June 2011
Evidence based diagnosis of CECS
Lt.col Wes Zimmermann M.D.
Royal Dutch Army
ACSM 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 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: 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
Army
Navy
Air force
Military 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 time
10% 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 time
33% to remedial platoon
21% 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.MTSS
2.CECS
3.Combined MTSS and CECS (75%?)
4.Fascial hernia
----------------------------------------very rare:
5.Stress fracture of the tibia
6.Peroneal nerve entrapment
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3. Fascial hernia
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3. Fascial hernia
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3. Diagnosis evidence based
Military 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 exercise
Stryker side ported needle
Cut off point for surgery: 35 mm
Sensitivity 93% ; specificity 74%
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3. Diagnosis: stryker ICP post exercise > 35mm
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3. Diagnosis evidence based
Military 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 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
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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?
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