Chronic exercise-related leg pain: diagnosis and treatment in the armed forces

Abstract

This thesis aimed to explore the utility of new and promising treatment forms for Exercise Related Leg Pain (ERLP) in the Royal Netherlands Armed Forces: Extracorporeal Shockwave Therapy (ESWT) for Medial Tibial Stress Syndrome (MTSS) and gait retraining for Chronic Exertional Compartment Syndrome (CECS). Eight studies were undertaken and the following lessons were learned: Chapter 2: The body of knowledge on ERLP in the military is growing and the number of publications is increasing. Despite these recent developments, the occupational problem of ERLP in the military is far from solved. These overuse injuries continue to have a high incidence, long recovery time and large impact on training. Chapter 3: In four years’ time, 573 Dutch service members were referred to the Central Military Hopsital (CMH) for evaluation of chronic ERLP and treatment suggestions. They underwent a new diagnostic protocol. Intracompartmental Pressure Measurement (ICPM), a standardized pain assessment tool (i.e., the Running Leg Pain Profile - RLPP) and a standardized running protocol were useful in subcategorizing patients with exertional leg pain. Subsets of patients may have high compartment pressures and low compartment pain scores, or vice versa. The clinical treatment ramifications of these categories is still evolving and further research into optimal treatment strategies for all subgroups of patients is warranted. Current advice to avoid or minimize ICPM due to needle pain concerns does not appear warranted. Chapter 4: Radial ESWT did not reduce the length of tenderness along the posterior medial tibial border during the weeks of application in patients with chronic MTSS. It is a painful treatment, but tolerable by self-application. The majority of patients did not experience post treatment pain. In this group of patients, 81% would recommend ESWT. More studies are necessary to establish if ESWT for MTSS is clinically effective. Chapter 5: In 19 patients diagnosed with CECS, a 6-week forefoot running intervention performed in both a center-based and home-based training setting led to decreased post running lower leg ICPM values, improved running performances, and self-assessed leg condition. The influence of training group, center-based or home-based, was not statistically significant. Overall, this finding is promising, taking into consideration the significantly reduced investments in time and resources needed for the home-based program. Chapter 6: Soldiers with exercise related leg pain, among them patients with chronic MTSS, responded well to a treatment program that included gait retraining. Ten months post gait retraining, repeated measures on a treadmill, still showed positive changes from intake. Chapter 7: Gait retraining in military boots achieved similar changes in stride length (reduction), cadence (increase), force and pressure in the heel (reduction) and in the fore foot (force reduction, pressure increase) compared to running shoes. However, in boots, mid foot maximal force and pressure increased. The same gait retraining cues can be used to optimize ground reaction forces in running shoes and in military boots. Chapter 8: Three commonly used gait retraining cues are: Cue 1. Change to a ball-of-foot strike; Cue 2. Increase cadence to 180 steps/minute; Cue 3. Stand up taller. When applied in isolation, all three cues achieved reduction of vertical ground reaction forces. The combination of the three cues achieved the largest reduction of vertical ground reaction forces. Chapter 9: A conservative treatment program for anterior CECS was able to return 65% of patients to active duty, without surgery. At two-year follow-up, the success rate decreased slightly, but remained positive at 57%. In this group, initiating a conservative treatment protocol with an emphasis on gait retraining can significantly reduce the need for surgical fasciotomy. For those who fail conservative treatment, surgical release may still be indicated.