Running mechanics of females with bilateral compartment syndrome

Exertional Compartment Syndrome Strategies for Evaluation and Management

OBJECTIVE

The exertional compartment syndrome (ECS) is often a delayed diagnosis. Compartment pressure measurements (CPM) confirm the diagnosis. Herein we present our algorithm for the evaluation and management (E&M) of ECS. It avoids multiple CPM and shows the importance of the history and examination for E&M of the ECS.

DESIGN

A literature review showed that limb abnormalities are hardly ever mentioned. Subsequently we show how the history, examination (for recognizing abnormalities), and CPM integrate with our algorithm for E&M of the ECS.

SETTING

Our algorithm evolved for a 32-year interval and approximately 150 ECS evaluations.

PATIENTS

Our E&M method was used for the above complement of patients.

INTERVENTIONS

The symptomatic muscle compartment(s) and the severity of pain during the inciting activity are ascertained. The examination detects abnormalities and tautness of muscle compartments. This information integrated into our ECS algorithm establishes which compartments need CPM.

MAIN OUTCOME MEASURES

Pain severity is quantified on a 0- to 10-point scale. This information is integrated with history, examination findings, and CPMs to guide E&M for a range of ECS presentations.

RESULTS

Abnormalities detected on the examination often explain why ECS occurs. This information is valued by the patient, minimizes CPM, and offers sound advice for E&M.

CONCLUSIONS

Our article heightens awareness of the ECS diagnosis for all levels of care providers. It objectifies pain severity, shows the importance of the examination, and minimizes ECM in giving advice to the referral sources.

Lower Extremity Strength Relative to Body Mass in Pediatric Female Athletes: Implications for Anterior Cruciate Ligament Injury

This study compared lower extremity (LE) muscular strength by 3 groups of female athletes using chronological age and consideration of age of peak height velocity (PHV). Isometric quadriceps, hamstrings, and hip abductors strength were assessed from physically active, pediatric females. The body mass normalized isometric strength (N m/kg) was compared by the 3 age groups. There were 388 young female athletes (<10 years [14.2%], 11-14 years [48.7%], and 15-18 years [37.1%]). The body mass normalized LE strength was lower in 11-14 years compared with <10 years (quadriceps [P = .001], hamstrings [P = .001], and hip abductors [P = .037]) as well as in 15-18 years relative to <10 years in quadriceps (P = .001) and hamstrings (P = .001). The analysis results were consistent with both chronological age alone and incorporating effects of age of PHV. In short, body mass normalized LE strength (quadriceps, hamstrings, and hip abductors) of 11-14 years females was lower than <10 years females.

Running Biomechanics and Clinical Features Among Adolescent Athletes With Lower Leg Chronic Exertional Compartment Syndrome

OBJECTIVE

To compare clinical measures between patients with chronic exertional compartment syndrome (CECS) and healthy controls and evaluate running biomechanics, physical measurements, and exertional intracompartmental (ICP) changes in adolescent athletes with lower leg CECS.

DESIGN

Cross-sectional case-control study.

SETTING

Large tertiary care hospital and affiliated injury prevention center.

PARTICIPANTS

Forty-nine adolescents with CECS (39 F, 10 M; age: 16.9 ± 0.8 years; body mass index (BMI): 23.1 ± 2.9 kg/m 2 ; symptom duration: 8 ± 12 months) were compared with 49 healthy controls (39 F, 10 M; age: 6.9 ± 0.8 years; BMI: 20.4 ± 3.7 kg/m 2 ).

INTERVENTIONS

All participants underwent gait analyses on a force plate treadmill and clinical lower extremity strength and range of motion testing. Patients with chronic exertional compartment syndrome underwent Stryker monitor ICP testing.

