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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 2009-07

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RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LEGHancock S, Mizuta I, Moore J, Neilsen P, Whiting FOUTLINE• INTRODUCTIONSystematic Review QuestionOutcome MeasuresOperational Definitions• BACKGROUND• METHODSSearch StrategyScreening StrategyQuality Assessment StrategyData Extraction Strategy• RESULTSStudy CharacteristicsQuality AssessmentReturn to Activity TimeComplications• DISCUSSION• CONCLUSION• DISSEMINATION• ACKNOWLEDGEMENTSINTRODUCTIONSystematic 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 treatmentOperational Definitions• Athletes: People involved in any sporting activity from recreational to professional levels of participation• Physical Activity: Activity requiring energy expenditure above resting levelBACKGROUND• 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 runnersPatient 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) diagnosticMuscles expandRestricted by stiff, non-compliant layer of fasciaIntramuscular pressures↑Impairment of the arterial/venous gradientPain Cramping Mm tightness Distal paresthesia ↓Mm functionRelieved by: rest Aggravated by: repetitive loadingPathophysiologyChronic 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 syndromeDiagnosis• 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 ICPMIncidence of CECS• Bilaterally (~50-70% of patients)• Gender distribution debated• 95% occurs in leg• Anterior > Deep Posterior/Lateral > Superficial Posterior compartmentTreatment Options• Conservative Treatment:massage acupuncturediuretic athletic tapingNSAIDS PT modalitiesorthotics myofascial releasestretching activity modificationrest• Surgical Treatment: fasciotomyRationale• 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.METHODSSearch 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 studiesMEDLINE Search Strategy1. 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 79. Leg/10. leg.ti,ab.11. 9 or 1012. 8 and 1113. 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/13-3841. 12 and 4042. 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/42-5254. 12 and 5355. 41 or 5456. limit 55 to "humans"Article Search ResultsDatabase n Title ScreenAbstract ScreenFull Text ScreenMet Eligibility ExcludedEMBASE 787 69 8 0 0 787MEDLINE 831 90 15 2 2 829PubMed 779 75 12 3 3 776CINAHL 541 61 18 1 1 540SPORT DISCUS 485 86 5 1 1 484Google Scholar 8 3 0 0 0 8Reference List 36 36 16 0 0 36TOTAL (N) 3467 7 3460Screening StrategyInclusion Exclusion- English- RCTs, CCTs, prospectivecohort studies, retrospectivecase 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 syndromeQuality Assessment Strategyvan Tulder’s Criteria List (1997)• 17 questions• Internal, descriptive, statistical criteria• Categorized into: • Patient selection• Interventions• Outcome measurements• StatisticsData 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 RCTsRESULTSStudy 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 • à 40.4%• Subjects: Anterior compartment most affected • à 70%Study CharacteristicsAthletic Level n %Recreational 47 38.5Amateur 36 29.5High Performance 12 9.8Non-Sport 11 9Professional 4 3.3Collegiate 4 3.3Competitive 4 3.3High-School 2 1.6Work-Related 2 1.6Total Reported 122Physical Activity n %Running 96 58.2In-line Skating 17 10.3Physical Activity Unspecified 16 9.7Soccer 6 3.6Skiing 6 3.6Athletics 5 3Golf 4 2.4Rowing 3 1.8Gymnastics 2 1.2Boxing 2 1.2Basketball 2 1.2Field Hockey 2 1.2Football 1 0.6Dancing 1 0.6Figure Skating 1 0.6Badminton 1 0.6Total 165Quality Assessment• van Tulder Methodological Quality Assessment Tool• No RCTs à low quality assessment scores• Retrospective studies scored between 6/19 – 9/19• Case studies scored between 4/19 – 5/19 First Author ScoreDetmer (1985) 7Farr (2008) 5Garcia (2001) 7Kitajima (2001) 4Ota (1999) 4Raikin (2005) 9Schepsis (1999) 6Return 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 wksFirst Author WeeksDetmer 3Farr 8Garcia-Mata 6Kitajima 8Ota 3Raikin 10.7Schepsis - A 8.1Schepsis - A&L 11.4Schepsis - bilateral 12.2Mean 7.82Standard Deviation 3.36Coefficient of Variance 42.93A: Anterior; L: LateralComplications• 43/165 subjects• Swelling à DVT• Overall complication proportion à 26%• Complication proportion without swelling à 13%Complications n %Swelling 22 13.3Hematoma 6 3.7Wound infection 4 2.5Peripheral cutaneous nerve injury 4 2.5Other 3 1.9Lymphocele 1 0.6Deep vein thrombosis 1 0.6Post-op regional pain syndrome 1 0.6Vascular injury 1 0.6Overall Complication Proportion 43 26.5Complication Proportion not Including Swelling 21 13DISCUSSIONWhat 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 post-fasciotomy• 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 criteriaCONCLUSION• 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 complicationsCONCLUSION• 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 reviewACKNOWLEDGEMENTS• Dr. Babak Shadgan• Dr. Darlene Reid• Dr. Elizabeth Dean• Charlotte BeckThank 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):209-213. 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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