Clinical Consensus on Diagnosis and Treatment of Patients with Chronic Exertional Compartment Syndrome of the Leg: A Delphi Analysis

AIM

Defining universally accepted guidelines for the diagnosis and treatment of chronic exertional compartment syndrome (CECS) is hampered by the absence of high-quality scientific research. The aim of this Delphi study was to establish consensus on practical issues guiding diagnosis and treatment of CECS of the leg in civilian and military patient populations.

METHODS

An international expert group was queried using the Delphi technique with a traditional three-round electronic consultation. Results of previous rounds were anonymously disclosed in the questionnaire of rounds 2 and 3, if relevant. Consensus was defined as > 70% positive or negative agreement for a question or statement.

RESULTS

The panel consisted of 27 civilian and military healthcare providers. Consensus was reached on five essential key characteristics of lower leg CECS. The panel achieved partial agreement regarding standardization of the diagnostic protocol, including muscle tissue pressure measurements. Consensus was reached on conservative and surgical treatment regimens. However, the experts did not attain consensus on their approach of postoperative rehabilitation and preferred treatment approach of recurrent or residual disease. A summary of best clinical practice for the diagnosis and management of CECS was formulated by experts working in civilian and military healthcare facilities.

CONCLUSION

The Delphi panel reached consensus on key criteria for signs and symptoms of CECS and several aspects for conservative and surgical treatment. The panel did not agree on the role of ICP values in the diagnostic process, postoperative rehabilitation guidelines protocol, or the preferred treatment approach for recurrent or residual disease. These aspects serve as a first attempt to initiate simple guidelines for clinical practice.

Despite an improved aerobic endurance, still high attrition rates in initially low-fit recruits-results of a randomised controlled trial

Background

Low baseline fitness of recruits entering basic military training (BMT) is associated with an increased risk of musculoskeletal injuries (MSIs) and attrition from training.

Objective

To determine the effects of a pre-training conditioning program (PCP) on aerobic endurance, incidence of musculoskeletal injuries (MSIs), and attrition rates in BMT of a special infantry unit of the Netherlands Armed Forces.

Participants

Recruits were considered eligible for this study when they were ‘low-fit’ at the start of BMT (time to complete a 2.7-km run ≥ 12′23″).

Interventions

‘Low-fit’ recruits were deferred to a seven to twelve week—depending on the time between two consecutive training platoons—PCP consisting of functional training to improve several fitness domains. The control (CON) group started regular BMT without delay.

Results

Forty-nine recruits were included in this study; 26 in the PCP-group and 23 in the CON-group. Recruits who followed the PCP started BMT with better aerobic endurance than the CON-group who started BMT immediately (2.7 km run timings: PCP 11′32″, CON 13′16″). The risk of dropout was lower in the PCP-group (incidence density ratio (IDR) 0.63, 95%CI 0.32; 1.26), but dropout due to training-related MSIs was more frequent (IDR 1.23, 95%CI 0.32; 4.76 (per-protocol 0.94, 95%CI 0.24; 3.63), without statistically significant differences between the groups.

Conclusion

Although a PCP was effective to improve aerobic endurance in low-fit recruits to return to meet pre-enlistment fitness criteria, we could not demonstrate an effect on dropout from military training.

Trial registration

Dutch trial register Trial NL6791 (NTR6977) https://www.trialregister.nl/trial/6791.

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Low baseline fitness of recruits is associated with musculoskeletal injuries and dropout from military training.

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A pre-training conditioning program was capable of improving physical fitness in low-fit recruits.

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However, dropout from training remained high, perhaps due to common other causes.

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Future research should focus on identifying these physical, social and mental factors, and their interactions.

One out of four recruits drops out from elite military training due to musculoskeletal injuries in the Netherlands Armed Forces

Introduction

Musculoskeletal injuries (MSIs) are among the main causes of dropout from military training. The main purpose of this study was to provide an overview of dropout rates and MSI incidence rates during elite military training. Second, this study aimed to explore restricted training days due to MSIs and to describe MSI-care by military physicians.

Methods

In a retrospective observational study, we collected dropout rates and injury surveillance data from the electronic patient records of two elite units of the Netherlands Armed Forces (NAF): the Royal Netherlands Marine Corps (RNLMC) and the Airmobile Brigade (AMB), from 1 January 2015 until 31 December 2017.

