IJSPT
CASE REPORT
POSTSURGICAL REHABILITATION FOLLOWING FASCIOTOMIES FOR BILATERAL CHRONIC EXERTIONAL COMPARTMENT SYNDROME IN A SPECIAL FORCES SOLDIER: A CASE REPORT Warren Flautt, PT, DPT, SCS, CSCS1 Joseph Miller, PT, DSc, OCS, SCS, CSCS2
ABSTRACT Background and Purpose: The etiology of Chronic Exertional Compartment Syndrome (CECS) is still unclear. The most commonly accepted theory suggests that it is a transient but debilitating process where there is an abnormally increased intracompartmental pressure during exercise/exertion due to non-compliant expansion of the osteofascial tissues. This most commonly occurs in the lower leg. Surgical intervention is often performed for symptom relief. However, there has been limited scientifically-based publication on post-surgical rehabilitation, especially with regard to return to function in the military population. The purpose of this case report is to demonstrate the utilization of a recommended post-operative protocol in a Special Forces Soldier. Case Description: The subject presented as a 25-year-old US Army Special Forces Soldier, who failed 8 weeks of conservative management for the diagnosis of CECS and subsequently underwent bilateral lower leg fasciotomies of the anterior and lateral compartments. Outcomes: Following recommended protocol guidelines he was progressed rapidly and within three months deployed without restriction or complications in a demanding combat zone. Discussion: This case report illustrates that following clearly defined, scientifically-based rehabilitation guidelines helped in addressing all of the involved structures and musculoskeletal dysfunctions that presented following the surgical intervention for CECS in a unique subject. Key Words: Chronic exertional compartment syndrome, special forces soldier, surgical Level of evidence: 5
1
THOR3 Performance Rehabilitation Coordinator, 1st Battalion 10th Special Forces Group (Airborne), Stuttgart, Germany 2 Assistant Chief of Physical Therapy and Human Performance Optimization, Evans Army Hospital, Ft. Carson, Colorado, USA No financial support was received for this case report. The author would like to acknowledge Shenandoah University Physical Therapy Doctoral Program and Dr. Victor Vaughan, PT for their guidance and support in developing this case report. The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government. Citations of
commercial products or organizations do not constitute an official DoD endorsement or approval of the products or services of these organizations. This report was approved for public release by the US Army Special Operations THOR3 (Human Performance) Director.
CORRESPONDING AUTHOR Warren Flautt CMR 445 Box 642, APO AE, 09046 Email: warren.fl[email protected]
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BACKGROUND AND PURPOSE Chronic Exertional Compartment Syndrome (CECS) was first described by Mavor1 in 1956 who is cited as the first surgeon to perform a compartment release fasciotomy for CECS. The prevalence of CECS has been well documented in both an athletic and nonathletic populations for over 55 years.2-6 There has been a large volume of research dedicated to the detection, diagnosis, and surgical management of CECS.7-22 However, there has been little published in the form of a scientifically-based post-operative protocol with regard to appropriate progression and tissue healing time.23 There is also no universally accepted instrument used to evaluate changes in self-reported physical function for individuals with leg, ankle and foot musculoskeletal disorders.24 Furthermore, little has been published regarding the management of this problem in military personnel, and particularly the Special Forces Soldier.9,11,25 Chronic exertional compartment syndrome is a well-recognized condition that chiefly affects young, physically active people. However, the etiology of CECS is still unclear.2,7,26-28 The pathophysiology of CECS is generally accepted as the rise in the intracompartmental pressure during and after exercise of the involved muscles due to the relative unyielding fascia of each compartment.26 Fronek et al12 suggests that vigorous exercise may acutely raise a compartments muscle weight by 20%. This leads to interstitial pressure increase and decreased blood perfusion.26 Tissue ischemia can then result, which in turn may bring on the symptoms of pain until the provoking activity is stopped and normal tissue perfusion returns.26 Physical overtraining and resul-
tant rapid muscle expansion may contribute to the intercompartmental compressive forces.7 CECS is seen in various extremities like the thigh, forearm and foot, although most frequently it involves the lower leg and occurs bilaterally from 60-95% of the cases.13,29-31 The anatomy of the leg consists of four compartments that contain muscles and neurovascular bundles.32 Each of these compartments is encased by fascia with their own anatomical structures (Table 1). The anterior compartment is most often involved followed by the lateral compartment and least commonly the deep posterior compartment.8,14 Cases involving lower extremity CECS are most often seen in runners.5,33 Men and women have a relatively equal rate of prevalence in developing CECS.34 The subject who presents with CECS complains of cramping, burning, or achy pain and tightness in the lower leg with exercise.2,7 Pain is often resolved in minutes to an hour following cessation of the provoking activity.3 There may be reports of transient parasthesia or paresis, as well.6,7 Several diagnostic methods have been described in the literature, including magnetic resonance imaging, near-infrared spectroscopy, and ultrasound.15-17 Intra-compartmental pressure tests are currently the “gold standard” for determining the presence of CECS,8,18,19,23 however there is still debate as to the initial resting pressures and the post-activity pressures.20,35 Pedowitz, et al uses the following criteria: a resting pressure/ measurement ≥15 mm Hg, and/or a measurement taken 1 minute after exercise ≥30 mm Hg, and/or a measurement taken 5 minutes after exercise ≥20
Table 1. Compartments of the lower leg and the structures contained within.
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mm Hg.19 Differential diagnosis includes tibial stress fractures, peripheral nerve entrapment, popliteal artery entrapment syndrome (PAES) and periostitis.35,36 Because pressure testing is invasive it is recommended the subject and provider exhaust all measures of differential diagnosis like computed tomography (CT) and MRI to rule out stress changes and PAES.6, 37,38 Non-surgical, conservative management can include activity modification, rest, massage, stretching and non-steroidal anti-inflamatories.8,29 Alteration of running technique using a forefoot strike has recently been examined in the treatment of CECS.27,28 However, there is limited conclusive evidence for any of these conservative treatments success in returning the subject to their prior level of function. If conservative management fails to obtain the desired outcomes, surgical intervention is the typical next intervention.26-28 Subjects with anterior and lateral compartment releases tend to have better outcomes than those with posterior and deep posterior releases.7,39 Previous studies have revealed an 80% success rate in subjects with anterior and lateral releases compared to those who undergo deep posterior releases, with only a 50% success rate.21,39 It has been suggested that in the presence of bilateral CECS, performing bilateral simultaneous fasciotomies is a preferred method for a more rapid return to sports participation.22 Successful responses to fasciotomies is typically defined as minimal or no pain with near complete functional recovery.23,39,40 Schubert23 recommends the Foot and Ankle Ability Measure (FAAM) outcomes assessment instrument as a reliable, responsive, and valid measure of physical function for musculoskeletal disorders of the lower leg, foot and ankle. Martin et al24 reported the validity of the FAAM and test retest reliability of 0.89 and 0.87 for the Activities of Daily Living (ADL) and Sport subscale, respectively. The minimal detectable change based on a 95% confidence interval was +/- 5.7 and +/- 12.3 points for the ADL and Sports subscales, respectively. Analysis of variance (ANOVA) and Receiver Operating Characteristic (ROC) analysis found both the subscales were responsive to change in status with a p value < 0.05. The minimal clinically important differences
were 8 and 9 points for the ADL and Sports subscales, respectively. This case report involves a US Army Special Forces Soldier who developed CECS due to training in preparation for an upcoming combat deployment. The Army Special Forces Soldier undergoes arduous physical and mental challenges. The physical demands are both unique and exceptional. For this reason they have recently been labeled as “tactical athletes”. The entire process of becoming a member of Special Forces can take over two years of intense training. This includes, but is not limited to intense psychological screening, timed run events up to 6 miles, obstacle courses, day and night land navigation, and long range movements up to 26 miles at once while carrying a 45 pound carriage load. Following selection into Special Forces advanced handto-hand combat training, sniper school, airborne free-fall school, scuba school, and other elite training programs await the new Special Forces Soldier. Of particular distress to the body is the requirement to maneuver in and out of extremely hostile environments with various carriage loads. It is not uncommon for the Special Forces Soldier to be required to carry over 100 pounds of equipment through challenging terrain for up to 10 miles. As a result, arduous training schedules have been created. The purpose of this case report is to demonstrate the successful utilization of a recommended rehabilitation protocol following bilateral fasciotomies of the lower extremity for CECS23 in a unique subject. CASE DESCRIPTION The subject was a 25 year old male who presented to his primary care physician’s office with complaints of an extremely “painful pressure” and “tightness” of the left greater than right anterior leg, with concomitant swelling and transient left foot drop of approximately 3 weeks duration. He was referred to Physical Therapy by his primary care physician with the suspicion of CECS. His prior activity level included 50-70 mile/week running and walking/jogging while carrying a load (aka: load carriage), commonly referred to as “rucking”, varying distances from 5 miles to 12 miles per session, 1-2 times per week with 45-60 lbs. Symptom onset occurred after 3 weeks of training that coincided with consistently
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training over 10 miles per session at 50 pound load carriage. By the third week of training the subject reported his symptoms on the Numeric Pain Rating Scale (NPRS) at 9/10 left leg, 8/10 right leg with rucking over 2 miles. Symptoms were transient and resolved within 1 hour after cessation of rucking, however his frequency of episodes was increasing to any rucking attempts that were over 2 miles. Prior to this episode he had no previous history of similar signs or symptoms. He underwent 8 weeks of conservative management of his symptoms. The initial 4 weeks included rest and soft tissue stretching of the lower extremities. He was introduced to a progressive walk-to-run program during weeks 5 and 6 of conservative management. He was able to run without symptoms for 3 miles at the end of week 6. Rucking with a 45 pound load carriage was introduced during the 7th and 8th week of conservative management. However, the subject’s symptoms of pain and tightness consistently returned when he rucked with 45 lbs for any longer than 2 miles at a pace of 10 minutes per mile. This was attempted on three occasions before the subject was referred to a military orthopedic surgeon for evaluation and possible surgical intervention. The subject was evaluated by an orthopedic surgeon with experience in surgical management of both acute and chronic exertional compartment syndromes. The surgeon proceeded to order plain film radiographs and a bone scan in order to rule out stress changes of the tibia. Results of these findings were negative for bony involvement. Once differential diagnoses were ruled out the orthopedic surgeon proceeded to measure compartment pressures. It should be noted that the subject walked on an inclined treadmill with a 45 lb load carriage at a 6 mile/hour (10 min mile)
pace in order to most accurately reproduce his symptoms.41 Compartment pressures were assessed preexercise and post-exercise (Table 2). Generally accepted guidelines for diagnosis based on pressure changes include a pre-exercise pressure of 15mm Hg or greater; 1 minute post-exercise pressure 30 mm Hg or greater; or 5 minutes post-exercise pressure 20 mm Hg or greater.15,19 Using the criteria described by Pedowitz, et al,19 the subject demonstrated significant difference between pre-exercise pressures and post-exercise pressures with post-exercise measurements occurring less than 5 minutes after exercise cessation. Once the subject’s diagnosis was confirmed, the discussion of whether to do the symptomatically worse leg or both legs was discussed. It was determined that a high likelihood of the subject having debilitating pain in the non-surgical leg existed. Therefore, the subject and the surgeon determined that bilateral fasciotomies of the anterior and possibly the lateral compartments would be the best plan of action.22 It should be noted that the interval from the surgical date to his pending deployment date was approximately 3 months. Therefore, a protocol with definitive functional benchmarks was utilized to ensure not only that the subject progressed at an appropriate time to meet his deployment, but also to ensure his supervisor was aware of his progress to facilitate a replacement if necessary.23 The subject presented to the PT clinic 1 week following surgery. EXAMINATION One-week status post bilateral anterior and lateral lower leg fasciotomies the subject was seen for his initial post-operative visit. His chief complaint was severe bilateral lower leg pain with ambulation. Precautions were weight bearing as tolerated (WBAT)
Table 2. Compartmental pressure measurements.
