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

2. 1-5-2015 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. 1-5-2015 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. 1-5-2015 4 1. Introduction: The Netherlands

5. 1-5-2015 5 1. Introduction: Professional armed forces Army Navy Air force Military police 65.000 personnel including civilians

6. 1-5-2015 6 2. Lower leg overuse injuries: bootcamp (BMT)

7. 1-5-2015 7 2. statistics: Basic Military Training (BMT), 2004 4 months training 90% succesfull first time 10% to remedial platoon Top 3 overuse injuries: 1. knee2. back3. 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. 1-5-2015 8 2. Lower leg overuse injuries: basic infantry training

9. 1-5-2015 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 legs2. knee3. 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. 1-5-2015 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. 1-5-2015 11 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

12. 1-5-2015 12 3. Fascial hernia

13. 1-5-2015 13 3. Fascial hernia

14. 1-5-2015 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. 1-5-2015 15 3. Diagnosis: stryker ICP post exercise > 35mm

16. 1-5-2015 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. 1-5-2015 17 3. Diagnosis: NIRS during exercise, 35 points drop in StO2

18. 1-5-2015 18 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

19. 1-5-2015 19 3. Diagnosis MTSS vs CECS

20. 1-5-2015 20 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)

21. 1-5-2015 21 5 future directions Improving conservative therapeutic strategies Improving the prediction of return to play / work MTSSCECS EtiologyXX EpidemiologyXX Risk factorsXX DiagnosisXX TherapyXX Prognosisxx

22. 1-5-2015 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. 1-5-2015 23 5 future directions: improving therapeutic strategies

24. 1-5-2015 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. 1-5-2015 25 1-5-2015 25 Thank you for your attention, questions?