia around a muscle • Tibialis anterior: 5% of population, 30-60% of CECS patients (?) • (our database 12,5% of patients with anterior lower leg pain) • Caused by: sports, trauma, cecs, perforating vessels • Diagnosis: clinical diagnosis; sonography • Treatment: 1. fasciotomy • 2. repair: fascial patch grafting or synthetic mesh

  22. Diagnosis: Fascial hernia, rare presentation

  23. Literature: tibial stress fracture • History: • pain with running, sudden onset, cracking sound (sometimes) • Physical examination: • Pain on palpation tibial border, circumscript location, edema , callus • Additional investigations: • X-ray, bone scan, mri, CT • Differentiate: medial border vs lateral border • Treatment: • Activity modification, crutches, analgesics, pneumatic bracing • (extremely rare in Dutch recruits)

  24. Literature: MTSS • Definition (descriptive): • Pain on the posteriomedial tibial border during exercise, with pain on palpation of the tibia over a length of at least 5 cm • History: • Dull or sharp pain with running, medial tibial border, remains after activity, minimal 7 days • Physical examination: • Pain on palpation medial tibial border > 5 cm, • bumpy surface • Additional investigations: • Non necessary (clinical diagnosis)

  25. Diagnosis: MTSS

  26. Literature: CECS • Definition (descriptive): • increased intracompartmental pressure within a fascial space, • caused by exercise, reversible when exercise stops • History: • Cramping or burning pain with exercise, front or side of the leg, at the same time, distance or intensity of exercise, forces the athlete to stop the activity, disappears when stopped • Physical examination: unremarkable • (hypertonic anterior tibial muscle – unreliable) • Additional investigations: • Intra compartmental pressure measurement (ICP), immediately post exercise (golden standard)

  27. Local literature, diagnosis CECS 1 • Military hospital, University of Utrecht • E.M.M. Verleisdonck (surgeon), phD thesis, 2000 • Title: exertional compartment syndrome (in Dutch) • Summary: • Single intracompartmental pressure measurement (ICP), • within 1 minute post exercise • Stryker side ported needle • Cut off point for surgery: 35 mm • Sensitivity 93% ; specificity 74% • P.m.: anterior compartment only!

  28. Diagnosis: stryker ICP post exercise > 35mm

  29. Local literature: diagnosis CECS (2) • Military hospital, University of Utrecht • J.G.H. van den Brand (surgeon), phD thesis, 2004 • Title: clinical aspects of lower leg compartment syndrome (in English) • Summary: • NIRS is an alternative for ICP (compelling evidence) • Hutchinson near infrared spectometer • Cut off point for diagnosis: 35 point decrease from resting values to peak exercise StO2 • Sensitivity 85% ; specificity 67% • NIRS is unreliable on pigmented (black) skin • The prognosis for CECS without surgery is poor • P.m.: anterior compartment only!

  30. Diagnosis: NIRS during exercise, 35 points drop in StO2

  31. Diagnosis: NIRS during exercise, complete fall of StO2 in CECS patients

  32. Summary literature: Diagnosis MTSS vs CECS • Distinction seems not very difficult! • (MTSS versus anterior or lateral compartment syndrome) • The symptoms are different • The anatomical location is different • Diagnosis MTSS: only history and examination • Diagnosis CECS: ICP immediately following exercise or NIRS • Pro memori: combined injuries are possible?

  33. 3.Organization of care

  34. 3. Organization of care • 30 minuteshistory + physicalexamination (template) • 30 minuteslower leg running pain profile* • Individualcombination of interventions • 3 monthsfollow up (6 weeks) • Include in studyifpossible • Store patient data for research purposes • * Publication in progress, W. Zimmermann

  35. (Anterior) Leg running pain profile

  36. 3. Organization of care • 30 minutes anterior leg running pain profile* • Individual running test to provoke pain • standard warm-up • MTSS provocation: flat surface, speed increase • CECS provocation: inclined surface, speedwalking • Pain score 1-10 (verbal rating scale), every minute 4 locations • (teach patient self-scoring) • Anterior compartment R • Medial tibia R • Medial tibia L • Anterior compartment L • Example: 9 – 0 – 0 – 9 = suspect for CECS • 0 – 8 – 8 – 0 = proves MTSS • 7 – 5 –5 – 7= proves MTSS + suspect CECS • * Publication in progress, W. Zimmermann