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bilaterally and any caution for any signs or symptoms of wound infection. The subject denied previous medical or surgical history. He was able to enter and exit his home and perform basic activities of daily living (ADLs). He could not drive due to both narcotic use and inability to operate the foot pedals in the car without severe pain. He was placed on convalescent absence from work by his surgeon for 4 weeks from the date of surgery. His long-term functional goals were to deploy with his Special Forces team in 3 months, with no recurrence of his symptoms, and full return to his prior level of work and recreational activity. All test and measures were performed by the lead author. The subject was 71 inches tall and weighed 169 pounds (BMI: 23.4). At the time of initial evaluation, the subject completed the Foot and Ankle Ability Measure (FAAM) considering both surgical legs and scored the following sub-scores for Activities of Daily Living and Sports, respectively: ADL 28/84 (33%) and Sport 0/32 (0%). Pain was recorded as a 4/10 left leg, 3/10 right leg on the NPRS when he was non-weight bearing. However, ambulation longer than 5 minutes was extremely painful with a NPRS of 8/10 bilaterally requiring the subject to sit and elevate his legs. Four inch surgical incisions along the distal antero-lateral legs (bilateral) were noted. He reported diminished response to light touch 2 cm on each side of the surgical incision with the exception of 10cm superior to the superior end point of the incision. Deep tendon reflexes of the Patellar and Achilles were +2 bilaterally. Gait assessment demonstrated moderate antalgic gait with the use of axillary crutches and a decreased stride length bilaterally and a bilateral step-to-gait pattern. Swing phase of gait demonstrated left “hip hike” in an effort to clear the left foot during swing due to difficulty obtaining ankle neutral dorsiflexion without pain. Hip, knee and ankle active range of motion (AROM) was assessed utilizing a handheld goniometer. Hip and knee AROM was full and pain-free. Hip extension/flexion 10 to 125 degrees bilateral; internal/external rotation 35/45 degrees, respectively. Hip abduction 45 degrees bilateral. Knee extension/flexion 0-135 degrees, bilaterally. (Table 2 provides ankle ROM) Gross manual muscle testing revealed that the subject was able to activate all primary movers of the ankle against gravity to
include tibialis anterior, tibialis posterior, gastrocnemius, soleus and peroneals. However, tests against manual resistance were deferred due to his high level of pain. There was mild swelling throughout the lower extremities without pitting edema. There were no signs or symptoms of infection. Lower leg circumferences were measured just proximal to malleoli (right 24.0 cm, left 23.5 cm) and Mid-calf (taken from the largest point right 42.0 cm, left 41.4 cm) throughout the rehabilitation. INTERVENTION All interventions were provided in accordance with the protocol taken from review of literature by Dr. Amy Schubert.23 The protocol was a progression of the rehabilitation areas mentioned above, to include PRICE, ROM, stretching and soft tissue mobility, neurodynamic mobilization, strengthening, and sport/ job specific activities. Each phase has specific objective and subjective benchmarks required in order to progress to the next phase including ROM, NPRS, and in most phases a specific minimum difference FAAM score increase. Timelines were suggested, but the benchmarks were the determining factor in progression of the protocol. For specific details of the protocol, please see the Appendix 1 (reproduced with written permission by Dr. Amy Shubert). Phase I initial assessment Rehabilitation was initiated seven days post-operatively, and continued for approximately two weeks. The subject was re-assessed at the end of post-operative week three. All protocol criteria were met prior to advancing the subject to the next phase. Outcomes for each phase are noted in Table 3. Phase II re-assessment The subject underwent Phase II rehabilitation for approximately two weeks and was re-assessed at the end of post-operative week five. Sensation was reported as unchanged since the initial evaluation. All protocol goals for Phase II (Table 3) were met and the subject was progressed to Phase III at the beginning of post-operative week six. Phase III re-assessment The subject underwent Phase III rehabilitation for approximately three weeks and was re-assessed at
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Table 3. Outcome measurements for each phase of treatment.
the end of post-operative week eight. Sensation was reported as unchanged since the initial evaluation. All protocol goals for Phase III (Table 3) were met and the subject was progressed to Phase IV at the beginning of post-operative week nine. Phase IV re-assessment The subject underwent Phase IV rehabilitation for approximately four weeks and was re-assessed at the end of post-operative week 12 (Table 3) for possible discharge from Physical Therapy. Sensation was reported as unchanged since the initial evaluation. OUTCOMES Objective measurements were re-assessed at the beginning of each phase of the protocol (Table 3), including NPRS, AROM of the ankles and knees, gross manual muscle test (GMMT), circumference, sensation to light touch, and the FAAM was repeated per protocol recommendations. The subject was able to meet all of his protocol timelines and short-term protocol goals prior to advancing to the next phase or discharge from Physical Therapy. He demonstrated improved outcomes both on objective measurements and functional outcome measure scores on the FAAM. His range of motion was full throughout all planes of motion, GMMT was 5/5 for the ankle/foot, and his NPRS was 0/10 with all activities. Regarding the FAAM the Minimal Clinically Important Difference of “8 points and 9 points” for the ADL and Sports sub-scores, respectively, were met at each interval and he was able to deploy to combat operations without further incidence. Additionally, the subject reported that Day 2 of his deployment
he was required to hike 10 miles with 60 pounds and reported no pain, tightness or limitations. DISCUSSION CECS can be a debilitating and complicated condition. There have been mixed results with conservative care.27-29,42 Surgical interventions have had some success but failure rates as high as 20% have been reported in the anterior and lateral compartments and up to 50% in the deep posterior compartment.2,7,21 Typically, when conservative measures have failed, surgical interventions are performed on patients with CECS.6,7,26 Following surgical interventions, specific post-operative rehabilitation protocols help to progress the patient while minimizing harm during healing.23 One published protocol exists for CECS that proposes a scientifically-based progression.23 No published case reports were found in the literature review utilizing this criterion-based guideline, nor were there any published case reports on post-operative management of CECS in the US Army Special Forces Soldier. This case report illustrates that following a clearly defined rehabilitation protocol helped give specific guidance in addressing all of the structures and dysfunctions involved in the surgical intervention of CECS. It also allowed for delineation of distinct timelines along with short and long term objectives that facilitate progress of highly active individual. This was extremely helpful not only for the subject and therapist to have defined goals, but also in reporting to his Special Forces team leadership regarding prognosis for return to combat. The utilization of a
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valid and reliable outcome assessment instrument, FAAM, accurately reflected progress in the subject’s functional return to duty. He exceeded the accepted minimal clinically important difference, which has been validated in subjects who felt they improved with rehabilitation from those who felt they did not improve over a four-week period of each scoring. Successful outcomes in this case could be attributed to several factors including rapid diagnosis, definitive management of this subject’s condition, as well as his age, fitness and health level (no co-morbidities). Results of this case report may suggest that the subject’s motivation and excellent compliance also played a critical factor in his overall success. These guidelines may not only be applicable to recreational and high level athletes, but also the unique training requirements of the Special Forces Soldier. There are several limitations with this case report. First, this is based on only one individual and therefore external validity is limited. Also, external validity is further reduced due to the unique physical and job requirements of the subject in this study. Circumferential measurements of the calf could have been documented initially at the largest point and utilizing fixed landmarks, rather than choosing to measure only the largest point of the calf, in order to improve intra-tester reliability. Finally, the FAAM may better assess long-term outcomes if initially administered prior to surgery in order to better compare functional improvements/outcomes pre-and post-surgery. With that said, the author’s encourage more health care professionals working with Special Operations or a wide variety of athletes to present data that can further assist in returning both tactical and traditional athletes back to the fight/competition. REFERENCES 1. Mavor, G.E. The anterior tibial syndrome. Journal of Bone Joint Surgery. 1956; 38B:513-517. 2. Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. 2000; 32(2):S4-S10. 3. Hutchinson MR, Ireland ML. Common compartment syndromes in athletes. Sports Med. 1994; 17(3):200-208. 4. Tzortziou V, Maffulli N, Padhiar N. Diagnosis and Management of Chronic Exertional Compartment Syndrome (CECS) in the United Kingdom. Clin J Sports Med. 2006; 16(3): 209-213.
