Presentation is loading. Please wait.

Presentation is loading. Please wait.

RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LEG Hancock S, Mizuta I, Moore J, Neilsen.

Similar presentations


Presentation on theme: "RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LEG Hancock S, Mizuta I, Moore J, Neilsen."— Presentation transcript:

1 RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LEG Hancock S, Mizuta I, Moore J, Neilsen P, Whiting F

2 OUTLINE INTRODUCTIONINTRODUCTION Systematic Review Question Outcome Measures Operational Definitions BACKGROUNDBACKGROUND METHODSMETHODS Search Strategy Screening Strategy Quality Assessment Strategy Data Extraction Strategy RESULTSRESULTS Study Characteristics Quality Assessment Return to Activity Time Complications DISCUSSIONDISCUSSION CONCLUSIONCONCLUSION DISSEMINATIONDISSEMINATION ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

3 INTRODUCTION Systematic Review Question “What is the effectiveness of treatment options for athletes diagnosed with Chronic Exertional Compartment Syndrome (CECS) in regards to return to activity (RTA) time and post-treatment complications?”

4 Outcome Measures Primary: RTA time Length of time required for the patient to return to their previous level of physical activity Secondary: ComplicationsSecondary: Complications Unplanned consequences of treatment

5 Operational Definitions Athletes: People involved in any sporting activity from recreational to professional levels of participation Physical Activity: Activity requiring energy expenditure above resting level

6 BACKGROUND 2 types of compartment syndromes: acute and chronic Acute commonly due to trauma and requires emergency fasciotomy CECS is a common cause of leg pain in competitive and recreational athletes, particularly runners

7 Patient History No pain at rest; pain gradually builds with exertion Type: dull ache, sensation of muscle tightness, cramping Specific onset variable between athletes, usually mins into exercise, forces athlete to stop activity, shorten the duration or decrease intensity Ache may remain up to 30 min after exercise X-rays negative, Bone scans negative Intracompartmental Pressure Measurement (ICPM) diagnostic

8 Muscles expand Restricted by stiff, non-compliant layer of fascia Intramuscular pressures↑ Impairment of the arterial/venous gradient Pain CrampingMm tightness Distal paresthesia ↓Mm function Relieved by: rest Aggravated by: repetitive loading Pathophysiology

9 Chronic Exertional Leg Pain Correct diagnosis is essential but often misdiagnosed Differential diagnosis: Umbrella term “shin splints” Medial Tibial Stress Syndrome (MTSS) Stress fractures CECS Nerve compression Fascial hernias Popliteal artery entrapment syndromePopliteal artery entrapment syndrome

10 Diagnosis Gold Standard: ICPM Diagnostic criteria:Diagnostic criteria: Resting ~15 mmHg 1-min. post-exs >30 mmHg 5-min. post-exs >20 mmHg Non-invasive diagnostic measures: Infra-red Spectroscopy MRI Currently being researched to establish validity and reliability compared with ICPM

11 Incidence of CECS Bilaterally (~50-70% of patients) Gender distribution debated 95% occurs in leg Anterior > Deep Posterior/Lateral > Superficial Posterior compartment

12 Treatment Options Conservative Treatment: massageacupuncture diureticathletic taping NSAIDSPT modalities orthoticsmyofascial release stretchingactivity modification rest Surgical Treatment: fasciotomy

13 Rationale CECS causes athletes to reconsider their athletic pursuitsCECS causes athletes to reconsider their athletic pursuits Successful treatment determines level of sport or activity they will be able to resumeSuccessful treatment determines level of sport or activity they will be able to resume Goal: Provide an evidence-based resource for clinicians to help educate athletes and physically active people diagnosed with CECS on the best available treatment options and treatment prognosis.Goal: Provide an evidence-based resource for clinicians to help educate athletes and physically active people diagnosed with CECS on the best available treatment options and treatment prognosis.

