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cause-article

Stress fracture

SportNetDoc

Risk factors for stress fractures.

Bennell K, Matheson G, Meeuwisse W, Brukner P. Sports Med 1999 Aug;28(2):91-122.

Preventing stress fractures requires knowledge of the risk factors that predispose to this injury. The aetiology of stress fractures is multifactorial, but methodological limitations and expediency often lead to research study designs that evaluate individual risk factors. Intrinsic risk factors include mechanical factors such as bone density, skeletal alignment and body size and composition, physiological factors such as bone turnover rate, flexibility, and muscular strength and endurance, as well as hormonal and nutritional factors. Extrinsic risk factors include mechanical factors such as surface, footwear and external loading as well as physical training parameters. Psychological traits may also play a role in increasing stress fracture risk. Equally important to these types of analyses of individual risk factors is the integration of information to produce a composite picture of risk. The purpose of this paper is to critically appraise the existing literature by evaluating study design and quality, in order to provide a current synopsis of the known scientific information related to stress fracture risk factors. The literature is not fully complete with well conducted studies on this topic, but a great deal of information has accumulated over the past 20 years. Although stress fractures result from repeated loading, the exact contribution of training factors (volume, intensity, surface) has not been clearly established. From what we do know, menstrual disturbances, caloric restriction, lower bone density, muscle weakness and leg length differences are risk factors for stress fracture. Other time-honoured risk factors such as lower extremity alignment have not been shown to be causative even though anecdotal evidence indicates they are likely to play an important role in stress fracture pathogenesis.

treatment-article3

Acute compartment syndrome

SportNetDoc

Acute compartment syndrome.

Engelund D, Kjersgaard AG. Ugeskr Laeger 1991 Apr 15;153(16):1110-3.

The object of this article is to review the current knowledge about the acute compartment syndrome. The syndrome is caused by increased pressure in a muscle compartment and may result from several different conditions: fractures, contusions, haemorrhage, poisoning etc. The pathological physiology is complicated but the main theory is that progressive venous hypertension is involved and that this causes cessation of the microcirculation of the muscle concerned. The clinical diagnosis is described and pressure recording apparatus is reviewed. Treatment of the acute compartment syndrome consists of fasciotomy. Common sites are indicated and operative techniques suggested. Fasciotomy should be performed with compartmental pressures of about 30 mmHg. The untreated compartment syndrome will result in muscular fibrosis and nerve injury and will thus cause incapacitating conditions which may be avoided entirely if fasciotomy is performed in time.

treatment-article2

Acute compartment syndrome

SportNetDoc

Acute compartment syndrome due to closed muscle rupture.

Gwynne Jones DP, Theis JC. Aust N Z J Surg 1997 Apr;67(4):227-8.

Acute compartment syndrome has multiple causes: fractures, crush injury, vascular trauma and burns. Exertional compartment syndrome may be acute (progressive) or chronic (usually reversible). The acute form usually occurs after intensive exercise. Closed muscle rupture is an uncommon cause with few reports. We report two cases, in the peroneal compartment of the leg and the flexor compartment of the forearm, to show that a high index of suspicion, allowing prompt diagnosis and fasciotomy, will enable a full recovery without complications.

treatment-article1

Acute compartment syndrome

SportNetDoc

Acute exertional compartment syndrome of the medial foot.

Blacklidge DK, Kurek JB, Soto AD, Kissel CG. J Foot Ankle Surg 1996 Jan-Feb;35(1):19-22.

A review of compartment syndrome, both acute and chronic, is presented. The pathophysiology, anatomy, diagnosis, and treatment are presented in relation to a unique case report. The case is one of acute exertional compartment syndrome of the medial foot treated by fasciotomy. This condition is uncommon in both its nature and location.

KONDITION

step4

Chronic compartment syndrome

[Back]

Training ladder for:
CHRONIC COMPARTMENT SYNDROME IN THE LOWER LEG
(KRONISK KOMPARTMENSYNDROM)

STEP 4
Increases in training intensity (Step I – Step II – Step III – Step IV) must occur very slowly, to ensure that the muscle membranes have the opportunity to give way or yield.
KONDITION
Unlimited: Cycling. Swimming. Running with increasing speed and distance.