5. Detmer DE, Sharpe K, Sufit RL, et al. Chronic compartment syndrome:Diagnosis, management and outcomes. Am J Sports Med. 1985;13:162-170. 6. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med. 2010;3:32-37. 7. Gill CS, Halstead ME, Matava MJ. Chronic exertional compartment syndrome of the leg in athletes: evaluation and management. Physician and Sports Medicine. 2010; 2(38):126-132. 8. Brennan FH, Kane SF. Diagnosis, treatment options, and rehabilitation of the chronic lower leg exertional compartment syndrome. Current Sp Med Reports. 2003; 2:247-250. 9. Waterman BR, Laughlin M, Kilcoyne K, Cameron KL, Owens, BD. Surgical treatment of chronic eertional compartment syndrome of the leg. J Bone Joint Surg Am. 2013;95:592-596. 10. Wilder RP, Magrum E. Exertional compartment syndrome. Clin Sports Med. 2010; 29:429-435. 11. Scheltinga MR, et al. Maximally invasive fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg: short- and long-term results. Military Medicine. 2006; 171:399-403. 12. Fronek J, Mubarak SJ, Hargens AR, et al. Management of the chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res. 1987; 220:217-227. 13. Touliopolous S, Hershman EB. Lower leg pain Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Med. 1999; 27(3):193-204. 14. Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Amer J Sports Med. 1988: 16(2):165-169. 15. Van den Brand JGH, Nelson T, Verleisdonk EJM, van der Werken C. The diagnosistic value of intercompartmental pressure measurement, magnetic resonance imaging, and near-infared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients. Amer J Sports Med. 2005: 33(5): 699-704. 16. Ringler MD, Litwiller DV, Felmlee JP, et al. MRI accurately detects chronic exertional compartment syndrome: a validation study. Skeletal Radiol. 2013;42:385-392. 17. Rajasekaran S, Beavis S, Aly A-R, Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clin J Sports Med. 2013;0:1-7. 18. Brewer RB, Gregory AJ. Chronic Lower Leg Pain in Athletes: A Guide for the Differential Diagnosis,
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Evaluation, and Treatment. Sports Health: A Multidisciplinary Approach. 2012; 4:121-127. Pedowitz RA, Hargens AR, Mubarak SJ, et al. Modified criteria for the objective diagnosis of the chronic compartment syndrome of the leg. Am J Sports Med 1990; 18(1):35-40. Hammerberg EM, Whitesides TE, Seiler, JG The Reliability of Measurement of tissue pressure in compartment syndrome. J Orthop Trauma. 2012; 26(1):24-31. Schepsis AA, Gill SS, Foster TA. Fasciotomy for exertional compartment syndrome: is lateral compartment release necessary? Am J Orthop Sports Med. 1999; 27(4):430-435. Raikin SM, Rapuri VR, Vitanzo P. Bilateral Simultaneous Fasciotomy for Chronic Exertional Compartment Syndrome. Foot and Ankle International. 2005; 26:1007-1011.
23. Schubert AG. Exertional compartment syndrome: review of the literature and proposed rehabilitation guidelines following surgical release. Int J Sports Phys Ther. 2011; 6(2):126-140. 24. Martin RL, Irrgang JJ, Burdett RG, et al. Evidence of validity for the foot and ankle ability measure (FAAM). Foot Ankle Int. 2005; 26(11):968-983. 25. Schissel DJ, Godwin J. Effort-related chronic compartment syndrome of the lower extremity. Military medicine. 1999; 164:180-182. 26. Fraipoint MJ, Adamson GJ. Chronic exertional compartment syndrome. J Am Acad OrthopSurg 2003: 11: 268-276. 27. Diebal AR, et al. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Amer J Sports Med 2012; 40:1060-1067. 28. Diebal AR, et al. Effects of Forefoot Running on Chronic Exertional Compartment Syndrome: A Case Series. Int J Sports Phys Ther 2011; 6(4): 312-321. 29. Blackman PG, Simmons LR, Crossley KM. Treatment of chronic exertional compartment syndrome with massage: a pilot study. Clin J Sport Med. 1998; 8:1417. 30. Colisimo AJ, Ireland ML. Thigh compartment syndrome in a football athlete: a case report and
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review of the literature. Medicine and Science in Sport and Exercise. 24(9): 958-963, 1992. Bird C, McCoy, J. Weightlifting as a cause of compartment syndrome in the forearm. J BoneJoint Surg Am. 1983;65: 406. Netter, FH. 1989. Atlas of Human Anatomy. Summit, NJ Ciba-Geigy Corporation Kohn HS. Shin pain and compartment syndromes in running. In: Running Injuries. Philadelphia, PA: WB Saunders; 1997:119-133. Shah SN, Miller BS, Kuhn JE. Chronic exertional compartment syndrome. Am J Ortho. 2004; 33(7):335-341. Styf JR, Korner LM. Chronic anterior-compartment syndrome of the leg. J of Bone and Joint Surg. 1986; 68:1338-1347. Baltopoulous P, Filippou DK, Sigala F. Popliteal artery entrapment syndrome: anatomic of functional syndrome? Clin J Sport Med. 2004;14:8-12. Gaeta M, Minutoli F, Scribano E, et al. Stress fractures in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235:553-561. Anil G, Tay KH, Howe TC, et al. Dynamic computed tomography angiography: role in the evaluation of popliteal artery entrapment syndrome. Cardiovasc Intervent Radiol. 2011;34:259-270. Packer, JD Day MS, McPhil JTN, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Amer J Sports Med. 2013;41(2):430-436. Slimmon D, Bennell K, Brukner P, et al. Long-term outcome of fasciotomy with partial fasciotomy for the chronic exertional compartment syndrome of the lower leg. Am J Sports Med. 2002; 30(4):581-588. Padhiar N, King JB. Exercise induced leg painchronic compartment syndrome. Is the increase in intracompartment pressure exercise specific? Br J Sports Med 1996; 30(4):360-362. Gebauer A, Schultz CR, Giangarra CE. Chronic exercise-induced leg pain in an athlete successfully treated with sympathetic block. Am J Sports Med. 2005; 33(10):1575-1578.
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APPENDIX 1 4 Phase Protocol Note: (*) represents subtle divergence from the Schubert protocol PHASE I. Protection and Mobility (Surgery to 2-3 weeks).
Category Phase I Appointments
Information Physician appointment: 5-10 days post-operatively for suture removal, no drain used. Rehabilitation appointments began 7 days after surgery, continued 1 time every 5 days.
Phase I Rehabili- Administer FAAM (ADL and sport subscales) tation Goals Protection of the post-surgical compartment Minimize postoperative swelling; lower extremity circumference within 2 cm of uninvolved side Instruction in safe positioning and limb self-management Restore normal knee and ankle range of motion (ankle ROM with knee flexed: DF=20, PF=50, inversion=30-35, eversion=15-20. Knee ROM: ext=full, flex=130) Able to lift leg involved leg in all directions in standing without pain or compensation. Restore ability to control leg in open and closed kinetic chain during gait. Non-antalgic gait on level surface with full weight bearing and no assistive device at >2 mph with equal step length bilaterally. Phase I Precautions
Use axillary crutches for gait with progressive weight bearing as tolerated, keeping pain at or below 2/10 on visual analog scale (1-2 weeks). Avoid any activity which causes increased swelling (for example: extended sitting or sitting with lower extremity in dependent position, tight clothing proximal to surgical release, and hot pack or bath.) Avoid any friction on new scar formation (for example: crossing legs, tight clothing, pushing object with legs or using weight machine that presses into skin over incision site). Avoid any impact activity including running, jumping, or hopping (6-8 weeks).