14 METHODS Search Strategy Searches performed: Oct ’08, Jan & June ’09Searches performed: Oct ’08, Jan & June ’09 Online Database SearchOnline Database Search CINAHL (from 1982), EMBASE (from 1980), MEDLINE (from 1950), PubMed (from 1949), SportDiscus (from 1837)CINAHL (from 1982), EMBASE (from 1980), MEDLINE (from 1950), PubMed (from 1949), SportDiscus (from 1837) Grey Literature SearchGrey Literature Search Google Scholar, Reference lists of included studiesGoogle Scholar, Reference lists of included studies

15 MEDLINE Search Strategy 1. exp Compartment Syndromes/ 2. compartment syndrome*.ti,ab. 3. (tibial stress or shin splint*).ti,ab. 4. (nerve adj2 (entrap* or compress*)).ti,ab. 5. (exertion* adj2 leg pain).ti,ab. 6. effort related compartment syndrome*.ti,ab. 7. chronic leg pain.ti,ab or 2 or 3 or 4 or 5 or 6 or 7 9. Leg/ 10. leg.ti,ab or and exp Therapeutics/ 14. treat*.ti,ab. 15. Surgery/ 16. surgery.ti,ab. 17. fasciotomy.ti,ab. 18. manag*.ti,ab. 19. taping.ti,ab. 20. diuretic*.ti,ab. 21. Acupuncture Therapy/ 22. acupuncture.mp. 23. exp Physical Therapy Modalities/ 24. Ultrasonic Therapy/ 25. ultrasound.ti,ab. 26. (physical therap* or physiotherap*).ti,ab. 27. exp Massage/ 28. massage.ti,ab. 29. myofascial release.ti,ab. 30. exp Orthotic Devices/ 31. (orthoses or orthotic*).ti,ab. 32. Muscle Stretching Exercises/ 33. stretch*.ti,ab. 34. strength*.ti,ab. 35. Weight Lifting/ 36. Exercise Therapy/ 37. Exercise/ 38. (resist* exercise or resist* training).ti,ab. 39. Rest/ 40. or/ and Prognosis/ 43. Treatment Outcome/ 44. Disease-free Survival/ 45. Medical Futility/ 46. Treatment Failure/ 47. Pain/ 48. "Recovery of Function"/ 49. exp Athletic Performance/ 50. activity.mp. 51. intracompartmental pressure.mp. 52. performance.mp. 53. or/ and or limit 55 to "humans"

16 Article Search Results Databasen Title Screen Abstract Screen Full Text Screen Met Eligibility Excluded EMBASE MEDLINE PubMed CINAHL SPORT DISCUS Google Scholar Reference List TOTAL (N)

17 Screening Strategy InclusionExclusion - English - RCTs, CCTs, prospective cohort studies, retrospective case series, case studies - Athletic population (recreational to professional) - Physically active people - All ages - Any compartment of the leg - Diagnosed by ICPM - Conservative or surgical treatment - Outcome measure: RTA time - Review articles - Acute compartment syndrome

18 Quality Assessment Strategy van Tulder’s Criteria List (1997) 17 questions17 questions Internal, descriptive, statistical criteriaInternal, descriptive, statistical criteria Categorized into:Categorized into: Patient selectionPatient selection InterventionsInterventions Outcome measurementsOutcome measurements StatisticsStatistics

19 Data Extraction Strategy Information recorded:Information recorded: MethodologyMethodology InterventionIntervention Participant characteristicsParticipant characteristics Primary and secondary outcomesPrimary and secondary outcomes Statistical meta-analysis not conducted:Statistical meta-analysis not conducted: Differences in population characteristicsDifferences in population characteristics Methodological variations between studiesMethodological variations between studies No RCTsNo RCTs

20 RESULTS Study Characteristics 7 studies met inclusion criteria7 studies met inclusion criteria 4 Retrospective Studies, 3 Case Studies4 Retrospective Studies, 3 Case Studies No conservative treatmentsNo conservative treatments Subjects aged 12-50Subjects aged Mean age: 21.1Mean age: % male; 51.4% female48.6% male; 51.4% female Compartments reported as limbs operated on or # of subjects affectedCompartments reported as limbs operated on or # of subjects affected Limbs: Anterior and Lateral compartments most affectedLimbs: Anterior and Lateral compartments most affected  40.4%  40.4% Subjects: Anterior compartment most affectedSubjects: Anterior compartment most affected  70%  70%

21 Study Characteristics Athletic Level n% Recreational Amateur High Performance Non-Sport119 Professional43.3 Collegiate43.3 Competitive43.3 High-School21.6 Work-Related21.6 Total Reported 122 Physical Activity n%Running In-line Skating Physical Activity Unspecified Soccer63.6 Skiing63.6 Athletics53 Golf42.4 Rowing31.8 Gymnastics21.2 Boxing21.2 Basketball21.2 Field Hockey 21.2 Football10.6 Dancing10.6 Figure Skating 10.6 Badminton10.6 Total Total165

