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Return to Activity Time for Athletes Undergoing Treatment for Chronic Exertional Compartment Syndrome.. Hancock, Steve; Mizuta, Isa; Moore, Julie; Nielsen, Paul; Whiting, Fawn 2009

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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  OUTLINE •  • •  •  INTRODUCTION Systematic Review Question Outcome Measures Operational Definitions  BACKGROUND METHODS Search Strategy Screening Strategy Quality Assessment Strategy Data Extraction Strategy  RESULTS Study Characteristics Quality Assessment Return to Activity Time Complications  • • • •  DISCUSSION CONCLUSION DISSEMINATION ACKNOWLEDGEMENTS  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?”  Outcome Measures • Primary: RTA time • Length of time required for the patient to return to their previous level of physical activity  • Secondary: Complications • Unplanned consequences of treatment  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  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  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 10-15 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  Pathophysiology Muscles expand Restricted by stiff, non-compliant layer of fascia Intramuscular pressures↑ Impairment of the arterial/venous gradient Pain  Cramping  Relieved by: rest  Mm tightness  Distal paresthesia  ↓Mm function  Aggravated by: repetitive loading  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 syndrome  Diagnosis • Gold Standard: ICPM • 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  Incidence of CECS • Bilaterally (~50-70% of patients) • Gender distribution debated • 95% occurs in leg • Anterior > Deep Posterior/Lateral > Superficial Posterior compartment  Treatment Options • Conservative Treatment: massage diuretic NSAIDS orthotics stretching rest  acupuncture athletic taping PT modalities myofascial release activity modification  • Surgical Treatment: fasciotomy  Rationale • CECS causes athletes to reconsider their athletic pursuits • Successful 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.  METHODS Search Strategy • Searches performed: Oct ’08, Jan & June ’09 • Online Database Search • CINAHL (from 1982), EMBASE (from 1980), MEDLINE (from 1950), PubMed (from 1949),  SportDiscus (from 1837) • Grey Literature Search • Google Scholar, Reference lists of included studies  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. 8. 1 or 2 or 3 or 4 or 5 or 6 or 7 9. Leg/ 10. leg.ti,ab. 11. 9 or 10 12. 8 and 11 13. 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/13-38 41. 12 and 40 42. 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/42-52 54. 12 and 53 55. 41 or 54 56. limit 55 to "humans"  Article Search Results Title Screen  Abstract Screen  Met Eligibility  Excluded  0  0  787  15  2  2  829  75  12  3  3  776  541  61  18  1  1  540  SPORT DISCUS  485  86  5  1  1  484  Google Scholar  8  3  0  0  0  8  Reference List  36  36  16  0  0  36  TOTAL (N)  3467  7  3460  Database  n  EMBASE  787  69  8  MEDLINE  831  90  PubMed  779  CINAHL  Full Text Screen  Screening Strategy Inclusion  Exclusion  - 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  Quality Assessment Strategy van Tulder’s Criteria List (1997) • • •  17 questions Internal, descriptive, statistical criteria Categorized into: • • • •  Patient selection Interventions Outcome measurements Statistics  Data Extraction Strategy • Information recorded: • • • •  Methodology Intervention Participant characteristics Primary and secondary outcomes  • Statistical meta-analysis not conducted: • • •  Differences in population characteristics Methodological variations between studies No RCTs  RESULTS Study Characteristics • 7 studies met inclusion criteria • 4 Retrospective Studies, 3 Case Studies • No conservative treatments  • Subjects aged 12-50 • Mean age: 21.1 • 48.6% male; 51.4% female  • Compartments reported as limbs operated on or # of subjects affected • Limbs: Anterior and Lateral compartments most affected •  40.4%  • Subjects: Anterior compartment most affected   70%  Study Characteristics Physical Activity  n  %  Running  96  58.2  In-line Skating  17  10.3  Physical Activity Unspecified  16  9.7  Soccer  6  3.6  Skiing  6  3.6  Athletics  5  3  Golf  4  Rowing  Athletic Level  n  %  Recreational  47  38.5  2.4  Amateur  36  29.5  3  1.8  High Performance  12  9.8  Gymnastics  2  1.2  Non-Sport  11  9  Boxing  2  1.2  Basketball  2  1.2  Professional  4  3.3  Field Hockey  2  1.2  Collegiate  4  3.3  Football  1  0.6  Competitive  4  3.3  Dancing  1  0.6  High-School  2  1.6  Figure Skating  1  0.6  