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Evidence based diagnosis of CECS

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

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

  2. 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

  3. 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

  4. 1. Introduction: The Netherlands

  5. 1. Introduction: Professional armed forces • Army • Navy • Air force • Military police • 65.000 personnel including civilians

  6. 2. Lower leg overuse injuries: bootcamp (BMT)

  7. 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%

  8. 2. Lower leg overuse injuries: basic infantry training

  9. 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%

  10. 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

  11. 3. Diagnosis • Lower leg injuries in Dutch army recruits • MTSS • CECS • Combined MTSS and CECS (75%?) • Fascial hernia • ----------------------------------------- • very rare: • Stress fracture of the tibia • Peroneal nerve entrapment

  12. 3. Fascial hernia

  13. 3. Fascial hernia

  14. 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%

  15. 3. Diagnosis: stryker ICP post exercise > 35mm

  16. 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

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

  18. 3. Diagnosis MTSS vs CECS • Distinction not very difficult! • 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: MTSS + CECS

  19. 3. Diagnosis MTSS vs CECS

  20. 4. controversy • 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)

  21. 5 future directions • Improving conservative therapeutic strategies • Improving the prediction of return to play / work

  22. 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)

  23. 5 future directions: improving therapeutic strategies

  24. 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.

  25. Thank you for your attention, questions? 22-9-2014 25

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