22 Quality Assessment van Tulder Methodological Quality Assessment Toolvan Tulder Methodological Quality Assessment Tool No RCTs  low quality assessment scoresNo RCTs  low quality assessment scores Retrospective studies scored between 6/19 – 9/19Retrospective studies scored between 6/19 – 9/19 Case studies scored between 4/19 – 5/19Case studies scored between 4/19 – 5/19 First Author Score Detmer (1985) 7 Farr (2008) 5 Garcia (2001) 7 Kitajima (2001) 4 Ota (1999) 4 Raikin (2005) 9 Schepsis (1999) 6

23 Return to Activity Time Return to Activity Time Cane ambulation: hrsCane ambulation: hrs Walking: 1, 2 or 3 daysWalking: 1, 2 or 3 days Running: 14, 21, 28 or 42 daysRunning: 14, 21, 28 or 42 days Full RTAFull RTA Simultaneous bilateral or unilateral: wksSimultaneous bilateral or unilateral: wks Mean RTA: 7.82 ± 3.36 wksMean RTA: 7.82 ± 3.36 wks Bilateral staged: 22.7 wksBilateral staged: 22.7 wks First AuthorWeeks Detmer3 Farr8 Garcia-Mata6 Kitajima8 Ota3 Raikin10.7 Schepsis - A8.1 Schepsis - A&L11.4 Schepsis - bilateral12.2 Mean7.82 Standard Deviation3.36 Coefficient of Variance42.93 A: Anterior; L: Lateral

24 Complications 43/165 subjects43/165 subjects Swelling  DVTSwelling  DVT Overall complication proportion  26%Overall complication proportion  26% Complication proportion without swelling  13%Complication proportion without swelling  13% Complicationsn% Swelling Hematoma63.7 Wound infection42.5 Peripheral cutaneous nerve injury42.5 Other31.9 Lymphocele10.6 Deep vein thrombosis10.6 Post-op regional pain syndrome10.6 Vascular injury10.6 Overall Complication Proportion Complication Proportion not Including Swelling2113

25 DISCUSSION What is known? Surgical treatment via fasciotomy considered best treatment for resolution of symptoms of CECSSurgical treatment via fasciotomy considered best treatment for resolution of symptoms of CECS Conservative treatment poorly supported by evidenceConservative treatment poorly supported by evidence Anterior compartment most commonly affectedAnterior compartment most commonly affected Gender predominance unclearGender predominance unclear Complications of fasciotomies: 11-13%Complications of fasciotomies: 11-13%

26 What does this study add? No reviews have looked at recovery time post- fasciotomyNo reviews have looked at recovery time post- fasciotomy Mean RTA time post-fasciotomyMean RTA time post-fasciotomy 7.82 ± 3.36 wks7.82 ± 3.36 wks ComplicationsComplications 13% of included subjects13% of included subjects Bilateral simultaneous fasciotomies result in faster recovery timesBilateral simultaneous fasciotomies result in faster recovery times

27 LIMITATIONS No RCTsNo RCTs RTA time:RTA time: Not primary outcome measure for any article includedNot primary outcome measure for any article included Lacked measures of variability (SD of RTA scores)Lacked measures of variability (SD of RTA scores) Unknown if reported based on surgeon’s protocol or individual athlete’s recoveriesUnknown if reported based on surgeon’s protocol or individual athlete’s recoveries Low methodological quality scores of included articlesLow methodological quality scores of included articles Only one study identified differences in RTA time based upon the compartment affectedOnly one study identified differences in RTA time based upon the compartment affected No studies reported RTA times with respect to duration of symptoms prior to treatment, age or genderNo studies reported RTA times with respect to duration of symptoms prior to treatment, age or gender Limited number of included articlesLimited number of included articles Strict inclusion criteriaStrict inclusion criteria

28 CONCLUSION No studies indicating RTA times post-conservative treatmentNo studies indicating RTA times post-conservative treatment Results indicate:Results indicate: RTA time: 7.82 ± 3.36 wks post-fasciotomyRTA time: 7.82 ± 3.36 wks post-fasciotomy Complication rate: 13% (excluding swelling)Complication rate: 13% (excluding swelling) Evidence-based resource for health care practitioners including sports medicine physicians, physiotherapists, coaches and athletic trainersEvidence-based resource for health care practitioners including sports medicine physicians, physiotherapists, coaches and athletic trainers Educate clients on expected recovery times and complicationsEducate clients on expected recovery times and complications

29 CONCLUSION Direction of researchDirection of research Improvement of research methodology regarding existing treatmentsImprovement of research methodology regarding existing treatments Shift toward research of alternate diagnostic tests (infrared spectroscopy)Shift toward research of alternate diagnostic tests (infrared spectroscopy)

30 DISSEMINATION Manuscript will be sent to the British Journal of Sports Medicine for reviewManuscript will be sent to the British Journal of Sports Medicine for review

31 ACKNOWLEDGEMENTS Dr. Babak ShadganDr. Babak Shadgan Dr. Darlene ReidDr. Darlene Reid Dr. Elizabeth DeanDr. Elizabeth Dean Charlotte BeckCharlotte Beck Thank you for all of your support, direction, and constructive feedback!

