Conservative treatment of anterior chronic exertional compartment syndrome in the military, with a mid-term follow-up

Key points

1. 0165% (49/75) returned to active duty without surgery after the conservative programme
2. 02At 2-year follow-up, 57% (24/42) remained on active duty without fasciotomy
3. 0328% (21/75) were referred for surgery after failing conservative treatment
4. 04Gait retraining of running and marching (in both shoes and boots) was the central component
5. 05Outcomes were similar whether patients had CECS alone or CECS combined with medial tibial stress syndrome

How it was conducted

Design

Historic cohort with telephone follow-up survey

Participants

75 surgically eligible military service members with pressure-positive anterior CECS (Group 1, n=37) or anterior CECS plus medial tibial stress syndrome (Group 2, n=38), seen 2015-2018

Setting

Department of Military Sports Medicine, Central Military Hospital, Utrecht, the Netherlands

Intervention

Comprehensive outpatient conservative programme averaging 144.9 days, including gait retraining (running and marching), stretching, strengthening, massage, dry needling, shockwave therapy (MTSS only), and a progressive running schedule

Primary outcome

Return to active military duty without surgical fasciotomy (initial and at follow-up)

Follow-up

Mid-term telephone survey at average 742 days (SD 267, range 381-1256) in 50 patients from 2015-2017

What they found

• 65% (49/75) achieved initial treatment success - return to active duty without surgery
• 28% (21/75) were referred for surgical fasciotomy
• 7% (5/75) left the armed forces voluntarily
• Average treatment duration was 144.9 (SD 59.6) days overall; 153.6 days for those who returned to base versus 125.6 days for those referred to surgery
• SANE score improved from 45.0 (SD 16.0) at intake to 74.2 (SD 21.2) at evaluation for all patients; 85.7 (SD 8.7) in those who returned to base versus 45.7 (SD 17.1) in those referred to surgery
• Follow-up survey response rate was 84% (42/50) at average 742 (SD 267) days
• 57% (24/42) were still active duty without fasciotomy at follow-up
• 43% (18/42) had returned to their original military specialty; 57% of those still serving were in a less physically demanding role
• 36% (15/42) had left the military by follow-up
• 48% (20/42) still reported symptoms at follow-up
• 12% (5/42) had received fasciotomy after the conservative programme
• Group 2 patients required 32 more treatment days on average (161.0 vs 128.4 days) but had similar outcomes to Group 1

Limitations

• Historic cohort design with no randomised control group, introducing potential observer bias
• Referral was not random - more complicated cases were sent to the inpatient Military Rehabilitation Center, which may have selected a less severe outpatient group
• Follow-up questionnaire was not a validated instrument
• Findings may not generalise beyond military populations or to other sports and recreational athletes

Why it matters

For patients

Military personnel with anterior CECS can try a structured conservative programme before committing to surgery, with a roughly two-thirds chance of returning to duty without an operation.

For clinicians

Initiating care with gait retraining-centred conservative treatment reduces fasciotomy rates significantly; surgery remains appropriate for the approximately one-third who do not respond.

For readers

This is the largest and longest case series on conservative CECS management to date, but the evidence level is low, and a randomised trial comparing conservative care with fasciotomy is still needed.