RETURN TO ACTIVITY TIME FOR ATHLETES RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL

COMPARTMENT SYNDROME OF THE LEGCOMPARTMENT SYNDROME OF THE LEGHancock S, Mizuta I, Moore J, Neilsen P, Whiting FHancock S, Mizuta I, Moore J, Neilsen P, Whiting F

OUTLINEOUTLINE• INTRODUCTIONINTRODUCTION

Systematic Review QuestionSystematic Review QuestionOutcome MeasuresOutcome MeasuresOperational DefinitionsOperational Definitions

• BACKGROUNDBACKGROUND• METHODSMETHODS

Search StrategySearch StrategyScreening StrategyScreening StrategyQuality Assessment StrategyQuality Assessment StrategyData Extraction StrategyData Extraction Strategy

• RESULTSRESULTSStudy CharacteristicsStudy CharacteristicsQuality AssessmentQuality AssessmentReturn to Activity TimeReturn to Activity TimeComplicationsComplications

• DISCUSSIONDISCUSSION• CONCLUSIONCONCLUSION• DISSEMINATIONDISSEMINATION• ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

INTRODUCTIONINTRODUCTIONSystematic Review QuestionSystematic 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 MeasuresOutcome 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

Operational DefinitionsOperational Definitions

• Athletes: People involved in any sporting activity from recreational to professional levels of participation

• Physical Activity: Activity requiring energy expenditure above resting level

BACKGROUNDBACKGROUND

• 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

Muscles expandMuscles expand

Restricted by stiff, Restricted by stiff, non-compliant layer of fascianon-compliant layer of fascia

Intramuscular Intramuscular pressures↑pressures↑

Impairment of the Impairment of the arterial/venous gradientarterial/venous gradient

Pain Cramping Mm tightnessDistal

paresthesia↓Mm function

Relieved by: rest Aggravated by: repetitive loading

PathophysiologyPathophysiology

Chronic Exertional Leg PainChronic 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

DiagnosisDiagnosis

• 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

Incidence of CECSIncidence of CECS

• Bilaterally (~50-70% of patients)

• Gender distribution debated• 95% occurs in leg• Anterior > Deep

Posterior/Lateral > Superficial Posterior compartment

Treatment OptionsTreatment Options

• Conservative Treatment: massage acupuncturediuretic athletic tapingNSAIDS PT modalitiesorthotics myofascial releasestretching activity modificationrest

• Surgical Treatment: fasciotomy

RationaleRationale

• CECS causes athletes to reconsider their CECS causes athletes to reconsider their athletic pursuitsathletic pursuits

• Successful treatment determines level of Successful treatment determines level of sport or activity they will be able to resumesport or activity they will be able to resume

• GoalGoal:: PProvide an evidence-based resource rovide an evidence-based resource for clinicians to help educate athletes and for clinicians to help educate athletes and physically active people diagnosed with physically active people diagnosed with CECS on the best available treatment CECS on the best available treatment options and treatment prognosis.options and treatment prognosis.

METHODSMETHODSSearch StrategySearch 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), CINAHL (from 1982), EMBASE (from 1980), MEDLINE (from 1950), PubMed (from 1949), MEDLINE (from 1950), PubMed (from 1949), SportDiscus (from 1837)SportDiscus (from 1837)

• Grey Literature SearchGrey Literature Search• Google Scholar, Reference lists of included Google Scholar, Reference lists of included

studiesstudies

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 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 ResultsArticle Search Results

DatabaseDatabase nn Title Title ScreenScreen

Abstract Abstract ScreenScreen

Full Text Full Text ScreenScreen

Met Met EligibilityEligibility

ExcludedExcluded

EMBASEEMBASE 787787 6969 88 00 00 787787

MEDLINEMEDLINE 831831 9090 1515 22 22 829829

PubMedPubMed 779779 7575 1212 33 33 776776

CINAHLCINAHL 541541 6161 1818 11 11 540540

SPORT DISCUSSPORT DISCUS 485485 8686 55 11 11 484484

Google ScholarGoogle Scholar 88 33 00 00 00 88

Reference ListReference List 3636 3636 1616 00 00 3636

TOTAL (N)TOTAL (N) 34673467 77 34603460

Screening StrategyScreening Strategy

Inclusion 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 syndrome

Quality Assessment StrategyQuality Assessment Strategy

van Tulder’s Criteria List (1997)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

Data Extraction StrategyData 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

RESULTSRESULTSStudy CharacteristicsStudy 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 12-50 Subjects aged 12-50 • Mean age: 21.1Mean age: 21.1• 48.6% male; 51.4% female 48.6% male; 51.4% female

• Compartments reported as limbs operated on or # of Compartments reported as limbs operated on or # of subjects affectedsubjects affected• Limbs: Anterior and Lateral compartments most affected Limbs: Anterior and Lateral compartments most affected

• 40.4%40.4%

• Subjects: Anterior compartment most affected Subjects: Anterior compartment most affected 70%70%