Results

In the RNLMC, total dropout rate was 53.9% and dropout due to MSIs was 23%. The most frequently affected locations were foot, knee and leg. In the AMB total dropout rate was 52.6% and dropout due to MSIs was 25%. In the AMB, the most frequently affected locations were back, knee and leg. Average restricted training days due to MSIs ranged between 8.3 and 20.8 days/injury. MSI-care by military physicians consisted mostly of the provision of injury-specific information and (self-)management options, imposing a specific activity restriction and referral to physiotherapy.

Conclusion

Our study findings showed that one out of four recruits who dropout from elite military training in the NAF, do so due to MSIs. Redesigning training programmes with the objective to reduce MSIs should be given high priority, as this may reduce dropout substantially.

A pre-training conditioning program to increase physical fitness and reduce attrition due to injuries in Dutch Airmobile recruits: Study protocol for a randomised controlled trial

Background

Low baseline fitness of recruits entering basic military training is shown to be associated with an increased risk of musculoskeletal injuries (MSIs) and attrition of military training. This in turn leads to an increased demand for health care, increased health care costs and decreased personnel occupancy rate of military units.

Design

Study protocol for a randomised controlled trial.

Objective

To determine the effects of a pre-training conditioning program on cardiovascular endurance, incidence of overuse injuries, and attrition rates in Dutch Airmobile recruits undertaking initial military training.

Setting

Royal Netherlands Army, Air Assault Brigade military training course.

Participants

Recruits are considered eligible for this study when they are ‘low-fit’ at the start of the initial military training. Time to complete a 2700 m run test in ≥12′23’’ is used as selection criteria.

Interventions

We use a complex system approach to cover multiple domains of MSI prevention and optimise intervention circumstance; a pre-training conditioning program, training staff support, process-focused culture and health accountability. The pre-training conditioning program contains functional training to improve mobility, power, agility, lower and upper body strength and cardiovascular endurance. Cardiovascular endurance will be targeted both by endurance training and high intensity interval training.

Main outcome measurements

Outcome measures include cardiovascular endurance, injury incidence, attrition rates, lost training days due to injuries, and implementation fidelity of the PCP.

Trial status

Recruitment of participants commenced April 18, 2018 and final results are expected in August 2019.

Trial registration

Dutch trial register www.trialregister.nl/=trial/6791.

The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomized study

OBJECTIVE

To study the additional effect of a pneumatic leg brace with standard rehabilitation for the treatment of medial tibial stress syndrome (MTSS) in recruits.

METHODS

In a single blinded randomized study, 15 recruits (age 17-22) followed a rehabilitation programme consisting of leg exercises and a graded running programme. Recruits performed daily exercises and ran three times a week. The running programme consisted of 6 consecutive phases. One group was, after randomization, additionally provided with a pneumatic leg brace. Follow-up was provided every other week. Days to completing the running programme was the primary outcome measure, the Sports Activity Rating Scale (SARS) score and satisfaction with the treatment were secondary outcome measures.

RESULTS

In total 14 recruits completed the rehabilitation programme. No differences were found in the number of days until phase six of the running schedule was finished between the brace and the control group (Brace 58.8 +/- 27.7 (mean +/- SD) vs Non-Brace 57.9 +/- 26.2 (mean +/- SD, p = 0.57). Also no differences were found in the SARS scores between the groups. Overall satisfaction with the treatment was 6.4 +/- 1.1 (mean +/- SD) on a 1-10 scale for the brace group and 7.1 +/- 0.7 (mean +/- SD) for the control group (p = 0.06). Comfort of the brace was assessed as 4.8 +/- 1.3 (mean +/- SD) on a 1-10 scale.

CONCLUSIONS

No additional large effect of the pneumatic leg brace could be found in recruits and wearing of the brace was not feasible, since the wearing comfort was low.

Risk factors and prognostic indicators for medial tibial stress syndrome

The objective of the study was to examine the risk factors and prognostic indicators for medial tibial stress syndrome (MTSS). In total, 35 subjects were included in the study. For the risk factor analysis, the following parameters were investigated: hip internal and external ranges of motion, knee flexion and extension, dorsal and plantar ankle flexion, hallux flexion and extension, subtalar eversion and inversion, maximal calf girth, lean calf girth, standing foot angle and navicular drop test. After multivariate regression decreased hip internal range of motion, increased ankle plantar flexion and positive navicular drop were associated with MTSS. A higher body mass index was associated with a longer duration to full recovery. For other prognostic indicators, no relationship was found.