Evidence based diagnosis of CECS

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Evidence based diagnosis of CECS Lt.col Wes Zimmermann M.D.Royal Dutch ArmyACSM 2011, Denver, Colorado.

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contents

1. Introduction

2. Lower leg overuse injuries in army recruits

3. Evidence based diagnosis of CECS

4. Controversies

5. Future direction

6. Take home message

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1. Introduction: your speakerUndergraduate degree: University of Nebraska (1987)Medical degree: University of Leiden (1995)Sports medicine: University of Utrecht (2000)Occupational medicine: University of Nijmegen (2005)

Work: clinical sports medicine physician, Royal Dutch Army

Other: former international diver and diving coach

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1. Introduction: The Netherlands

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1. Introduction: Professional armed forces

ArmyNavyAir forceMilitary police

65.000 personnel including civilians

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2. Lower leg overuse injuries: bootcamp (BMT)

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2. statistics: Basic Military Training (BMT), 2004

4 months training

90% succesfull first time10% to remedial platoon

Top 3 overuse injuries: 1. knee 2. back 3. lower legs

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%

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2. Lower leg overuse injuries: basic infantry training

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2. statistics: Basic Infantery Training, 2005

11 weeks training

46% succesfull first time33% to remedial platoon21% dismissed

Top 3 overuse injuries: 1. lower legs 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%

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2. lower leg injuries in army recruits: summary

Lower 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 than other injuries

poor prognosis, 50% does not return to the original training course / duty

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3. Diagnosis

Lower leg injuries in Dutch army recruits

1.MTSS2.CECS3.Combined MTSS and CECS (75%?)4.Fascial hernia

----------------------------------------- very rare:5.Stress fracture of the tibia6.Peroneal nerve entrapment

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3. Fascial hernia

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3. Fascial hernia

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3. Diagnosis evidence basedMilitary hospital, University of Utrecht

E.M.M. Verleisdonck (surgeon), phD thesis, 2000

Title: exertional compartment syndrome

Summary:

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

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3. Diagnosis: stryker ICP post exercise > 35mm

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3. Diagnosis evidence basedMilitary hospital, University of Utrecht

J.G.H. van den Brand (surgeon), phD thesis, 2004

Title: clinical aspects of lower leg compartment syndrome

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

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

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3. Diagnosis MTSS vs CECS

Distinction not very difficult!

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: MTSS + CECS

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3. Diagnosis MTSS vs CECS

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4. controversy

1. we concentrate on anterior and lateral compartments (no posterior pressure measurements)

2. CECS: when is it chronic?

Many recruits fulfill the diagnostic criteria of CECS after a few weeks of service. Does is make sense to postpone surgery and wait for recovery?

3. NIRS: old machine no longer in use, new machine very different (different depth of penetration)

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5 future directions

Improving conservative therapeutic strategies

Improving the prediction of return to play / work

MTSS CECS

Etiology X X

Epidemiology X X

Risk factors X X

Diagnosis X X

Therapy X X

Prognosis x x

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5. Future directions

Improving conservative therapeutic strategies:

Sportcompression stockings (Zimmermann 2009)

MTSS: shock wave therapy (Moen 2010)

MTSS: bisphosphonates (Moen 2011)

Predicting return to play / work:

MTSS: BMI (Moen, Zimmermann 2009)

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5 future directions: improving therapeutic strategies

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Take home message

In the Royal Dutch Army many recruits suffer from lower leg overuse injuries, often a combination of CECS and MTSS

The diagnosis CECS is made by a single post exercise intracompartmental pressure measurement (Stryker side ported needle) and can be made with NIRS.

150-250 patients a year get a fasciotomy of the anterior compartment (often both sides)

There is some controversy over the moment of surgery

The focus for future research is on conservative treatment strategies and prediction of return to play for CECS and MTSS.

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Thank you for your attention, questions?