MAIN OUTCOME MEASURES

Symptoms, menstrual history, and ICP pressures of the patients with CECS using descriptive statistics. Mann-Whitney U and χ 2 analyses were used to compare CECS with healthy patients for demographics, clinical measures, and gait biomechanics continuous and categorical outcomes, respectively. For patients with CECS, multiple linear regressions analyses were used to assess associations between gait biomechanics, lower extremity strength and range of motion, and with ICP measures.

RESULTS

The CECS group demonstrated higher mass-normalized peak ground reaction force measures (xBW) compared with controls (0.21 ± 0.05 xBW ( P < 0.001) and were more likely to have impact peak at initial contact ( P = 0.04). Menstrual dysfunction was independently associated with higher postexertion ICP (ß = 14.6; P = 0.02).

CONCLUSIONS

The CECS group demonstrated increased total force magnitude and vertical impact transient peaks. In women with CECS, menstrual dysfunction was independently associated with increased postexertion ICP. These biomechanical and physiological attributes may play a role in the development of CECS.

Sex and gender differences in lower limb chronic exertional compartment syndrome: a systematic review

OBJECTIVES

Chronic exertional compartment syndrome (CECS) is a cause of exertional leg pain and has been reported in varying frequencies in males and females. Currently, it is unclear whether there are significant sex and gender differences in lower-limb CECS. Delineating sex and gender differences is vital in determining the causes of CECS and best treatments. This systematic review aimed to determine the sex/gender distribution of CECS and to assess for sex and gender differences in CECS diagnosis and outcomes.

METHODS

PubMed (Medline), Cochrane Library, and EMBASE databases were searched for studies that were published from January 2000-March 2022 and reported lower-limb CECS data in males and/or females. Data on CECS diagnosis (intracompartmental pressures) and outcomes (e.g. post-surgical return-to-sport, need for re-operation) with sex/gender breakdowns were extracted. The sex/gender distribution of CECS and prevalence of CECS by sex/gender were calculated.

RESULTS

Forty-one studies were included in the systematic review; there were 27 retrospective reviews, 8 prospective studies, and 6 retrospective studies with prospective follow-ups. Thirty studies involved surgical populations. Sex/gender distribution of CECS was calculated using data from 24 studies; 51% were female. Prevalence of CECS was available in five studies and ranged widely for males (54%-73%) and females (43%-65%). Intracompartmental pressure data varied by sex/gender. Male athletes were more likely than female athletes to return to sport following surgery for CECS, but variations in all other post-surgical outcomes were observed between sexes and genders in the general population.

CONCLUSION

Females represented 51% of the patients who were diagnosed with CECS among studies. Most CECS diagnosis and outcomes data varied by sex/gender, except for post-surgical outcomes data in athletes, which demonstrated that males had higher rates of return to sport than females. Future studies are needed to examine factors contributing to sex and gender differences in CECS diagnosis and outcomes.

Wrist Guards/Supports in Gymnastics: Are They Helping or Hurting You?

BACKGROUND

The prevalence of wrist pain among gymnasts ranges from 46% to 79%. To alleviate wrist pain, gymnasts wear wrist guards/supports (WG/S).

PURPOSE

To investigate the effect of WG/S on the wrist joint through joint moment, angles, total joint range of motion (ROM) arc, and ground-reaction force (GRF).

STUDY DESIGN

Controlled laboratory study.

METHODS

A cross-sectional study design was used to investigate 23 female gymnasts (mean ± SD: age, 12.3 ± 1.5 years; height, 143.4 ± 7.6 cm; mass, 37.7 ± 6.6 kg; body mass index, 18.6 ± 2.9) who performed back handsprings (analyzed by first half [phase 1] and second half [phase 2]) with the following 3 conditions: no WG/S, Skids/Ultimate Wrist Supports (S/UWS), and Tiger Paws (TP). Wrist joint moments, angles, total ROM arc, and GRF were examined by the 3 conditions using analysis of variance with Bonferroni correction and effect size (Cohen d).

