1

May

201

2

Overuse injuries of the anterior leg in military personnel;literature and Dutch experiencesLt.col Wes Zimmermann MDRoyal Dutch ArmyMay 2012, USU/Walter Reed, Washington DC, 60 minutes

2

contents1. Introduction

2. Literature

3. Organization of care

4. Complex cases

5. Future directions

6. Take home messages

3

1. introduction

22-0

4-23

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

22-0

4-23

5

Introduction: The Netherlands

Introduction: professional armed forces

ArmyNavyAir forceMilitary police

personnel:40.000 military 20.000 civilians

22-0

4-23

6

7

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!

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

22-0

4-23

8

9

2.Literature

22-0

4-23

10

Literature, pubmed (2012)

• Medial tibial stress syndrome 1975 90 items

• Shin splints 1963 198 items

• Chronic exertional compartment syndrome1978 157 items

• Compare:

• Anterior knee pain 1973 2235 items

• Anterior cruciate ligament injuries 1954 7324 items

22-0

4-23

11

Basic Military Training (BMT)

22-0

4-23

12

Local epidemiology

Basic Military Training (BMT)

4 months training

85% boys; 15% girls90% 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)

22-0

4-23

13

Basic Infantry Training

22-0

4-23

14

Local epidemiology

Basic Infantry training

11 weeks training, boys only

46% succesfull first time33% to remedial platoon21% 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)

22-0

4-23

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.

22-0

4-23

16

Literature: differential diagnosisBone MTSS, shin splints, periostitis tibiaeBone stress fracture Bone tibiofibular syndromeBone tumorSoft tissue chronic exertional compartment synrome (CECS)Soft tissue fascial herniaSoft tissue tendinopathySoft tissue muscular ruptureSoft tissue nerbe entrapmentSoft tissue acute compartment syndromeSoft tissue muscular hypertensionNeuro spinal stenosisNeuro lumbar disc herniationNeuro diabetic neuropathyVascular popliteal artery syndromeVascular claudicationVascular chronic venous insufficiencyVascular endofibrosis (intima hyperplasia)Vascular sympathetic hyperfunction (arterial flow reduction)

22-0

4-23

17

Differential diagnosis: short list

Anterior leg injuries in Dutch army recruits

1.MTSS = medial tibial stress syndrome2.CECS = chronic exercise induced compartment syndrome3.Combined MTSS and anterior compartment pain (in our population 44%)4.Fascial hernia

----------------------------------------- very rare:

5.Stress fracture of the tibia6.Peroneal nerve entrapment

22-0

4-23

18

Literature: Surface anatomy

22-0

4-23

19

Literature: 4 compartments of the lower leg

22-0

4-23

20

Diagnosis: Fascial hernia, common presentation

22-0

4-23

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. fasciotomy2. repair: fascial patch grafting or synthetic mesh

22-0

4-23

22

Diagnosis: Fascial hernia, rare presentation

22-0

4-23

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)

22-0

4-23

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)

22-0

4-23

25

Diagnosis: MTSS

22-0

4-23

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)

22-0

4-23

27

Local literature, diagnosis CECS 1Military hospital, University of UtrechtE.M.M. Verleisdonck (surgeon), phD thesis, 2000Title: exertional compartment syndrome (in Dutch)

Summary:

Single intracompartmental pressure measurement (ICP), within 1 minute post exerciseStryker side ported needleCut off point for surgery: 35 mmSensitivity 93% ; specificity 74%

P.m.: anterior compartment only!

22-0

4-23

28

Diagnosis: stryker ICP post exercise > 35mm

22-0

4-23

29

Local literature: diagnosis CECS (2)Military hospital, University of UtrechtJ.G.H. van den Brand (surgeon), phD thesis, 2004Title: clinical aspects of lower leg compartment syndrome (in English)

Summary:

NIRS is an alternative for ICP (compelling evidence)Hutchinson near infrared spectometerCut off point for diagnosis: 35 point decrease from resting values to peak exercise StO2Sensitivity 85% ; specificity 67%

NIRS is unreliable on pigmented (black) skinThe prognosis for CECS without surgery is poor

P.m.: anterior compartment only!