UDSPÆNDING
(15 min)

Stand with the injured leg stretched backwards with the toes facing front. Slowly bend the knee so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand with the injured leg outstretched with the ankle joint bent up against the wall. Press your abdomen against the wall so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support on the wall with the hand on the same side. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the big toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn slightly outwards so that increased stretching is experienced on the inside of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support from the wall with the opposite hand. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the little toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn over the good leg so that increased stretching is experienced on the outer side of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

KOORDINATION
(5 min)

Stand on the leg to be trained. Take-off and land on the same leg.

Seesaw. Balance on two legs, possibly using a hand as support against the wall, balancing subsequently on one leg without support. Look straight ahead and keep knees bent.

STYRKE
(40 min)

Sit on the floor. Tip the foot up and down with elastic under the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot up and down with elastic on top of the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot from side to side with elastic on the outer side of the foot, without moving the knee.

Sit on the floor. Tip the foot from side to side with elastic on the inner side of the foot, without moving the knee.

Stand on a soft surface. Rise slowly up on tiptoe and go down again.

Go up and down from the stool. Go up with alternating right and left legs.

Stand on the healthy leg with elastic fixed around the hip. The elastic should be fixed to the wall or a wall bar. Take-off on the healthy leg and land on the leg to be trained and keep your balance. Remember that the elastic should be positioned so that it gives resistance at the moment of take-off. Change legs.

Stand with both legs on the stool with elastic around the hip. Take-off and land with feet together.

Stand with feet together. Using the ankle joint to take off, hop approx. 5 cm and land on both feet. The exercise should be done on one leg when you are able to do it without discomfort using both legs.

Stretching is carried out in the following way: stretch the muscle group for 3-5 seconds. Relax for 3-5 seconds. The muscle group should subsequently be stretched for 20 seconds. The muscle is allowed to be tender, but must not hurt. Relax for 20 seconds, after which the procedure can be repeated. The time consumed for stretching, coordination and strength training can be altered depending on the training opportunities available and individual requirements.

KONDITION

step3

Chronic compartment syndrome

[Back]

Training ladder for:
CHRONIC COMPARTMENT SYNDROME IN THE LOWER LEG
(KRONISK KOMPARTMENSYNDROM)

STEP 3
Increases in training intensity (Step I – Step II – Step III – Step IV) must occur very slowly, to ensure that the muscle membranes have the opportunity to give way or yield.
KONDITION
Unlimited: Cycling. Swimming. Running with increasing distance.

UDSPÆNDING
(15 min)

Stand with the injured leg stretched backwards with the toes facing front. Slowly bend the knee so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand with the injured leg outstretched with the ankle joint bent up against the wall. Press your abdomen against the wall so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support on the wall with the hand on the same side. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the big toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn slightly outwards so that increased stretching is experienced on the inside of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support from the wall with the opposite hand. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the little toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn over the good leg so that increased stretching is experienced on the outer side of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

KOORDINATION
(5 min)

Seesaw. Balance on two legs, possibly using a hand as support against the wall, balancing subsequently on one leg without support. Look straight ahead and keep knees bent.

STYRKE
(40 min)

Sit on the floor. Tip the foot up and down with elastic under the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot up and down with elastic on top of the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot from side to side with elastic on the outer side of the foot, without moving the knee.

Sit on the floor. Tip the foot from side to side with elastic on the inner side of the foot, without moving the knee.

Stand on a soft surface. Rise slowly up on tiptoe and go down again.

Go up and down from the stool. Go up with alternating right and left legs.

Stand on the healthy leg with elastic fixed around the hip. The elastic should be fixed to the wall or a wall bar. Take-off on the healthy leg and land on the leg to be trained and keep your balance. Remember that the elastic should be positioned so that it gives resistance at the moment of take-off. Change legs.

Stand with both legs on the stool with elastic around the hip. Take-off and land with feet together.

Stretching is carried out in the following way: stretch the muscle group for 3-5 seconds. Relax for 3-5 seconds. The muscle group should subsequently be stretched for 20 seconds. The muscle is allowed to be tender, but must not hurt. Relax for 20 seconds, after which the procedure can be repeated. The time consumed for stretching, coordination and strength training can be altered depending on the training opportunities available and individual requirements.

