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
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Introduction: your speaker
•Undergraduate degree:
•Medical degree:
•Sports medicine:
•Occupational medicine:
University
University
University
University
of Nebraska
of Leiden
of Utrecht
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
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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
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!
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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 > 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 > 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
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)
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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
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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 > 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 > 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)
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?
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3.Organization of care
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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
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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)
1.
2.
3.
4.
Example:
Anterior compartment R
Medial tibia R
Medial tibia L
Anterior compartment L
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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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
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Treatment: individual combination of interventions
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Treatment: analyse and alter running technique
barefoot walking, shod running
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Treatment: sportcompression stockings
with 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:
Stryker ICP 1:
6–0–0–3
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
3–0–0–3
2400 meter run, stockings
4–0–2–4
3 months follow up, 2400 m
Stryker ICP 2:
right 47, left 55
1–0–3–1
Patient satisfaction with socks 3 of 10
Outcome: change from infantry to lighter function
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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:
Stryker ICP 1:
9–5–5–9
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
Stryker ICP 2:
not measured
3 – 2 – 2 – 3 most pain calve
(posterior compartment?)
Patient satisfaction with socks 8 of 10
Outcome: voluntary discharge from army
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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 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
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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?
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
(Scand j med sci sports, feb 2012, pp 34-39)
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