May 2012 Overuse injuries of the anterior leg

May 2012 Overuse injuries of the anterior leg

May 2012 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 1 contents 1. Introduction 2. Literature 3. Organization of care 4. Complex cases

5. Future directions 6. Take home messages 2 1. introduction 3 27-01-20 Introduction: your speaker Undergraduate degree: Medical degree: Sports medicine:

Occupational medicine: University of Nebraska University of Leiden University of Utrecht University of Nijmegen (1987) (1995) (2000) (2005) Work: primary care physician in sports medicine, Royal Dutch Army Other: former international diver and age group diving coach

4 27-01-20 Introduction: The Netherlands 5 27-01-20 Introduction: professional armed forces Army Navy Air force

Military police personnel: 40.000 military 20.000 civilians 6 Introduction: Training and placing recruits 1. pre-employment: military training in civilian schools ( 75% of soldiers !) 2. employment: Selection procedure + medical screening Basic military training 4 months (or 3 months) Secondary military training Placement in first position

3. Fitness during the career 4. Fitness when leaving the forces P.m.: Injured recruits do not get fired! 7 27-01-20 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 8 2.Literature 9 27-01-20 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 10

27-01-20 Basic Military Training (BMT) 11 27-01-20 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) 12 27-01-20 Basic Infantry Training

13 27-01-20 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) 14 27-01-20 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. 15 27-01-20 Literature: differential diagnosis Bone Bone Bone Bone Soft tissue

Soft tissue Soft tissue Soft tissue Soft tissue Soft tissue Soft tissue Neuro Neuro Neuro Vascular Vascular Vascular Vascular Vascular

MTSS, shin splints, periostitis tibiae stress fracture tibiofibular syndrome tumor chronic exertional compartment synrome (CECS) fascial hernia tendinopathy muscular rupture nerbe entrapment acute compartment syndrome muscular hypertension spinal stenosis lumbar disc herniation diabetic neuropathy popliteal artery syndrome

claudication chronic venous insufficiency endofibrosis (intima hyperplasia) sympathetic hyperfunction (arterial flow reduction) 16 27-01-20 Differential diagnosis: short list Anterior leg injuries in Dutch army recruits 1.MTSS = medial tibial stress syndrome 2.CECS = chronic exercise induced compartment syndrome 3.Combined MTSS and anterior compartment pain (in our population 44%) 4.Fascial hernia

----------------------------------------very rare: 5.Stress fracture of the tibia 6.Peroneal nerve entrapment 17 27-01-20 Literature: Surface anatomy 18 27-01-20 Literature: 4 compartments of the lower leg

19 27-01-20 Diagnosis: Fascial hernia, common presentation 20 27-01-20 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 21 27-01-20 Diagnosis: Fascial hernia, rare presentation 22

27-01-20 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) 23

27-01-20 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)

24 27-01-20 Diagnosis: MTSS 25 27-01-20 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) 26 27-01-20 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! 27 27-01-20 Diagnosis: stryker ICP post exercise > 35mm

28 27-01-20 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! 29 27-01-20 Diagnosis: NIRS during exercise, 35 points drop in StO2 30 27-01-20

Diagnosis: NIRS during exercise, complete fall of StO2 in CECS patients 31 27-01-20 Summary literature: Diagnosis MTSS vs CECS Distinction seems not very difficult! (MTSS versus anterior or lateral compartment syndrome) 1. The symptoms are different 2. The anatomical location is different 3. Diagnosis MTSS: only history and examination 4. Diagnosis CECS: ICP immediately following exercise or NIRS

Pro memori: combined injuries are possible? 32 3.Organization of care 33 27-01-20 3. Organization of care 1.30 minutes history + physical examination (template) 2.30 minutes lower leg running pain profile* 3.Individual combination of interventions 4.3 months follow up (6 weeks)

5.Include in study if possible 6.Store patient data for research purposes * Publication in progress, W. Zimmermann 34 27-01-20 (Anterior) Leg running pain profile 35 27-01-20 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) 1. 2.

3. 4. 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 36

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 strengthening Progressive return to running Analyse running technique Adjust running technique Other: (e.g. dietician) -------------------------------Shock wave (pilot) 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 27-01-20 Treatment: individual combination of interventions 37

27-01-20 Treatment: analyse and alter running technique barefoot walking, shod running 38 27-01-20 Treatment: sportcompression stockings with foot (stocking) / without foot (tube) 39 27-01-20

Treatment: Shockwave for NIRS (pilot study 2012) 40 27-01-20 Treatment: a. fasciotomy, anterior and lateral incision b. fasciectomy (medial incision) 41 27-01-20 Treatment: a. acute fasciotomy

b. incomplete fasciotomy? 42 4. Complex cases 43 27-01-20 4. Complex case: complaints , pressure Man, 21 years old, 172 cm; 72 kg; bmi 24,3 Pain profile 1: Stryker ICP 1:

6003 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 3003 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 44 27-01-20 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: Stryker ICP 1: 9559 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 45 5. Future directions 46 27-01-20 5. Future directions MTSS CECS

epidemiology x x etiology / diagnosis x x therapy

x x prognosis (military) x x prevention / risk factors x

x 47 27-01-20 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 48 6. Take home messages 49 27-01-20 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: introducing the 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. 50 27-01-20

Thank you for your attention, questions? www.Divingliterature.com 51 27-01-20 Relevant papers and publications by Wes Zimmermann MD 2004 review MTSS (in Dutch, not published) 2005 the remedial platoon of basic military training

(NMGT, march 2005, no 2, pp 47-56; in Dutch with a summary in English) 2007 lower leg injuries in infantry training (in Dutch, not published) 2008 the remedial platoon of infantry training (NMGT, januariy2008, no 1, pp 21-24; in Dutch with a summary in English) 2009 aircast treatment for MTSS (JR Army Med Corps 156 (4): 236-240) 2009 sportcompression stockings for soldiers (NMGT, november 2009, no 6, pp 209-213; in Dutch with a summary in English) 2012 prognosis of MTSS

(Scand j med sci sports, feb 2012, pp 34-39) 52

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