  37. Treatment: individual combination of interventions MTSS CECS Explanation to patient Less running Nsaid Ice Massage Dryneedling Joint Mobilization (manual therapy) New shoes Custom made orthotics (inlays) Sportcompression stockings (study) Stretching and strenghtening Progressive return to running Analyse running technique Adjust running technique Other: (e.g. dietician) -------------------------------- Surgery • Explanation to patient • Less running • Nsaid • Ice • Massage • Dryneedling • Joint mobilization (manual therapy) • New shoes • Custom made orthotics (inlays) • Sportcompression stockings (study) • Stretching and strengthening • Progressive return to running • Analyse running technique • Adjust running technique • Other: (e.g. dietician) • -------------------------------- • Shock wave (pilot)

  38. Treatment: analyse and alter running techniquebarefoot walking, shod running

  39. Treatment: sportcompression stockingswith foot (stocking) / without foot (tube)

  40. Treatment: Shockwave for NIRS (pilot study 2012)

  41. Treatment: a. fasciotomy, anterior and lateral incision b. fasciectomy (medial incision)

  42. Treatment: a. acute fasciotomy b. incomplete fasciotomy?

  43. 4. Complex cases

  44. 4. Complex case: complaints ↓, pressure ↑ • Man, 21 years old, 172 cm; 72 kg; bmi 24,3 • Pain profile 1: 6 – 0 – 0 – 3 • Stryker ICP 1: right 35, left 32 • Diagnosis: 1. MTSS grade 1 of 4 right and left leg • 2. richt leg: anterior compartment pain > 35 = CECS • 3. left leg: anterior compartment pain < 35 • Combination of interventions • Included in study: sportcompression stockings • 2400 meter run, no stockings 3 – 0 – 0 – 3 • 2400 meter run, stockings 4 – 0 – 2 – 4 • 3 months follow up, 2400 m 1 – 0 – 3 – 1 • Stryker ICP 2: right 47, left 55 • Patient satisfaction with socks 3 of 10 • Outcome: change from infantry to lighter function

  45. 4. Complex case: changing pain profiles • Man, 22 years old, 180 cm; 86 kg; bmi 26,5 • Fasciotomy of both anterior compartments 1 year ago • Pain profile 1: 9 – 5 – 5 – 9 • Stryker ICP 1: right 35, left 32 • Diagnosis: 1. MTSS grade 3 of 4 right and left leg • 2. richt leg: anterior compartment pain > 35 = CECS • 3. left leg: anterior compartment pain < 35 • Combination of interventions: dryneedling • Included in study: sportcompression stockings study • 2400 meter run, no stockings 4 – 6 – 4 – 3 most pain medial • 2400 meter run, stockings 4 – 3 – 2 – 4 most pain lateral • 3 months follow up, 2400 m 3 – 2 – 2 – 3 most pain calve • Stryker ICP 2: not measured(posterior compartment?) • Patient satisfaction with socks 8 of 10 • Outcome: voluntary discharge from army

  46. 5. Futuredirections

  47. 5. Future directions

  48. 5. Future directions • Improving conservative therapeutic strategies: • Current study: Sportcompression stockings • Current pilot: shock wave therapy for MTSS • Comming soon: changing running technique in CECS (Diebal 2011+2012) • Bisphosphonates? • Prolotherapy? (irritant injection, e.g. hyperosmolar dextrose) • Homeopathy? (symphytum) • Predicting return to play / work: • Study completed: BMI predicts MTSS recovery (Moen, Zimmermann 2009) • Comming soon: optimization of post fasciotomy rehabilitation

  49. 6. Take home messages

  50. 6. Take home messages • In the Royal Dutch Army many recruits suffer from (anterior) leg overuse injuries, often a combination of MTSS and anterior compartment pain . • The diagnosis MTSS can be made in the office based on history and exam, the diagnosis CECS is secured by a single post exercise intracompartmental pressure measurement (Stryker side ported needle). • Diagnosis is relatively simple for MTSS and CECS of the frontal and lateral compartment. • Treatment is first conservatively (multiple interventions), treatment for CECS often results in surgery. • The unique feature of our treatment approach is to make all patients run in the lab on a treadmill for diagnosis and again for treatment evaluation: introducingthe lower leg running pain score. • The focus for future research is on conservative treatment strategies (ECSW, compression stockings, changing running technique) and accurate prediction of return to work / play for CECS and MTSS.

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