32 REFERENCES (1) Cunningham A, Spears IR. A successful conservative approach to managing lower leg pain in a university sports injury clinic: a two patient case study. Br.J.Sports Med ;38(2): (2) Garcia-Mata S, Hidalgo-Ovejero A, Martinez-Grande M. Chronic exertional compartment syndrome of the legs in adolescents. J.Pediatr.Orthop May-Jun;21(3): (3) Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Medicine & Science in Sports & Exercise 2000 Mar;32(3 Suppl):S4-10. (4) Edwards P, Myerson MS. Exertional compartment syndrome of the leg: steps for expedient return to activity. Physician Sportsmed ;24(4):31. (5) Brennan Jr FH. Diagnosis, Treatment Options, and Rehabilitation of Chronic Lower Leg Exertional Compartment Syndrome. Current Sports Medicine Reports 2003;2(5):247. (6) Brukner P, Khan K. Clinical sports medicine. 3rd ed.: McGraw-Hill; (7) Howard JL, Mohtadi N, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin.J.Sport Med ;10(3): (8) Mouhsine E, Garofalo R, Moretti B, Gremion G, Akiki A. Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg. Knee Surg.Sports Traumatol.Arthrosc Feb;14(2): (9) van Zoest W, Hoogeveen AR, Scheltinga M, Sala HA, van Mourik J, Brink P. Chronic deep posterior compartment syndrome of the leg in athletes: postoperative results of fasciotomy. Int.J.Sports Med ;29(5): (10) Englund J. Chronic compartment syndrome: tips on recognizing and treating. The Journal of family practice 2005;54(11):955. (11) Trease L. A prospective blinded evaluation of exercise thallium-201 SPET in patients with suspected chronic exertional compartment syndrome of the leg. European journal of nuclear medicine 2001;28(6):688. (12) Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin.J.Sport Med ;16(3):

33 REFERENCES (13) Cook S, BRUCE G. Fasciotomy for chronic compartment syndrome in the lower limb. ANZ J.Surg. 2002;72(10):720. (14) Pedowitz RA. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. The American journal of sports medicine 1990;18(1):35. (15) van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM. Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for spinal disorders. Spine 1997;22(20):2323. (16) Ota Y, Senda M, Hashizume H, Inoue H. Chronic compartment syndrome of the lower leg: a new diagnostic method using near-infrared spectroscopy and a new technique of endoscopic fasciotomy. Arthroscopy 1999 May;15(4): (17) Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am.J.Sports Med May-Jun;13(3): (18) Kitajima I, Tachibana S, Hirota Y, Nakamichi K, Miura K. One-portal technique of endoscopic fasciotomy: Chronic compartment syndrome of the lower leg. Arthroscopy 2001 Oct;17(8):33. (19) Farr D, Selesnick H. Chronic exertional compartment syndrome in a collegiate soccer player: a case report and literature review. Am J.Orthop Jul;37(7): (20) Raikin SM, Rapuri VR, Vitanzo P. Bilateral simultaneous fasciotomy for chronic exertional compartment syndrome. Foot Ankle Int ;26(12): (21) Birtles DB, Rayson MP, Casey A, Jones DA, Newham DJ. Venous obstruction in healthy limbs: a model for chronic compartment syndrome? Med.Sci.Sports Exerc ;35(10): (22) Verleisdonk E, Van Gils A, Van der Werken C. The diagnostic value of MRI scans for the diagnosis of chronic exertional compartment syndrome of the lower leg. Skeletal Radiol. 2001;30(6): (23) McQueen MM. (v) Acute compartment syndrome in tibial fractures. Current Orthopaedics 1999;13(2): (24) Schepsis AA, Gill SS, Foster TA. Fasciotomy for exertional anterior compartment syndrome: is lateral compartment release necessary? Am.J.Sports Med ;27(4):


Download ppt "RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LEG Hancock S, Mizuta I, Moore J, Neilsen."

Similar presentations


Ads by Google