KONDITION

step2

Chronic compartment syndrome

[Back]

Training ladder for:
CHRONIC COMPARTMENT SYNDROME IN THE LOWER LEG
(KRONISK KOMPARTMENSYNDROM)

STEP 2
Increases in training intensity (Step I – Step II – Step III – Step IV) must occur very slowly, to ensure that the muscle membranes have the opportunity to give way or yield.
KONDITION
Unlimited: Cycling. Swimming. Light jogging.

UDSPÆNDING
(15 min)

Stand with the injured leg stretched backwards with the toes facing front. Slowly bend the knee so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand with the injured leg outstretched with the ankle joint bent up against the wall. Press your abdomen against the wall so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support on the wall with the hand on the same side. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the big toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn slightly outwards so that increased stretching is experienced on the inside of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support from the wall with the opposite hand. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the little toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn over the good leg so that increased stretching is experienced on the outer side of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

KOORDINATION
(5 min)

Seesaw. Balance on two legs, possibly using a hand as support against the wall, balancing subsequently on one leg without support. Look straight ahead and keep knees bent.

STYRKE
(40 min)

Sit on the floor. Tip the foot up and down with elastic under the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot up and down with elastic on top of the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot from side to side with elastic on the outer side of the foot, without moving the knee.

Sit on the floor. Tip the foot from side to side with elastic on the inner side of the foot, without moving the knee.

Stand behind a chair. Rise slowly up on tiptoe and go down again.

Stretching is carried out in the following way: stretch the muscle group for 3-5 seconds. Relax for 3-5 seconds. The muscle group should subsequently be stretched for 20 seconds. The muscle is allowed to be tender, but must not hurt. Relax for 20 seconds, after which the procedure can be repeated. The time consumed for stretching, coordination and strength training can be altered depending on the training opportunities available and individual requirements.

KONDITION

step1

Chronic compartment syndrome

[Back]

Training ladder for:
CHRONIC COMPARTMENT SYNDROME IN THE LOWER LEG
(KRONISK KOMPARTMENSYNDROM)

STEP 1
Increases in training intensity (Step I – Step II – Step III – Step IV) must occur very slowly, to ensure that the muscle membranes have the opportunity to give way or yield.

The indications of time after stretching, coordination training and strength training show the division of time for the respective type of training when training for a period of one hour. The time indications are therefore not a definition of the daily training needs, as the daily training is determined on an individual basis.
KONDITION
Unlimited: Cycling. Swimming. Running in deep water.

UDSPÆNDING
(15 min)

Stand with the injured leg stretched backwards with the toes facing front. Slowly bend the knee so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand with the injured leg outstretched with the ankle joint bent up against the wall. Press your abdomen against the wall so that the calf muscles become increasingly stretched. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support on the wall with the hand on the same side. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the big toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn slightly outwards so that increased stretching is experienced on the inside of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

Stand on the good leg while gaining support from the wall with the opposite hand. Bend the knee of the injured leg and draw the heel towards the buttocks. Take hold of the little toe side of the foot and draw slowly upwards so that the ankle joint is stretched to the maximum and drawn over the good leg so that increased stretching is experienced on the outer side of the shin bone. Hold the position for 20 seconds and relax for 20 seconds before repeating.

KOORDINATION
(5 min)

Seesaw. Balance on two legs, possibly using a hand as support against the wall, balancing subsequently on one leg without support. Look straight ahead and keep knees bent.

STYRKE
(45 min)

Sit on the floor. Tip the foot up and down with elastic under the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot up and down with elastic on top of the forefoot so that the elastic becomes taut.

Sit on the floor. Tip the foot from side to side with elastic on the outer side of the foot, without moving the knee.

Sit on the floor. Tip the foot from side to side with elastic on the inner side of the foot, without moving the knee.

Lay on the floor with a cushion under the calf. Tip the foot up and down without putting any resistance on the foot.

Lay on your back with your foot above heart-height. Tip the foot up and down and from side to side.

Sit on a chair. Keep the heel firmly on the ground and tip the toes up.

Stretching is carried out in the following way: stretch the muscle group for 3-5 seconds. Relax for 3-5 seconds. The muscle group should subsequently be stretched for 20 seconds. The muscle is allowed to be tender, but must not hurt. Relax for 20 seconds, after which the procedure can be repeated. The time consumed for stretching, coordination and strength training can be altered depending on the training opportunities available and individual requirements.

treatment-article2

Chronic compartment syndrome

SportNetDoc

Good results of fasciotomy in chronic compartment syndrome of the lower leg.