Study CharacteristicsStudy Characteristics

Athletic LevelAthletic Level nn %%

RecreationalRecreational 4747 38.538.5

AmateurAmateur 3636 29.529.5

High PerformanceHigh Performance 1212 9.89.8

Non-SportNon-Sport 1111 99

ProfessionalProfessional 44 3.33.3

CollegiateCollegiate 44 3.33.3

CompetitiveCompetitive 44 3.33.3

High-SchoolHigh-School 22 1.61.6

Work-RelatedWork-Related 22 1.61.6

Total ReportedTotal Reported 122122

Physical Activity Physical Activity nn %%RunningRunning 9696 58.258.2

In-line SkatingIn-line Skating 1717 10.310.3

Physical Activity UnspecifiedPhysical Activity Unspecified 1616 9.79.7

SoccerSoccer 66 3.63.6

SkiingSkiing 66 3.63.6

AthleticsAthletics 55 33

GolfGolf 44 2.42.4

RowingRowing 33 1.81.8

GymnasticsGymnastics 22 1.21.2

BoxingBoxing 22 1.21.2

BasketballBasketball 22 1.21.2

Field HockeyField Hockey 22 1.21.2

FootballFootball 11 0.60.6

DancingDancing 11 0.60.6

Figure SkatingFigure Skating 11 0.60.6

BadmintonBadminton 11 0.60.6

  TotalTotal 165165   

Quality AssessmentQuality Assessment

• van Tulder Methodological van Tulder Methodological Quality Assessment ToolQuality Assessment Tool

• No RCTs No RCTs low quality low quality assessment scoresassessment scores

• Retrospective studies scored Retrospective studies scored between 6/19 – 9/19between 6/19 – 9/19

• Case studies scored between Case studies scored between 4/19 – 5/19 4/19 – 5/19

First AuthorFirst Author ScoreScore

Detmer (1985)Detmer (1985) 77

Farr (2008)Farr (2008) 55

Garcia (2001)Garcia (2001) 77

Kitajima (2001)Kitajima (2001) 44

Ota (1999)Ota (1999) 44

Raikin (2005)Raikin (2005) 99

Schepsis (1999)Schepsis (1999) 66

Return to Activity TimeReturn to Activity Time

• Cane ambulation: 24 - 36hrsCane ambulation: 24 - 36hrs• 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 Simultaneous bilateral or

unilateral: 3 - 12.2 wksunilateral: 3 - 12.2 wks• Mean RTA: 7.82 Mean RTA: 7.82 ± 3.36 wks± 3.36 wks

• Bilateral staged: 22.7 wksBilateral 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 42.93

A: Anterior; L: Lateral

ComplicationsComplications

• 43/165 subjects43/165 subjects• Swelling Swelling DVT DVT• Overall complication Overall complication

proportion proportion 26% 26%• Complication proportion Complication proportion

without swelling without swelling 13% 13%

Complications n %

Swelling 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

DISCUSSIONDISCUSSIONWhat is known?What is known?• Surgical treatment via fasciotomy Surgical treatment via fasciotomy

considered best treatment for resolution of considered best treatment for resolution of symptoms of CECSsymptoms of CECS

• Conservative treatment poorly supported Conservative treatment poorly supported by evidence by evidence

• Anterior compartment most commonly Anterior compartment most commonly affected affected

• Gender predominance unclearGender predominance unclear• Complications of fasciotomies: 11-13%Complications of fasciotomies: 11-13%

What does this study add?What does this study add?

• No reviews have looked at recovery time post-No reviews have looked at recovery time post-fasciotomyfasciotomy

• Mean RTA time post-fasciotomyMean RTA time post-fasciotomy• 7.82 7.82 ± ± 3.36 wks3.36 wks

• ComplicationsComplications• 13% of included subjects13% of included subjects

• Bilateral simultaneous fasciotomies result in Bilateral simultaneous fasciotomies result in faster recovery times faster recovery times

LIMITATIONSLIMITATIONS• 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 Unknown if reported based on surgeon’s protocol or if reported based on surgeon’s protocol or

individual athlete’s recoveriesindividual athlete’s recoveries• Low methodological quality scores of included articlesLow methodological quality scores of included articles• Only one study identified differences in RTA time Only one study identified differences in RTA time

based upon the compartment affectedbased upon the compartment affected• No studies reported RTA times with respect to No studies reported RTA times with respect to

duration of symptoms prior to treatment, age or duration of symptoms prior to treatment, age or gender gender

• Limited number of included articles Limited number of included articles • Strict inclusion criteriaStrict inclusion criteria

CONCLUSIONCONCLUSION

• No studies indicating RTA times post-conservative No studies indicating RTA times post-conservative treatmenttreatment

• Results indicate:Results indicate:• RTA time: 7.82 ± 3.36 wks post-fasciotomy RTA 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 Evidence-based resource for health care practitioners including sports medicine physicians, physiotherapists, including sports medicine physicians, physiotherapists, coaches and athletic trainerscoaches and athletic trainers

• Educate clients on expected recovery times and Educate clients on expected recovery times and complicationscomplications

CONCLUSIONCONCLUSION

• Direction of researchDirection of research• Improvement of research methodology Improvement of research methodology

regarding existing treatmentsregarding existing treatments• Shift toward research of alternate diagnostic Shift toward research of alternate diagnostic

tests (infrared spectroscopy)tests (infrared spectroscopy)

DISSEMINATIONDISSEMINATION

• Manuscript will be sent to the British Manuscript will be sent to the British Journal of Sports Medicine for reviewJournal of Sports Medicine for review

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

• 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, Thank you for all of your support, direction, and constructive feedback!direction, and constructive feedback!

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