Phase I Therapeutic Exercise
Active ankle range of motion immediately to maintain extensibility of soft tissues as they heal to prevent postoperative contractures (include ankle PF, DF, inversion and eversion, knee flex and ext), begin with 10 repetitions in each direction, 1-2 times/day and progress number of repetitions as tolerated. May also consider initiation of open kinetic chain strengthening; began with theraband level 1-2, 1-2 sets of 10 in each direction, 1 time/day, at 3 weeks post-op. Progress as tolerated. Quadriceps sets for isometric strengthening. Begin with 5-10 second holds, 10 repetitions, 1-2 times/day. Progress hold time or repetitions followed by progression into short arc or long arc quad or straight leg raise. Leg lifts for hip strength: hip flexion, abduction and extension. Began in supine, side lying and prone, respectively, and progress into standing. 1 set of 10 in each direction, 1-2 times/day. Progress as tolerated.
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PHASE I. Protection and Mobility (Surgery to 2-3 weeks). (continued)
Category
Information Elevation of the operative extremity (above level of heart) begin with 30-40 minutes every 1-2 hours and modify as needed, ice 15-20 minutes with barrier between skin and icepack, and compression garment (Ace wrap or TED stocking), as needed, for swelling control Active muscle pumping exercises at distal/ankle joint while lower extremity is elevated on wall to assist with venous return and swelling. 1-2 minutes of active ankle pumping; 3-6 times/day or as needed for swelling control. Gentle distal-to-proximal massage to assist with venous return and swelling. Can perform with leg elevated on wall. Avoid contact with incisions. 3-5 minutes, 1-2 times/day or as needed to assist with swelling control.
Phase I Cardio- Upper body circuit training or upper body ergometer, as able. Began with 5-10 minutes, vascular Exercise 1-2 times/day, and progress as able. Progression Criteria to Phase II
Subject may progress to Phase II if they have met the above stated goals.
*Subject was able to attend Physical Therapy 2 times per week during phase I, but was instructed to perform the above exercise and modality treatment plan at the prescribed frequency, per the protocol.
PHASE II. Light Strengthening (begin after meeting Phase I criteria, approximately 3-4 weeks following surgery).
Category
Information
Phase II Appointments
Rehabilitation appointments are 1 time per week on average
Phase II Rehabilitation Goals
Lower extremity circumference within 1 cm of uninvolved side Incision is well healed Minimize muscle atrophy and flexibility deficits in anterior/involved compartment Single leg stance control with eyes open on unstable surface for 30-60 seconds Full flexibility of gastrocnemius (ankle DF with knee extended): 15-20 degrees Maintain motion and strength of uninvolved muscle groups, as well as cardiovascular endurance, as able Perform active or gentle resisted exercises of the hip of the operated lower extremity and resistance exercises of the upper extremities Proper lower extremity control and alignment with no pain during functional double leg squats Non-antalgic gait on level surface with full weight bearing and no assistive device, >3 mph with equal step length bilaterally 8 point (or greater) improvement on FAAM (ADL portion)
Phase II Precautions Avoid over-stressing new scar formation by avoiding any friction over tissue (as per Phase I) The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 710
PHASE II. Light Strengthening (begin after meeting Phase I criteria, approximately 3-4 weeks following surgery). (continued)
Category
Information Avoid post-activity swelling by limiting prolonged weight bearing activity as appropriate. If swelling occurred, managed with rest, ice, elevation and compression (as per Phase I). Avoid eccentric loading with any impact activity.
Phase II Therapeutic Exercise
Scar massage/mobility and desensitization (once incision was healed). Began with 3-5 minutes, 1-2x/day and modify as needed. Gentle stretching and nerve mobilizations to tissue in involved compartment. Stretch holds for 30-60 seconds, 2-3x/day. Nerve mobilizations begin with 5-8 reps, 3-5x/day; progress number of reps as tolerated. For nerve mobilizations, begin with supine positioning with the lower extremity in a straight-leg raise position; ankle plantarflexion with inversion places tension on the common peroneal tract. Progressed by adding hip adduction or internal rotation while doing the straight-leg raise to increase tension on the nervous system. Passive neck flexion will also pull the spinal cord superiorly and places the entire nervous system on a stretch. Progress to open kinetic chain ankle strengthening. 2-3 sets of 10; progress resistance, sets and reps as tolerated. Balance and proprioception exercises: initiate a progression of bilateral to unilateral balance activities first on a level, firm surface, then on a soft/unstable surface, such as dense foam or Bosu ball, and then on a balance board. Begin with eyes open; progress with head turns and eyes closed as able. Goal of 30-60 second holds; 2-3 repetitions, 1-2 times/day. Gait drills: begin with sagittal plane and progress to frontal and transverse planes. Examples include forward and backward marching (sagittal plane), sidestepping or side marching (frontal plane), and carioca/grapevine walking (transverse plane). Begin with 10-20 steps, 2-3 repetitions, 1-2 times/day. Progressed as tolerated.
Phase II Cardiovascular Exercise
Upper body circuit training, upper body ergometer (as per Phase I) Begin stationary biking if wound is healed; begin with 5-10 minutes at a low resistance (for example, level 1-2 on a bike with 10 levels), and low cadence (for example 60-80 revolutions per minute). Progress time, cadence, and resistance as able. Begin treadmill if wound is healed; begin with 5-10 minutes at 2-3 mph and progress time and speed as able. May swim or water walk if wound is FULLY healed (do not risk infection); begin with 10-15 minutes and progress time and speed as able.
Progression Criteria to Phase III
Subject may progress to Phase III if they have met the above stated goals
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PHASE III. Progression of Strengthening (begin after meeting Phase II criteria, approximately 4-6 weeks following surgery).
Category
Information
Phase III Appointments
Rehabilitation appointments were 1x every week on average
Phase III Rehabilitation Goals
Prevent post-operative recurrence of symptoms with all activity Tolerate 15-30 minutes of continuous aerobic activity without the onset of symptoms/pain Reinforce self-monitoring and review signs of recurrence and complications. Full 5/5 pain free ankle strength with manual muscle testing of muscles in involved compartments Proper lower extremity control and alignment and no pain with single leg functional movements including squats and lunges No residual swelling 12-24 hours following all physical activity (including impact exercises) No pain 1-2 hours following physical activity (including impact exercises)
Phase III Precautions
Avoid friction over scar tissue (as per phase I-II) Avoid post-activity swelling (as per phase I-II) No strenuous activity until wound is fully healed Suggest no running until 6 weeks postoperatively (subject should be advised by physical therapist and MD prior to initiation of any running) Avoid pain with any exertional activity
Phase III Therapeutic Exercise
Lower extremity stretching and nerve mobilizations as appropriate (per Phase II) Lower extremity myofascial stretching/massage and “The Stick” or a foam roller (rolling lower extremities over the roller in long sitting or prone with legs internally rotated, for posterior or anterior legs) for rolling deep massage to improve flexibility and soft tissue mobility. Began with 1-3 minutes 1x/day and progress as tolerated. Progression of lower extremity closed chain functional strengthening including lunges, step-backs (off of a standard step), and single leg squats. Double leg heel rise progressing to single leg heel rise with and without gait drills (such as marching), toe and heel walking. Begin with 2-3 sets of 10 reps, 1 time/day, and progress as tolerated. Initiate plyometric exercises (with focus on lower extremity control and alignment at hip, knee, and ankle) at 6 weeks. Begin with 2 feet to 2 feet jumping, progressing from 1 foot to other (leaping) and then 1 foot to same foot (hopping). Focus on proper landing/ deceleration mechanics. Begin with 1-2 sets of 10 repetitions. Progress number of repetitions, sets, as well as height or distance as tolerated. (See Figure A1)
Phase III Cardio- Initiate or progress swimming or water walking if wounds are fully healed (as per Phase vascular Exercise II) Progressive walking time and speed (as per Phase II) Begin elliptical trainer for 10-15 minutes at low resistance (for example, level 1-2 on an elliptical with 10 levels). Progress time and resistance as able.
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PHASE III. Progression of Strengthening (begin after meeting Phase II criteria, approximately 4-6 weeks following surgery). (continued).
Category
Information Light jogging can be initiated at 6-8 weeks; initially began on level surface while avoiding hills and speed work. For runners, consider 5 minute interval training involving walking (for example 1-2 minutes of jogging followed by 3-4 minutes of walking). Progressive jog interval times, incline, and speed as appropriate for return to sport/work goals. For those returning to multi-planar sport, consider progression outlined in Appendix 1 (see original Schubert article) (*Initial running in case report utilized unloading treadmill. See Figure A2.)
Progression Crite- Subject may progress to Phase IV if they have met the above stated goals. ria to Phase IV
Figure A1. Plyometrics
Figure A2. Unloading Treadmill
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PHASE IV. Impact/Sport Training (begin after meeting Phase III criteria, approximately 8 weeks following surgery).
Category
Information
Phase IV Appointments
Rehabilitation appointments are 1 time every week
Phase IV Rehabilitation Goals
Administer FAAM (ADL and sport subscales) prior to discontinuation of therapy. 9 point (or greater) improvement on FAAM (sport subscale portion) Proper dynamic neuromuscular control and alignment with eccentric and concentric multi-plane activities (including impact) for return to work/sports, without pain, instability or swelling Within 90% of pain free strength (compared to uninvolved side) on leg press (heel raise/PF)
Phase IV Precautions
Avoid pain with any exertional activity Avoid post-activity swelling (as per phase I-III)
Phase IV Therapeutic Exercise
Biomechanical assessment of specific sport activity with video analysis as needed (running, biking, etc) Instruct in proper return to activity progression (incremental running, biking, etc) (* Table A5 introduces rucking progression for case report subject) Progressive strengthening exercises using higher stability, and neuromuscular control with increased loads and speeds and combined movement patterns; begin with low velocity, single plane activities and progressing to higher velocity, multi-plane activities. Begin with forward and backward, progress to side-to-side, diagonals and transverse plane movements Integrate movements and positions into exercises that simulate functional activities. Sport and work-specific training beginning with low-intensity simulated movements.