RESULTS

For mean wrist flexion moment, both S/UWS and TP showed significantly higher values than the no-WG/S condition in landing phase 1 (S/UWS: P = .001, d = 1.30; TP: P = .019, d = 0.87). In angle comparisons in landing phase 1, no WG/S showed greater mean wrist extension angles compared with S/UWS (P = .046; d = 0.80), but no significant differences with TP (P = .096; d = 0.65). Also, in landing phase 1, total ROM arc of the right wrist was greater in the no-WG/S condition compared with S/UWS (P = .018; d = 0.88), but there were no differences with TP (P = .400; d = 0.52).

CONCLUSION

These data show an increased wrist flexion moment using S/UWS and TP compared with the no-WG/S condition in landing phase 1 of back handsprings. Also, increased wrist extension angles and total arc ROM of the right wrist were found in the no-WG/S condition compared with S/UWS, but not with TP in landing phase 1. S/UWS may be helpful to reduce wrist joint angles, specifically wrist extension in landing phase 1, but both S/UWS and TP caused higher wrist flexion joint moment in landing phase 1. There were no differences found in GFG among the three variables.

CLINICAL RELEVANCE

In the first half of the back handspring, wrist guards can limit wrist extension joint angles and total arc ROM; however, an increased wrist flexion moment was found when wrist guards were worn, which may potentially lead to an increased risk of injury. Injury history, especially overuse signs/symptoms, and previous surgery on the wrist joint need to be well considered before the application or use of wrist guards. Also, the amount of time/exposure wearing wrist guards should be carefully controlled in young female gymnasts.

Reliability of 2D video analysis assessing running kinematic variables in patients with exercise-related leg pain in a primary care practice

BACKGROUND

Suboptimal lower limb and trunk positionings is known to influence exercise-related leg pain (ERLP). It is unknown whether simple 2D video analysis is useful for recording and interpreting running variables in a primary care practice.

RESEARCH QUESTION

Is 2D video analysis a reliable instrument to assess running variables in patients with ERLP in a primary care practice?

METHODS

Participants undergoing an evaluation for ERLP in two primary care practices were studied. In this reliability study, analysis of running variables was performed by 4 blinded raters on one-stride videos captured with non-high speed cameras (30 fps). Intraclass correlation coefficients (two-way random; ICC 2,1) were calculated to determine the inter-rater reliability. The intra-rater reliability was presented by ICC type two-way mixed (3,1). Footstrike pattern was analyzed by calculating the Fleiss' kappa for inter-rater agreement and Cohen's kappa for intra-rater agreement. Sample size calculation indicated that 16 participants would be required for answering the research question.

RESULTS

Data of all 16 participants (9 males, age 31 ± 10 yr) were of sufficient quality for analysis. The 2D video analysis demonstrated excellent inter-rater reliability with an overall ICC value of 0.999 (95 % CI = 0.998-0.999). The ICC value of the eversion was 0.384 (95 % CI = 0.148-0.66) and after correction of the systematic error, 0.817 (95 % CI = 0.664-0.922). The agreement on footstrike was substantial with a Fleiss kappa of 0.737. The overall intra-rater reliability was excellent with an ICC value of 0.997 (95 % CI = 0.996-0.997). The intra-rater agreement of the footstrike was excellent with a Cohen's kappa of 0.868.

SIGNIFICANCE

2D video analysis provides a highly reliable, relative inexpensive, feasible and suitable measuring instrument for determining running variables in patients ERLP in a primary care setting. This simple technique may identify possible running variables associated with different types of ERLP and may serve as an instrument for tailor-made gait retraining programs.

