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

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Overuse injuries of the anterior leg in military
personnelliterature 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

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• 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

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Introduction The Netherlands
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Introduction professional armed forces

• Army
• Navy
• Air force
• Military police
• personnel
• 40.000 military
• 20.000 civilians

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Introduction Training and placing recruits

• 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
• Fitness when leaving the forces
• P.m. Injured recruits do not get fired!

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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

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• 2.Literature

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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

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Basic Military Training (BMT)
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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 gt boys
• Average duration of rehab training 23 weeks
• Return to training / active duty 50
• (Zimmermann, NMGT, march 2005, no 2, pp 47-56)

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Basic Infantry Training

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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)

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Local epidemiology, summary

• Royal Dutch Army (2005-2008)
• (anterior) leg injuries are in the top 3 of
  overuse injuries
• Relative Risk (RR) girls gt 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.

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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)

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Differential diagnosis short list

• Anterior leg injuries in Dutch army recruits
• MTSS medial tibial stress syndrome
• CECS chronic exercise induced compartment
  syndrome
• Combined MTSS and anterior compartment pain
• (in our population 44)
• 4.Fascial hernia
• -----------------------------------------
• very rare
• Stress fracture of the tibia
• Peroneal nerve entrapment

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Literature Surface anatomy
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Literature 4 compartments of the lower leg
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Diagnosis Fascial hernia, common presentation
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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

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Diagnosis Fascial hernia, rare presentation
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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)

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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 gt 5 cm,
• bumpy surface
• Additional investigations
• Non necessary (clinical diagnosis)

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Diagnosis MTSS
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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)

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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!

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Diagnosis stryker ICP post exercise gt 35mm
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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!

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Diagnosis NIRS during exercise, 35 points
drop in StO2
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Diagnosis NIRS during exercise, complete fall
of StO2 in CECS patients
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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?

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• 3.Organization of care

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3. Organization of care

• 30 minutes history physical examination
  (template)
• 30 minutes lower leg running pain profile
• Individual combination of interventions
• 3 months follow up (6 weeks)
• Include in study if possible
• Store patient data for research purposes
• Publication in progress, W. Zimmermann

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(Anterior) Leg running pain profile
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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

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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)

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Treatment analyse and alter running
techniquebarefoot walking, shod running
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Treatment sportcompression stockingswith foot
(stocking) / without foot (tube)
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Treatment Shockwave for NIRS (pilot study 2012)
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Treatment a. fasciotomy, anterior and lateral
incision b. fasciectomy (medial incision)
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Treatment a. acute fasciotomy b. incomplete
fasciotomy?
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• 4. Complex cases

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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 gt 35
  CECS
• 3. left leg anterior compartment pain lt 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

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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 gt 35
  CECS
• 3. left leg anterior compartment pain lt 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?)

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• 5. Future directions

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5. Future directions

  MTSS CECS
epidemiology x x
etiology / diagnosis x x
therapy x x
prognosis (military) x x
prevention / risk factors x x
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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 20112012)
• 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

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• 6. Take home messages

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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.

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Thank you for your attention, questions?
29-10-2013

• www.Divingliterature.com

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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