Phase IV Cardio- Replicate sport or work specific energy demands vascular Exercise (*case report subject introduced to speed and agility required of his work duties. See Figure A3 & A4) Return To Sport/ Work Criteria
Patient may return to sport/work, including a graduated physical training regime if they have met the above stated goals and has had physician and rehabilitation specialist approval. Precautions to reduce the risk of re-injury when returning to sports or high-demand activities as appropriate.
*At this point the subject was instructed to begin progressive rucking initially starting with 60% of his preinjury level for weight, pace and distance. Subject maintained 2-3 day rest intervals between ruck marches. He was progressed 10% weekly for 4 weeks with the expectation he would independently complete his 100% training in the “area of operations” (AO). See Table A.1. He was also returned to all job-related training to include progressive shooting and movement (Close-Quarter-Battle - CQB) drills in full battle gear.
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Table A.1.
Week 1: Light ruck 7.2mi; 27lb; 13-14min-mi/Heavy ruck 3.0mi; 36lb;13-14min-mi Week 2: Light ruck 8.4mi; 32lb; 12-13min-mi/ Heavy ruck 3.5mi; 42lb;12-13min-mi Week 3: Light ruck 9.6mi; 36lb; 11-12min-mi/Heavy ruck 4.0mi; 48lb; 11-12min-mi Week 4: Light ruck 11.0mi;41lb; 10-12 min/Heavy ruck 4.5mi; 54lb; 10-12min-mi
Figure A3. Speed
Figure A4. Agility
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CASE REPORT
POSTSURGICAL REHABILITATION FOLLOWING FASCIOTOMIES FOR BILATERAL CHRONIC EXERTIONAL COMPARTMENT SYNDROME IN A SPECIAL FORCES SOLDIER: A CASE REPORT Warren Flautt, PT, DPT, SCS, CSCS1 Joseph Miller, PT, DSc, OCS, SCS, CSCS2
ABSTRACT Background and Purpose: The etiology of Chronic Exertional Compartment Syndrome (CECS) is still unclear. The most commonly accepted theory suggests that it is a transient but debilitating process where there is an abnormally increased intracompartmental pressure during exercise/exertion due to non-compliant expansion of the osteofascial tissues. This most commonly occurs in the lower leg. Surgical intervention is often performed for symptom relief. However, there has been limited scientifically-based publication on post-surgical rehabilitation, especially with regard to return to function in the military population. The purpose of this case report is to demonstrate the utilization of a recommended post-operative protocol in a Special Forces Soldier. Case Description: The subject presented as a 25-year-old US Army Special Forces Soldier, who failed 8 weeks of conservative management for the diagnosis of CECS and subsequently underwent bilateral lower leg fasciotomies of the anterior and lateral compartments. Outcomes: Following recommended protocol guidelines he was progressed rapidly and within three months deployed without restriction or complications in a demanding combat zone. Discussion: This case report illustrates that following clearly defined, scientifically-based rehabilitation guidelines helped in addressing all of the involved structures and musculoskeletal dysfunctions that presented following the surgical intervention for CECS in a unique subject. Key Words: Chronic exertional compartment syndrome, special forces soldier, surgical Level of evidence: 5
1
THOR3 Performance Rehabilitation Coordinator, 1st Battalion 10th Special Forces Group (Airborne), Stuttgart, Germany 2 Assistant Chief of Physical Therapy and Human Performance Optimization, Evans Army Hospital, Ft. Carson, Colorado, USA No financial support was received for this case report. The author would like to acknowledge Shenandoah University Physical Therapy Doctoral Program and Dr. Victor Vaughan, PT for their guidance and support in developing this case report. The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government. Citations of
commercial products or organizations do not constitute an official DoD endorsement or approval of the products or services of these organizations. This report was approved for public release by the US Army Special Operations THOR3 (Human Performance) Director.
CORRESPONDING AUTHOR Warren Flautt CMR 445 Box 642, APO AE, 09046 Email: warren.fl[email protected]
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BACKGROUND AND PURPOSE Chronic Exertional Compartment Syndrome (CECS) was first described by Mavor1 in 1956 who is cited as the first surgeon to perform a compartment release fasciotomy for CECS. The prevalence of CECS has been well documented in both an athletic and nonathletic populations for over 55 years.2-6 There has been a large volume of research dedicated to the detection, diagnosis, and surgical management of CECS.7-22 However, there has been little published in the form of a scientifically-based post-operative protocol with regard to appropriate progression and tissue healing time.23 There is also no universally accepted instrument used to evaluate changes in self-reported physical function for individuals with leg, ankle and foot musculoskeletal disorders.24 Furthermore, little has been published regarding the management of this problem in military personnel, and particularly the Special Forces Soldier.9,11,25 Chronic exertional compartment syndrome is a well-recognized condition that chiefly affects young, physically active people. However, the etiology of CECS is still unclear.2,7,26-28 The pathophysiology of CECS is generally accepted as the rise in the intracompartmental pressure during and after exercise of the involved muscles due to the relative unyielding fascia of each compartment.26 Fronek et al12 suggests that vigorous exercise may acutely raise a compartments muscle weight by 20%. This leads to interstitial pressure increase and decreased blood perfusion.26 Tissue ischemia can then result, which in turn may bring on the symptoms of pain until the provoking activity is stopped and normal tissue perfusion returns.26 Physical overtraining and resul-
tant rapid muscle expansion may contribute to the intercompartmental compressive forces.7 CECS is seen in various extremities like the thigh, forearm and foot, although most frequently it involves the lower leg and occurs bilaterally from 60-95% of the cases.13,29-31 The anatomy of the leg consists of four compartments that contain muscles and neurovascular bundles.32 Each of these compartments is encased by fascia with their own anatomical structures (Table 1). The anterior compartment is most often involved followed by the lateral compartment and least commonly the deep posterior compartment.8,14 Cases involving lower extremity CECS are most often seen in runners.5,33 Men and women have a relatively equal rate of prevalence in developing CECS.34 The subject who presents with CECS complains of cramping, burning, or achy pain and tightness in the lower leg with exercise.2,7 Pain is often resolved in minutes to an hour following cessation of the provoking activity.3 There may be reports of transient parasthesia or paresis, as well.6,7 Several diagnostic methods have been described in the literature, including magnetic resonance imaging, near-infrared spectroscopy, and ultrasound.15-17 Intra-compartmental pressure tests are currently the “gold standard” for determining the presence of CECS,8,18,19,23 however there is still debate as to the initial resting pressures and the post-activity pressures.20,35 Pedowitz, et al uses the following criteria: a resting pressure/ measurement ≥15 mm Hg, and/or a measurement taken 1 minute after exercise ≥30 mm Hg, and/or a measurement taken 5 minutes after exercise ≥20
Table 1. Compartments of the lower leg and the structures contained within.
