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Overuse injuries of the leg in the Royal Dutch armed forces Lt.col Wes Zimmermann M.D., Royal Dutch Army, Adj. Ass. prof. USUHS, Bethesda Maryland Bethesda june 2013.

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Contents 1) introduction 2) start of a mission 3) current best practice 4) Royal Dutch Army: our current protocol 5) current studies 6) take home messages

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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: primary care physician in sports medicine,

Royal Dutch Army

Other: former international diver and age group diving coach

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1. Introduction: The Netherlands

1. Introduction: professional armed forces Army Navy Air force Military police personnel: 40.000 military 20.000 civilians Currently undergoing severe cuts in personnel and budgets

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1. 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, they get a minimum of 6

months rehab time!

1. 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. Start of a mission: military training injuries 14-6

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2. Start of a mission: epidemiology

Basic military training 4 months 90% succesfull first time 10% to remedial platoon Top 3 overuse injuries: 1.knee 2.back 3.legs Duration of rehab: 23 weeks Return to duty 60% Zimmermann, 2005

Basic infantry training 11 weeks 46% succesfull first time 33% to remedial platoon 21% dismissed Top 3 overuse injuries: 1. legs 2. knee 3. back Duration of rehab: 20 weeks Return to duty 57% Zimmermann, 2008

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2. 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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2. Start of a mission: focus on legs

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3. 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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3. Current best practice: differential diagnosis

Bone MTSS, shin splints, periostitis tibiae Bone stress fracture Bone tibiofibular syndrome Bone tumor Soft tissue chronic exertional compartment synrome (CECS) Soft tissue fascial hernia Soft tissue tendinopathy Soft tissue muscular rupture Soft tissue nerve entrapment Soft tissue acute compartment syndrome Soft tissue muscular hypertension Neuro spinal stenosis Neuro lumbar disc herniation Neuro peripheral neuropathy Neuro diabetic neuropathy Vascular popliteal artery syndrome Vascular claudication Vascular chronic venous insufficiency Vascular endofibrosis (intima hyperplasia) Vascular sympathetic hyperfunction (arterial flow reduction)

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3. Current best practice: diagnostic short list

Leg injuries in Dutch army recruits 1. MTSS 2. CECS 3. Combined MTSS and CECS (50%) 4. Fascial hernia (5-15%, comorbidity with CECS)

----------------------------------------- very rare: 5. Stress fracture of the tibia 6. Peroneal nerve entrapment

3. Fascial hernia

Common presentation Rare presentation

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3. Current best practice: literature

MTSS History Location No additional tests necessary Exclude: stress fracture and CECS Treatment: conservative

CECS History Location Single intracompartmental pressure measurement, 1 minute post exercise Aweid 2012 Roberts 2012 Treatment: Surgical 4 compartments!

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3. Current best practice: CECS diagnosis Intracompartimental pressure Measurement (Stryker)> 35 mm Hg Sensitivity 93% ; specificity 74% Verleisdonck 2000

or

NIRS 35 point decrease from resting values to peak exercise StO2 Sensitivity 85% ; specificity 67% Van de Brand 2004

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4. Royal Dutch Army: current treatment protocol

1. 30 min.: history + physical examination (template)

2. 30 min.: leg running pain profile*

3. Additional tests if indicated (Stryker, ultrasound, mri etc.)

4. 3 specialists: sports medicine, surgeon, physiatrist

5. Treatment: a mix of interventions per patient

6. Reassessment: 6 weeks, 3 months

7. Include in a study if possible

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4. Leg Running Pain Profile (LRPP)

Zimmermann, 2012 Pain profile 7-0-0-7: CECS Pain profile 0-7-7-0: MTSS Pain profile 3-8-8-3: Combination MTSS>CECS Allows for a diagnosis and grade of severity per leg

4. Treatment: a mix of interventions per patient

MTSS Explanation to patient Less running Nsaid Ice Massage Dryneedling Joint mobilization (manual therapy) New shoes Custom made orthotics (inlays) Sportcompression stockings Stretching and strengthening Progressive return to running Analyse / adjust running technique Other: (e.g. dietician), prolotherapy -------------------------------- Shock wave

CECS Explanation to patient Less running Nsaid Ice Massage Dryneedling Joint mobilization (manual therapy) New shoes Custom made orthotics (inlays) Sportcompression stockings Stretching and strenghtening Progressive return to running Analyse / adjust running technique Other: (e.g. dietician), prolotherapy -------------------------------- Surgery (150-200 patients per year)

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4. treatment: sportcompression stockings

First study to test onset of pain in patients 100 patients 25 MTSS 12 CECS 4 Anterior comp < 35 9 MTSS + ant comp <35 15 MTSS + CECS 18 Calve 8 Achillestendinopathy 9 Other / mix

Standardized 20 minute treadmill

running test with and without stockings, within 2-3 days

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4. treatment: sportcompression stockings

No effect on time to painscore 1, neither to a pain score 4 out of 10. Positive opinion for comfort and support 5.8 (sd 2.0) Posterior leg: achillodynia and calve complaints 7.0 (sd 1.3) Anterior leg: CECS and MTSS+CECS 4.4 (sd 2.1) Conclusion: the socks reduce time to onset of pain in CECS patients

Zimmermann, 2009 + 2013

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5 studies and future directions

MTSS CECS

Etiology X X

Epidemiology X X

Risk factors X X

Diagnosis X X

Therapy X X

Prognosis X X

5. Current studies In progress:

Dr. P Helmhout

CECS:

Adjust running technique

(smaller steps, midfoot strike)

Diebal 2012

•Works for CECS of the anterior compartment; patient must be willing and able to alter technique. •Does not work for multiple compartments and patients with correct technique

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5. Current studies

In progress:

Zimmermann

MTSS:

Shockwave

Rompe 2010, Moen 2011

•4 sessions in 4 weeks or 5 sessions in 6 weeks, then resume running •2000 shocks / 8 per sec / press 2.5 •Painfull procedure, first 500 easy •20-30 points increase in SANE in week 12.

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5. Current studies In progress:

Zimmermann

Soft tissue pain locations:

Lyftogt 2005-2008

•26 of 30 patients with chronic ERLP have trigger points / PNI (Peripheral nerve inflammation) •Near nerve subcutaneous Injections (neuro-prolotherapy with Glucose 10%) gives temporary pain relieve •Soft tissues deserve more attention

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6. Take home messages

In the Royal Dutch Army many recruits suffer from leg overuse injuries, often a combination of CECS and MTSS 150-200 patients a year get a fasciotomy for CECS, often of multiple compartments on both sides 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 leg running pain profile (LRPP). The topics of our recent research have been 2005-2008 epidemiology, Zimmermann 2011 predicting time to recovery in MTSS, Moen 2011 Running leg pain profile, Zimmermann 2012 sport compression stockings, Zimmermann 2013 in progress: pain in the soft tissues, Zimmermann 2013 in progress: altering running technique, Helmhout 2013 In progress: shockwave, Zimmermann

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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 leg injuries in infantry training (in Dutch, not published) 2008 the remedial platoon of infantry training (NMGT, january 2008, 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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Relevant papers and publications by Wes Zimmermann MD (2) 2012 Running Leg pain profile (NMGT september 2012, no 5, pp 160-162) 2013: sportcompression stockings part 2 (NMGT january 2013, no 1, pp 11-17 2013: chronic overuse injuries of the legs: new findings in the soft tissues? (NMGT to be published)