Verleisdonk EJ, van den Helder CJ, Hoogendoorn HA, van der Werken C. Ned Tijdschr Geneeskd 1996 Dec 14;140(50):2513-7.

OBJECTIVE.
To assess the results of fasciotomy in patients with a chronic compartmental syndrome.

DESIGN.
Retrospective study.

SETTING.
Department of Surgery, Central Military Hospital, Utrecht, the Netherlands.

METHOD.
Closed fasciotomy was performed in 81 patients (151 compartments) after standardized measurement of the pressure of the symptomatic compartment during exercise. The anterior compartment was affected 149 times and the lateral compartment twice. The pressure reading was repeated at least 3 months after the operation. All operated patients 6 months postoperatively were sent a written questionnaire inquiring about the results of the operation.

RESULTS.
Postoperative complications included a neurinoma (3 times) and a seroma (once). The mean postoperative intramuscular pressures were lower than the preoperative ones: the pressure at rest fell from 22.1 to 14.0 mm Hg (p < 0.05), the exercise pressure from 57.5 to 25.4 mm Hg (p < 0.01) and the relaxation pressure from 34.4 to 25.2 mm Hg (p < 0.05). Tn patients had an unchanged increased pressure after the operation, for which a second fasciotomy was performed 4 times. Attenuation of symptoms was reported by 59 patients (76%). Nine patients with poor results had already had a combination with some other hyperpressure injury before the operation.

CONCLUSION.
Closed fasciotomy in a demonstrated chronic compartmental syndrome in most cases gave good results, viz. attenuation of symptoms and a decrease of the intramuscular pressure, especially after exercise.

treatment-article1

Chronic compartment syndrome

SportNetDoc

Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg.

Howard JL, Mohtadi NG, Wiley JP. Clin J Sport Med 2000 Jul;10(3):176-84.

OBJECTIVE.
To evaluate outcomes in patients who had a fasciotomy performed on their leg(s) for chronic exertional compartment syndrome (CECS).

DESIGN.
A retrospective descriptive cohort study.

SETTING.
Tertiary care sport medicine referral practice.

PATIENTS.
A consecutive series of 62 patients surgically treated for CECS from January 1991 to December 1997.

MAIN OUTCOME MEASURES.
A questionnaire was designed and developed to assess pain (using a 100 mm visual analogue scale), level of improvement, level of maximum activity, satisfaction level, and the occurrence of reoperations.

RESULTS.
Fifty patients had anterior/lateral compartment involvement, 8 patients had deep posterior compartment involvement, and 4 patients had anterior/lateral/deep posterior compartment involvement. The demographics of the 39 respondents and 23 nonrespondents were similar. The mean percent pain relief of respondents was 68% (95% CI [confidence interval] = 54% to 82%). There was no relationship between percent pain relief and the documented immediate post exercise compartment pressures. A clinically significant improvement was reported by 26 of 32 (81%) anterior/lateral compartment patients and 3 of 6 (50%) patients with deep posterior compartment involvement. Patient level of activity after fasciotomy was classified as equal to or higher than before the operation with a lesser degree of pain by 28 of 36 (78%) patients, while 8 of 36 (22%) patients reported lower activity levels than before the operation. Of the patients reporting lower activity, seven were due to exercise related pain in the post operative leg(s) and one was due to lifestyle changes. Thirty of 38 patients (79%) were satisfied with the outcome of the operation. Four of 62 patients (6%) failed the initial surgical procedure and required revision surgery for exercise-induced pain. In addition, one of these individuals also had a sympathectomy and another had a neurolysis performed at the time of revision surgery. Three of the 62 (5%) patients had subsequent operations for exercise-induced pain on different compartments than the initial surgical procedure. One individual had an unsuccessful operative repair of a posttraumatic neuroma. Postoperative complications were reported by 5 of 39 (13%) patients in the additional comments section of the questionnaire.

CONCLUSIONS.
The majority of patients surgically treated for CECS experience a high level of pain relief and are satisfied with the results of their operation. The level of pain relief experienced by patients is not related to the magnitude of the immediate post exercise compartment pressures. Despite the possibility that some patients have less favorable outcomes, experience complications, or need subsequent operations, fasciotomy is recommended for patients with CECS as there is no other treatment for this condition.