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mm Hg.19 Differential diagnosis includes tibial stress fractures, peripheral nerve entrapment, popliteal artery entrapment syndrome (PAES) and periostitis.35,36 Because pressure testing is invasive it is recommended the subject and provider exhaust all measures of differential diagnosis like computed tomography (CT) and MRI to rule out stress changes and PAES.6, 37,38 Non-surgical, conservative management can include activity modification, rest, massage, stretching and non-steroidal anti-inflamatories.8,29 Alteration of running technique using a forefoot strike has recently been examined in the treatment of CECS.27,28 However, there is limited conclusive evidence for any of these conservative treatments success in returning the subject to their prior level of function. If conservative management fails to obtain the desired outcomes, surgical intervention is the typical next intervention.26-28 Subjects with anterior and lateral compartment releases tend to have better outcomes than those with posterior and deep posterior releases.7,39 Previous studies have revealed an 80% success rate in subjects with anterior and lateral releases compared to those who undergo deep posterior releases, with only a 50% success rate.21,39 It has been suggested that in the presence of bilateral CECS, performing bilateral simultaneous fasciotomies is a preferred method for a more rapid return to sports participation.22 Successful responses to fasciotomies is typically defined as minimal or no pain with near complete functional recovery.23,39,40 Schubert23 recommends the Foot and Ankle Ability Measure (FAAM) outcomes assessment instrument as a reliable, responsive, and valid measure of physical function for musculoskeletal disorders of the lower leg, foot and ankle. Martin et al24 reported the validity of the FAAM and test retest reliability of 0.89 and 0.87 for the Activities of Daily Living (ADL) and Sport subscale, respectively. The minimal detectable change based on a 95% confidence interval was +/- 5.7 and +/- 12.3 points for the ADL and Sports subscales, respectively. Analysis of variance (ANOVA) and Receiver Operating Characteristic (ROC) analysis found both the subscales were responsive to change in status with a p value < 0.05. The minimal clinically important differences
were 8 and 9 points for the ADL and Sports subscales, respectively. This case report involves a US Army Special Forces Soldier who developed CECS due to training in preparation for an upcoming combat deployment. The Army Special Forces Soldier undergoes arduous physical and mental challenges. The physical demands are both unique and exceptional. For this reason they have recently been labeled as “tactical athletes”. The entire process of becoming a member of Special Forces can take over two years of intense training. This includes, but is not limited to intense psychological screening, timed run events up to 6 miles, obstacle courses, day and night land navigation, and long range movements up to 26 miles at once while carrying a 45 pound carriage load. Following selection into Special Forces advanced handto-hand combat training, sniper school, airborne free-fall school, scuba school, and other elite training programs await the new Special Forces Soldier. Of particular distress to the body is the requirement to maneuver in and out of extremely hostile environments with various carriage loads. It is not uncommon for the Special Forces Soldier to be required to carry over 100 pounds of equipment through challenging terrain for up to 10 miles. As a result, arduous training schedules have been created. The purpose of this case report is to demonstrate the successful utilization of a recommended rehabilitation protocol following bilateral fasciotomies of the lower extremity for CECS23 in a unique subject. CASE DESCRIPTION The subject was a 25 year old male who presented to his primary care physician’s office with complaints of an extremely “painful pressure” and “tightness” of the left greater than right anterior leg, with concomitant swelling and transient left foot drop of approximately 3 weeks duration. He was referred to Physical Therapy by his primary care physician with the suspicion of CECS. His prior activity level included 50-70 mile/week running and walking/jogging while carrying a load (aka: load carriage), commonly referred to as “rucking”, varying distances from 5 miles to 12 miles per session, 1-2 times per week with 45-60 lbs. Symptom onset occurred after 3 weeks of training that coincided with consistently
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training over 10 miles per session at 50 pound load carriage. By the third week of training the subject reported his symptoms on the Numeric Pain Rating Scale (NPRS) at 9/10 left leg, 8/10 right leg with rucking over 2 miles. Symptoms were transient and resolved within 1 hour after cessation of rucking, however his frequency of episodes was increasing to any rucking attempts that were over 2 miles. Prior to this episode he had no previous history of similar signs or symptoms. He underwent 8 weeks of conservative management of his symptoms. The initial 4 weeks included rest and soft tissue stretching of the lower extremities. He was introduced to a progressive walk-to-run program during weeks 5 and 6 of conservative management. He was able to run without symptoms for 3 miles at the end of week 6. Rucking with a 45 pound load carriage was introduced during the 7th and 8th week of conservative management. However, the subject’s symptoms of pain and tightness consistently returned when he rucked with 45 lbs for any longer than 2 miles at a pace of 10 minutes per mile. This was attempted on three occasions before the subject was referred to a military orthopedic surgeon for evaluation and possible surgical intervention. The subject was evaluated by an orthopedic surgeon with experience in surgical management of both acute and chronic exertional compartment syndromes. The surgeon proceeded to order plain film radiographs and a bone scan in order to rule out stress changes of the tibia. Results of these findings were negative for bony involvement. Once differential diagnoses were ruled out the orthopedic surgeon proceeded to measure compartment pressures. It should be noted that the subject walked on an inclined treadmill with a 45 lb load carriage at a 6 mile/hour (10 min mile)
pace in order to most accurately reproduce his symptoms.41 Compartment pressures were assessed preexercise and post-exercise (Table 2). Generally accepted guidelines for diagnosis based on pressure changes include a pre-exercise pressure of 15mm Hg or greater; 1 minute post-exercise pressure 30 mm Hg or greater; or 5 minutes post-exercise pressure 20 mm Hg or greater.15,19 Using the criteria described by Pedowitz, et al,19 the subject demonstrated significant difference between pre-exercise pressures and post-exercise pressures with post-exercise measurements occurring less than 5 minutes after exercise cessation. Once the subject’s diagnosis was confirmed, the discussion of whether to do the symptomatically worse leg or both legs was discussed. It was determined that a high likelihood of the subject having debilitating pain in the non-surgical leg existed. Therefore, the subject and the surgeon determined that bilateral fasciotomies of the anterior and possibly the lateral compartments would be the best plan of action.22 It should be noted that the interval from the surgical date to his pending deployment date was approximately 3 months. Therefore, a protocol with definitive functional benchmarks was utilized to ensure not only that the subject progressed at an appropriate time to meet his deployment, but also to ensure his supervisor was aware of his progress to facilitate a replacement if necessary.23 The subject presented to the PT clinic 1 week following surgery. EXAMINATION One-week status post bilateral anterior and lateral lower leg fasciotomies the subject was seen for his initial post-operative visit. His chief complaint was severe bilateral lower leg pain with ambulation. Precautions were weight bearing as tolerated (WBAT)
Table 2. Compartmental pressure measurements.
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bilaterally and any caution for any signs or symptoms of wound infection. The subject denied previous medical or surgical history. He was able to enter and exit his home and perform basic activities of daily living (ADLs). He could not drive due to both narcotic use and inability to operate the foot pedals in the car without severe pain. He was placed on convalescent absence from work by his surgeon for 4 weeks from the date of surgery. His long-term functional goals were to deploy with his Special Forces team in 3 months, with no recurrence of his symptoms, and full return to his prior level of work and recreational activity. All test and measures were performed by the lead author. The subject was 71 inches tall and weighed 169 pounds (BMI: 23.4). At the time of initial evaluation, the subject completed the Foot and Ankle Ability Measure (FAAM) considering both surgical legs and scored the following sub-scores for Activities of Daily Living and Sports, respectively: ADL 28/84 (33%) and Sport 0/32 (0%). Pain was recorded as a 4/10 left leg, 3/10 right leg on the NPRS when he was non-weight bearing. However, ambulation longer than 5 minutes was extremely painful with a NPRS of 8/10 bilaterally requiring the subject to sit and elevate his legs. Four inch surgical incisions along the distal antero-lateral legs (bilateral) were noted. He reported diminished response to light touch 2 cm on each side of the surgical incision with the exception of 10cm superior to the superior end point of the incision. Deep tendon reflexes of the Patellar and Achilles were +2 bilaterally. Gait assessment demonstrated moderate antalgic gait with the use of axillary crutches and a decreased stride length bilaterally and a bilateral step-to-gait pattern. Swing phase of gait demonstrated left “hip hike” in an effort to clear the left foot during swing due to difficulty obtaining ankle neutral dorsiflexion without pain. Hip, knee and ankle active range of motion (AROM) was assessed utilizing a handheld goniometer. Hip and knee AROM was full and pain-free. Hip extension/flexion 10 to 125 degrees bilateral; internal/external rotation 35/45 degrees, respectively. Hip abduction 45 degrees bilateral. Knee extension/flexion 0-135 degrees, bilaterally. (Table 2 provides ankle ROM) Gross manual muscle testing revealed that the subject was able to activate all primary movers of the ankle against gravity to
include tibialis anterior, tibialis posterior, gastrocnemius, soleus and peroneals. However, tests against manual resistance were deferred due to his high level of pain. There was mild swelling throughout the lower extremities without pitting edema. There were no signs or symptoms of infection. Lower leg circumferences were measured just proximal to malleoli (right 24.0 cm, left 23.5 cm) and Mid-calf (taken from the largest point right 42.0 cm, left 41.4 cm) throughout the rehabilitation. INTERVENTION All interventions were provided in accordance with the protocol taken from review of literature by Dr. Amy Schubert.23 The protocol was a progression of the rehabilitation areas mentioned above, to include PRICE, ROM, stretching and soft tissue mobility, neurodynamic mobilization, strengthening, and sport/ job specific activities. Each phase has specific objective and subjective benchmarks required in order to progress to the next phase including ROM, NPRS, and in most phases a specific minimum difference FAAM score increase. Timelines were suggested, but the benchmarks were the determining factor in progression of the protocol. For specific details of the protocol, please see the Appendix 1 (reproduced with written permission by Dr. Amy Shubert). Phase I initial assessment Rehabilitation was initiated seven days post-operatively, and continued for approximately two weeks. The subject was re-assessed at the end of post-operative week three. All protocol criteria were met prior to advancing the subject to the next phase. Outcomes for each phase are noted in Table 3. Phase II re-assessment The subject underwent Phase II rehabilitation for approximately two weeks and was re-assessed at the end of post-operative week five. Sensation was reported as unchanged since the initial evaluation. All protocol goals for Phase II (Table 3) were met and the subject was progressed to Phase III at the beginning of post-operative week six. Phase III re-assessment The subject underwent Phase III rehabilitation for approximately three weeks and was re-assessed at
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Table 3. Outcome measurements for each phase of treatment.