Work-Related  2  1.6  Badminton  1  0.6  Total Reported  Total  165  122  Quality Assessment • van Tulder Methodological Quality Assessment Tool • No RCTs  low quality assessment scores • Retrospective studies scored between 6/19 – 9/19 • Case 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  Return to Activity Time • Cane ambulation: 24 - 36hrs • Walking: 1, 2 or 3 days • Running: 14, 21, 28 or 42 days • Full RTA • Simultaneous bilateral or unilateral: 3 - 12.2 wks • Mean RTA: 7.82 ± 3.36 wks  • Bilateral staged: 22.7 wks  First Author  Weeks  Detmer  3  Farr  8  Garcia-Mata  6  Kitajima  8  Ota  3  Raikin  10.7  Schepsis - A  8.1  Schepsis - A&L  11.4  Schepsis - bilateral  12.2  Mean  7.82  Standard Deviation  3.36  Coefficient of Variance A: Anterior; L: Lateral  42.93  Complications • • •  43/165 subjects Swelling  DVT Overall complication proportion  26% • Complication proportion without swelling  13%  Complications Swelling  n  %  22  13.3  Hematoma  6  3.7  Wound infection  4  2.5  Peripheral cutaneous nerve injury  4  2.5  Other  3  1.9  Lymphocele  1  0.6  Deep vein thrombosis  1  0.6  Post-op regional pain syndrome  1  0.6  Vascular injury  1  0.6  Overall Complication Proportion  43  26.5  Complication Proportion not Including Swelling  21  13  DISCUSSION What is known? • Surgical treatment via fasciotomy considered best treatment for resolution of symptoms of CECS • Conservative treatment poorly supported by evidence • Anterior compartment most commonly affected • Gender predominance unclear • Complications of fasciotomies: 11-13%  What does this study add? • No reviews have looked at recovery time postfasciotomy • Mean RTA time post-fasciotomy • 7.82 ± 3.36 wks  • Complications • 13% of included subjects  • Bilateral simultaneous fasciotomies result in faster recovery times  LIMITATIONS • No RCTs • RTA time: • • •  Not primary outcome measure for any article included Lacked measures of variability (SD of RTA scores) Unknown if reported based on surgeon’s protocol or individual athlete’s recoveries  • Low methodological quality scores of included articles • Only 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 gender • Limited number of included articles • Strict inclusion criteria  CONCLUSION • No studies indicating RTA times post-conservative treatment • Results indicate: • RTA time: 7.82 ± 3.36 wks post-fasciotomy • Complication rate: 13% (excluding swelling)  • Evidence-based resource for health care practitioners including sports medicine physicians, physiotherapists, coaches and athletic trainers • Educate clients on expected recovery times and complications  CONCLUSION • Direction of research • Improvement of research methodology regarding existing treatments • Shift toward research of alternate diagnostic tests (infrared spectroscopy)  DISSEMINATION • Manuscript will be sent to the British Journal of Sports Medicine for review  ACKNOWLEDGEMENTS • • • •  Dr. Babak Shadgan Dr. Darlene Reid Dr. Elizabeth Dean Charlotte Beck Thank you for all of your support, direction, and constructive feedback!  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. 2004 04;38(2):233-234. (2) Garcia-Mata S, Hidalgo-Ovejero A, Martinez-Grande M. Chronic exertional compartment syndrome of the legs in adolescents. J.Pediatr.Orthop. 2001 May-Jun;21(3):328-334. (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. 1996 04;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; 2007. (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. 2000 07;10(3):176-184. (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. 2006 Feb;14(2):193-197. (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. 2008 05;29(5):419-423. (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. 2006 05;16(3):209213.  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):439-443. (17) Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am.J.Sports Med. 1985 May-Jun;13(3):162-170. (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. 2008 Jul;37(7):374-377. (20) Raikin SM, Rapuri VR, Vitanzo P. Bilateral simultaneous fasciotomy for chronic exertional compartment syndrome. Foot Ankle Int. 2005 12;26(12):1007-1011. (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. 2003 10;35(10):1638-1644. (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):321-325. (23) McQueen MM. (v) Acute compartment syndrome in tibial fractures. Current Orthopaedics 1999;13(2):113-119. (24) Schepsis AA, Gill SS, Foster TA. Fasciotomy for exertional anterior compartment syndrome: is lateral compartment release necessary? Am.J.Sports Med. 1999 07;27(4):430-435.  

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