Sport specialization of female figure skaters: cumulative effects on low back injuries

Objective: 1) to determine the proportion of sport specialization among female figure skaters, 2) to compare proportion of low back injuries between specialized female figure skaters and non-specialized female figure skaters, and 3) to identify an independent risk factor(s) for low back injuries in female figure skaters.Methods: A cross-sectional questionnaire study was used. Young female figure skaters were asked questions related to sport specialization and any history of low back injuries. The primary outcome variables were status of sport specialization, weekly training hours, and low back injury. Descriptive statistics, t-test, chi-square analyses, and binary logistic regressions were used.Results: Responses from 132 female figure skaters (mean age: 16.3 ± 2.7 years, age range: 8-22 years) were analyzed. Sixty-two percent (82/132) of figure skaters were specialized. Specialized female figure skaters spent more time in training (11.3 ± 6.5 hours/week) than non-specialized skaters (7.6 ± 4.9 hours/week, p = 0.001). No statistical differences were found in proportion of low back injury history between specialized (25.6%) and non-specialized female figure skaters (24.0%, p = 0.836). Chronological age was also identified as an independent risk factor for low back injuries in female figure skaters (aOR: 1.24, 95%CI: 1.00, 1.54, p = 0.048).Conclusions: The majority of female figure skaters in this cohort were specialized. An association between chronological age and low back injuries, found in the current study, may be a result of cumulative effects of participating in figure skating over time.

Demographic Characteristics Among Patients With Chronic Exertional Compartment Syndrome of the Lower Leg

Clinical Scenario: Chronic exertional compartment syndrome (CECS) is a condition related with ischemia of the body's tissue due to increases in intracompartmental pressures, which involves, among other symptoms, pain with exertion. CECS is often overlooked or misdiagnosed due to an ambiguous presentation. Diagnostic accuracy of CECS and subsequent management can be improved when contributing factors are known. Research is lacking on the type of patient most likely to experience CECS, highlighting the need for identification of common demographic characteristics among affected individuals. Clinical Question: What are the common demographic characteristics among patients exhibiting CECS of the lower leg? Summary of Key Findings: Four studies were identified (1 prospective consecutive study, 2 retrospective reviews, and 1 retrospective cohort study) that examined common characteristics among patients with CECS. Conflicting evidence exists on whether CECS is more commonly seen in men or in women. CECS has often been reported in young, active individuals but may present in older populations as well. Soccer, field hockey, lacrosse, competitive running, and speed skating have been associated with an increased likelihood of CECS development. Clinical Bottom Line: Current evidence has identified commonalities in sex, age, and sport participation as characteristics often present among individuals experiencing lower leg CECS. Other factors, such as overuse, trauma, diabetes, and gait mechanics, have also been identified in association with CECS. Further data through future prospective studies will help confirm the type of patient mostly likely to experience CECS. Strength of Recommendation: Grade B evidence exists that certain sex, age, and sport participation demographic characteristics are common among patients with CECS of the lower leg.

Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners

BACKGROUND

Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running.

HYPOTHESIS

Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy.

RESULTS

A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively.

CONCLUSION

Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery.

CLINICAL RELEVANCE

Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Running Propensities of Athletes with Hamstring Injuries

The current study aims to compare the mechanical propensities between healthy runners and runners with hamstring injuries. Retrospective case-control video analysis was used. A total of 35 (12 male and 23 female) videos of runners with hamstring injuries were compared with videos of sex-, age-, mass-, and height-matched healthy control runners. The main outcome variables were trunk posture angles, overstride angles, and foot strike patterns. An independent t-test and chi-squared tests were employed to analyze the main outcome variables between the runners with hamstring injuries and the healthy control runners. The statistical significance of less than 0.05 (p < 0.05) was used. The runners with hamstring injuries had a 1.6° less forward-trunk posture angles compared with the healthy control runners (p = 0.043). Also, the runners with hamstring injuries demonstrated a 4.9° greater overstride angles compared with the healthy control runners (p = 0.001). Finally, the runners with hamstring injuries had a tendency of rearfoot strike, while the healthy control runners showed a forefoot strike pattern (p = 0.004). In conclusion, the runners with hamstring injuries demonstrated different running mechanical propensities compared with the healthy runners.