the end of post-operative week eight. Sensation was reported as unchanged since the initial evaluation. All protocol goals for Phase III (Table 3) were met and the subject was progressed to Phase IV at the beginning of post-operative week nine. Phase IV re-assessment The subject underwent Phase IV rehabilitation for approximately four weeks and was re-assessed at the end of post-operative week 12 (Table 3) for possible discharge from Physical Therapy. Sensation was reported as unchanged since the initial evaluation. OUTCOMES Objective measurements were re-assessed at the beginning of each phase of the protocol (Table 3), including NPRS, AROM of the ankles and knees, gross manual muscle test (GMMT), circumference, sensation to light touch, and the FAAM was repeated per protocol recommendations. The subject was able to meet all of his protocol timelines and short-term protocol goals prior to advancing to the next phase or discharge from Physical Therapy. He demonstrated improved outcomes both on objective measurements and functional outcome measure scores on the FAAM. His range of motion was full throughout all planes of motion, GMMT was 5/5 for the ankle/foot, and his NPRS was 0/10 with all activities. Regarding the FAAM the Minimal Clinically Important Difference of “8 points and 9 points” for the ADL and Sports sub-scores, respectively, were met at each interval and he was able to deploy to combat operations without further incidence. Additionally, the subject reported that Day 2 of his deployment
he was required to hike 10 miles with 60 pounds and reported no pain, tightness or limitations. DISCUSSION CECS can be a debilitating and complicated condition. There have been mixed results with conservative care.27-29,42 Surgical interventions have had some success but failure rates as high as 20% have been reported in the anterior and lateral compartments and up to 50% in the deep posterior compartment.2,7,21 Typically, when conservative measures have failed, surgical interventions are performed on patients with CECS.6,7,26 Following surgical interventions, specific post-operative rehabilitation protocols help to progress the patient while minimizing harm during healing.23 One published protocol exists for CECS that proposes a scientifically-based progression.23 No published case reports were found in the literature review utilizing this criterion-based guideline, nor were there any published case reports on post-operative management of CECS in the US Army Special Forces Soldier. This case report illustrates that following a clearly defined rehabilitation protocol helped give specific guidance in addressing all of the structures and dysfunctions involved in the surgical intervention of CECS. It also allowed for delineation of distinct timelines along with short and long term objectives that facilitate progress of highly active individual. This was extremely helpful not only for the subject and therapist to have defined goals, but also in reporting to his Special Forces team leadership regarding prognosis for return to combat. The utilization of a
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valid and reliable outcome assessment instrument, FAAM, accurately reflected progress in the subject’s functional return to duty. He exceeded the accepted minimal clinically important difference, which has been validated in subjects who felt they improved with rehabilitation from those who felt they did not improve over a four-week period of each scoring. Successful outcomes in this case could be attributed to several factors including rapid diagnosis, definitive management of this subject’s condition, as well as his age, fitness and health level (no co-morbidities). Results of this case report may suggest that the subject’s motivation and excellent compliance also played a critical factor in his overall success. These guidelines may not only be applicable to recreational and high level athletes, but also the unique training requirements of the Special Forces Soldier. There are several limitations with this case report. First, this is based on only one individual and therefore external validity is limited. Also, external validity is further reduced due to the unique physical and job requirements of the subject in this study. Circumferential measurements of the calf could have been documented initially at the largest point and utilizing fixed landmarks, rather than choosing to measure only the largest point of the calf, in order to improve intra-tester reliability. Finally, the FAAM may better assess long-term outcomes if initially administered prior to surgery in order to better compare functional improvements/outcomes pre-and post-surgery. With that said, the author’s encourage more health care professionals working with Special Operations or a wide variety of athletes to present data that can further assist in returning both tactical and traditional athletes back to the fight/competition. REFERENCES 1. Mavor, G.E. The anterior tibial syndrome. Journal of Bone Joint Surgery. 1956; 38B:513-517. 2. Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. 2000; 32(2):S4-S10. 3. Hutchinson MR, Ireland ML. Common compartment syndromes in athletes. Sports Med. 1994; 17(3):200-208. 4. Tzortziou V, Maffulli N, Padhiar N. Diagnosis and Management of Chronic Exertional Compartment Syndrome (CECS) in the United Kingdom. Clin J Sports Med. 2006; 16(3): 209-213.
5. Detmer DE, Sharpe K, Sufit RL, et al. Chronic compartment syndrome:Diagnosis, management and outcomes. Am J Sports Med. 1985;13:162-170. 6. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med. 2010;3:32-37. 7. Gill CS, Halstead ME, Matava MJ. Chronic exertional compartment syndrome of the leg in athletes: evaluation and management. Physician and Sports Medicine. 2010; 2(38):126-132. 8. Brennan FH, Kane SF. Diagnosis, treatment options, and rehabilitation of the chronic lower leg exertional compartment syndrome. Current Sp Med Reports. 2003; 2:247-250. 9. Waterman BR, Laughlin M, Kilcoyne K, Cameron KL, Owens, BD. Surgical treatment of chronic eertional compartment syndrome of the leg. J Bone Joint Surg Am. 2013;95:592-596. 10. Wilder RP, Magrum E. Exertional compartment syndrome. Clin Sports Med. 2010; 29:429-435. 11. Scheltinga MR, et al. Maximally invasive fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg: short- and long-term results. Military Medicine. 2006; 171:399-403. 12. Fronek J, Mubarak SJ, Hargens AR, et al. Management of the chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res. 1987; 220:217-227. 13. Touliopolous S, Hershman EB. Lower leg pain Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Med. 1999; 27(3):193-204. 14. Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Amer J Sports Med. 1988: 16(2):165-169. 15. Van den Brand JGH, Nelson T, Verleisdonk EJM, van der Werken C. The diagnosistic value of intercompartmental pressure measurement, magnetic resonance imaging, and near-infared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients. Amer J Sports Med. 2005: 33(5): 699-704. 16. Ringler MD, Litwiller DV, Felmlee JP, et al. MRI accurately detects chronic exertional compartment syndrome: a validation study. Skeletal Radiol. 2013;42:385-392. 17. Rajasekaran S, Beavis S, Aly A-R, Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clin J Sports Med. 2013;0:1-7. 18. Brewer RB, Gregory AJ. Chronic Lower Leg Pain in Athletes: A Guide for the Differential Diagnosis,
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APPENDIX 1 4 Phase Protocol Note: (*) represents subtle divergence from the Schubert protocol PHASE I. Protection and Mobility (Surgery to 2-3 weeks).
Category Phase I Appointments
Information Physician appointment: 5-10 days post-operatively for suture removal, no drain used. Rehabilitation appointments began 7 days after surgery, continued 1 time every 5 days.
Phase I Rehabili- Administer FAAM (ADL and sport subscales) tation Goals Protection of the post-surgical compartment Minimize postoperative swelling; lower extremity circumference within 2 cm of uninvolved side Instruction in safe positioning and limb self-management Restore normal knee and ankle range of motion (ankle ROM with knee flexed: DF=20, PF=50, inversion=30-35, eversion=15-20. Knee ROM: ext=full, flex=130) Able to lift leg involved leg in all directions in standing without pain or compensation. Restore ability to control leg in open and closed kinetic chain during gait. Non-antalgic gait on level surface with full weight bearing and no assistive device at >2 mph with equal step length bilaterally. Phase I Precautions
Use axillary crutches for gait with progressive weight bearing as tolerated, keeping pain at or below 2/10 on visual analog scale (1-2 weeks). Avoid any activity which causes increased swelling (for example: extended sitting or sitting with lower extremity in dependent position, tight clothing proximal to surgical release, and hot pack or bath.) Avoid any friction on new scar formation (for example: crossing legs, tight clothing, pushing object with legs or using weight machine that presses into skin over incision site). Avoid any impact activity including running, jumping, or hopping (6-8 weeks).
Phase I Therapeutic Exercise
Active ankle range of motion immediately to maintain extensibility of soft tissues as they heal to prevent postoperative contractures (include ankle PF, DF, inversion and eversion, knee flex and ext), begin with 10 repetitions in each direction, 1-2 times/day and progress number of repetitions as tolerated. May also consider initiation of open kinetic chain strengthening; began with theraband level 1-2, 1-2 sets of 10 in each direction, 1 time/day, at 3 weeks post-op. Progress as tolerated. Quadriceps sets for isometric strengthening. Begin with 5-10 second holds, 10 repetitions, 1-2 times/day. Progress hold time or repetitions followed by progression into short arc or long arc quad or straight leg raise. Leg lifts for hip strength: hip flexion, abduction and extension. Began in supine, side lying and prone, respectively, and progress into standing. 1 set of 10 in each direction, 1-2 times/day. Progress as tolerated.
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PHASE I. Protection and Mobility (Surgery to 2-3 weeks). (continued)
Category
Information Elevation of the operative extremity (above level of heart) begin with 30-40 minutes every 1-2 hours and modify as needed, ice 15-20 minutes with barrier between skin and icepack, and compression garment (Ace wrap or TED stocking), as needed, for swelling control Active muscle pumping exercises at distal/ankle joint while lower extremity is elevated on wall to assist with venous return and swelling. 1-2 minutes of active ankle pumping; 3-6 times/day or as needed for swelling control. Gentle distal-to-proximal massage to assist with venous return and swelling. Can perform with leg elevated on wall. Avoid contact with incisions. 3-5 minutes, 1-2 times/day or as needed to assist with swelling control.
Phase I Cardio- Upper body circuit training or upper body ergometer, as able. Began with 5-10 minutes, vascular Exercise 1-2 times/day, and progress as able. Progression Criteria to Phase II
Subject may progress to Phase II if they have met the above stated goals.
*Subject was able to attend Physical Therapy 2 times per week during phase I, but was instructed to perform the above exercise and modality treatment plan at the prescribed frequency, per the protocol.
PHASE II. Light Strengthening (begin after meeting Phase I criteria, approximately 3-4 weeks following surgery).