22-0

4-23

30

Diagnosis: NIRS during exercise, 35 points drop in StO2

22-0

4-23

31

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

22-0

4-23

32

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?

33

3.Organization of care

22-0

4-23

34

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

22-0

4-23

35

(Anterior) Leg running pain profile

22-0

4-23

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)

1. Anterior compartment R2. Medial tibia R3. Medial tibia L4. Anterior compartment L

Example: 9 – 0 – 0 – 9 = suspect for CECS0 – 8 – 8 – 0 = proves MTSS7 – 5 –5 – 7= proves MTSS + suspect CECS

* Publication in progress, W. Zimmermann

Treatment: individual combination of interventions

MTSSExplanation to patientLess runningNsaidIceMassageDryneedlingJoint mobilization (manual therapy)New shoesCustom made orthotics (inlays)Sportcompression stockings (study)Stretching and strengtheningProgressive return to runningAnalyse running techniqueAdjust running techniqueOther: (e.g. dietician)--------------------------------Shock wave (pilot)

CECSExplanation to patientLess runningNsaidIceMassageDryneedlingJoint Mobilization (manual therapy)New shoesCustom made orthotics (inlays)Sportcompression stockings (study)Stretching and strenghteningProgressive return to runningAnalyse running techniqueAdjust running techniqueOther: (e.g. dietician)--------------------------------Surgery

22-0

4-23

37

22-0

4-23

38

Treatment: analyse and alter running techniquebarefoot walking, shod running

22-0

4-23

39

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

Treatment: Shockwave for NIRS (pilot study 2012)

22-0

4-23

40

22-0

4-23

41

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

22-0

4-23

42

Treatment: a. acute fasciotomy b. incomplete fasciotomy?

43

4. Complex cases

22-0

4-23

44

4. Complex case: complaints ↓, pressure ↑Man, 21 years old, 172 cm; 72 kg; bmi 24,3

Pain profile 1: 6 – 0 – 0 – 3Stryker ICP 1: right 35, left 32

Diagnosis: 1. MTSS grade 1 of 4 right and left leg2. richt leg: anterior compartment pain > 35 = CECS3. left leg: anterior compartment pain < 35

Combination of interventions

Included in study: sportcompression stockings2400 meter run, no stockings 3 – 0 – 0 – 32400 meter run, stockings 4 – 0 – 2 – 4

3 months follow up, 2400 m 1 – 0 – 3 – 1Stryker ICP 2: right 47, left 55

Patient satisfaction with socks 3 of 10Outcome: change from infantry to lighter function

22-0

4-23

45

4. Complex case: changing pain profilesMan, 22 years old, 180 cm; 86 kg; bmi 26,5Fasciotomy of both anterior compartments 1 year ago

Pain profile 1: 9 – 5 – 5 – 9Stryker ICP 1: right 35, left 32

Diagnosis: 1. MTSS grade 3 of 4 right and left leg2. richt leg: anterior compartment pain > 35 = CECS3. left leg: anterior compartment pain < 35

Combination of interventions: dryneedling

Included in study: sportcompression stockings study2400 meter run, no stockings 4 – 6 – 4 – 3 most pain medial2400 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 10Outcome: voluntary discharge from army

46

5. Future directions

22-0

4-23

47

5. Future directions

  MTSS CECS

epidemiology x x

etiology / diagnosis x x

therapy x xprognosis(military) x xprevention / risk factors x x

22-0

4-23

48

5. Future directionsImproving 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

22-0

4-23

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: 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.

22-0

4-23

51

22-0

4-23

51

Thank you for your attention, questions?

www.Divingliterature.com

22-0

4-23

52

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)