Category
Information
Phase II Appointments
Rehabilitation appointments are 1 time per week on average
Phase II Rehabilitation Goals
Lower extremity circumference within 1 cm of uninvolved side Incision is well healed Minimize muscle atrophy and flexibility deficits in anterior/involved compartment Single leg stance control with eyes open on unstable surface for 30-60 seconds Full flexibility of gastrocnemius (ankle DF with knee extended): 15-20 degrees Maintain motion and strength of uninvolved muscle groups, as well as cardiovascular endurance, as able Perform active or gentle resisted exercises of the hip of the operated lower extremity and resistance exercises of the upper extremities Proper lower extremity control and alignment with no pain during functional double leg squats Non-antalgic gait on level surface with full weight bearing and no assistive device, >3 mph with equal step length bilaterally 8 point (or greater) improvement on FAAM (ADL portion)
Phase II Precautions Avoid over-stressing new scar formation by avoiding any friction over tissue (as per Phase I) The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 710
PHASE II. Light Strengthening (begin after meeting Phase I criteria, approximately 3-4 weeks following surgery). (continued)
Category
Information Avoid post-activity swelling by limiting prolonged weight bearing activity as appropriate. If swelling occurred, managed with rest, ice, elevation and compression (as per Phase I). Avoid eccentric loading with any impact activity.
Phase II Therapeutic Exercise
Scar massage/mobility and desensitization (once incision was healed). Began with 3-5 minutes, 1-2x/day and modify as needed. Gentle stretching and nerve mobilizations to tissue in involved compartment. Stretch holds for 30-60 seconds, 2-3x/day. Nerve mobilizations begin with 5-8 reps, 3-5x/day; progress number of reps as tolerated. For nerve mobilizations, begin with supine positioning with the lower extremity in a straight-leg raise position; ankle plantarflexion with inversion places tension on the common peroneal tract. Progressed by adding hip adduction or internal rotation while doing the straight-leg raise to increase tension on the nervous system. Passive neck flexion will also pull the spinal cord superiorly and places the entire nervous system on a stretch. Progress to open kinetic chain ankle strengthening. 2-3 sets of 10; progress resistance, sets and reps as tolerated. Balance and proprioception exercises: initiate a progression of bilateral to unilateral balance activities first on a level, firm surface, then on a soft/unstable surface, such as dense foam or Bosu ball, and then on a balance board. Begin with eyes open; progress with head turns and eyes closed as able. Goal of 30-60 second holds; 2-3 repetitions, 1-2 times/day. Gait drills: begin with sagittal plane and progress to frontal and transverse planes. Examples include forward and backward marching (sagittal plane), sidestepping or side marching (frontal plane), and carioca/grapevine walking (transverse plane). Begin with 10-20 steps, 2-3 repetitions, 1-2 times/day. Progressed as tolerated.
Phase II Cardiovascular Exercise
Upper body circuit training, upper body ergometer (as per Phase I) Begin stationary biking if wound is healed; begin with 5-10 minutes at a low resistance (for example, level 1-2 on a bike with 10 levels), and low cadence (for example 60-80 revolutions per minute). Progress time, cadence, and resistance as able. Begin treadmill if wound is healed; begin with 5-10 minutes at 2-3 mph and progress time and speed as able. May swim or water walk if wound is FULLY healed (do not risk infection); begin with 10-15 minutes and progress time and speed as able.
Progression Criteria to Phase III
Subject may progress to Phase III if they have met the above stated goals
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PHASE III. Progression of Strengthening (begin after meeting Phase II criteria, approximately 4-6 weeks following surgery).
Category
Information
Phase III Appointments
Rehabilitation appointments were 1x every week on average
Phase III Rehabilitation Goals
Prevent post-operative recurrence of symptoms with all activity Tolerate 15-30 minutes of continuous aerobic activity without the onset of symptoms/pain Reinforce self-monitoring and review signs of recurrence and complications. Full 5/5 pain free ankle strength with manual muscle testing of muscles in involved compartments Proper lower extremity control and alignment and no pain with single leg functional movements including squats and lunges No residual swelling 12-24 hours following all physical activity (including impact exercises) No pain 1-2 hours following physical activity (including impact exercises)
Phase III Precautions
Avoid friction over scar tissue (as per phase I-II) Avoid post-activity swelling (as per phase I-II) No strenuous activity until wound is fully healed Suggest no running until 6 weeks postoperatively (subject should be advised by physical therapist and MD prior to initiation of any running) Avoid pain with any exertional activity
Phase III Therapeutic Exercise
Lower extremity stretching and nerve mobilizations as appropriate (per Phase II) Lower extremity myofascial stretching/massage and “The Stick” or a foam roller (rolling lower extremities over the roller in long sitting or prone with legs internally rotated, for posterior or anterior legs) for rolling deep massage to improve flexibility and soft tissue mobility. Began with 1-3 minutes 1x/day and progress as tolerated. Progression of lower extremity closed chain functional strengthening including lunges, step-backs (off of a standard step), and single leg squats. Double leg heel rise progressing to single leg heel rise with and without gait drills (such as marching), toe and heel walking. Begin with 2-3 sets of 10 reps, 1 time/day, and progress as tolerated. Initiate plyometric exercises (with focus on lower extremity control and alignment at hip, knee, and ankle) at 6 weeks. Begin with 2 feet to 2 feet jumping, progressing from 1 foot to other (leaping) and then 1 foot to same foot (hopping). Focus on proper landing/ deceleration mechanics. Begin with 1-2 sets of 10 repetitions. Progress number of repetitions, sets, as well as height or distance as tolerated. (See Figure A1)
Phase III Cardio- Initiate or progress swimming or water walking if wounds are fully healed (as per Phase vascular Exercise II) Progressive walking time and speed (as per Phase II) Begin elliptical trainer for 10-15 minutes at low resistance (for example, level 1-2 on an elliptical with 10 levels). Progress time and resistance as able.
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PHASE III. Progression of Strengthening (begin after meeting Phase II criteria, approximately 4-6 weeks following surgery). (continued).
Category
Information Light jogging can be initiated at 6-8 weeks; initially began on level surface while avoiding hills and speed work. For runners, consider 5 minute interval training involving walking (for example 1-2 minutes of jogging followed by 3-4 minutes of walking). Progressive jog interval times, incline, and speed as appropriate for return to sport/work goals. For those returning to multi-planar sport, consider progression outlined in Appendix 1 (see original Schubert article) (*Initial running in case report utilized unloading treadmill. See Figure A2.)
Progression Crite- Subject may progress to Phase IV if they have met the above stated goals. ria to Phase IV
Figure A1. Plyometrics
Figure A2. Unloading Treadmill
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PHASE IV. Impact/Sport Training (begin after meeting Phase III criteria, approximately 8 weeks following surgery).
Category
Information
Phase IV Appointments
Rehabilitation appointments are 1 time every week
Phase IV Rehabilitation Goals
Administer FAAM (ADL and sport subscales) prior to discontinuation of therapy. 9 point (or greater) improvement on FAAM (sport subscale portion) Proper dynamic neuromuscular control and alignment with eccentric and concentric multi-plane activities (including impact) for return to work/sports, without pain, instability or swelling Within 90% of pain free strength (compared to uninvolved side) on leg press (heel raise/PF)
Phase IV Precautions
Avoid pain with any exertional activity Avoid post-activity swelling (as per phase I-III)
Phase IV Therapeutic Exercise
Biomechanical assessment of specific sport activity with video analysis as needed (running, biking, etc) Instruct in proper return to activity progression (incremental running, biking, etc) (* Table A5 introduces rucking progression for case report subject) Progressive strengthening exercises using higher stability, and neuromuscular control with increased loads and speeds and combined movement patterns; begin with low velocity, single plane activities and progressing to higher velocity, multi-plane activities. Begin with forward and backward, progress to side-to-side, diagonals and transverse plane movements Integrate movements and positions into exercises that simulate functional activities. Sport and work-specific training beginning with low-intensity simulated movements.
Phase IV Cardio- Replicate sport or work specific energy demands vascular Exercise (*case report subject introduced to speed and agility required of his work duties. See Figure A3 & A4) Return To Sport/ Work Criteria
Patient may return to sport/work, including a graduated physical training regime if they have met the above stated goals and has had physician and rehabilitation specialist approval. Precautions to reduce the risk of re-injury when returning to sports or high-demand activities as appropriate.
*At this point the subject was instructed to begin progressive rucking initially starting with 60% of his preinjury level for weight, pace and distance. Subject maintained 2-3 day rest intervals between ruck marches. He was progressed 10% weekly for 4 weeks with the expectation he would independently complete his 100% training in the “area of operations” (AO). See Table A.1. He was also returned to all job-related training to include progressive shooting and movement (Close-Quarter-Battle - CQB) drills in full battle gear.
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Table A.1.
Week 1: Light ruck 7.2mi; 27lb; 13-14min-mi/Heavy ruck 3.0mi; 36lb;13-14min-mi Week 2: Light ruck 8.4mi; 32lb; 12-13min-mi/ Heavy ruck 3.5mi; 42lb;12-13min-mi Week 3: Light ruck 9.6mi; 36lb; 11-12min-mi/Heavy ruck 4.0mi; 48lb; 11-12min-mi Week 4: Light ruck 11.0mi;41lb; 10-12 min/Heavy ruck 4.5mi; 54lb; 10-12min-mi
Figure A3. Speed
Figure A4. Agility
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