Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Dr. Dave Roscoe

I am a Sport and Exercise Medicine (SEM) and Rehabilitation Medicine trainee currently posted at the Defence Medical Rehabilitation Centre (DMRC), Headley Court. I am also a qualified GP and have recently had the privilege of completing a PhD in SEM under the supervision of the University of Surrey (UoS) Department of Biomedical Engineering. I focused on the diagnosis and management of Exercise Induced Leg Pain (EILP) and Chronic Exertional Compartment Syndrome (CECS).

Before transferring to the Army in 2014, I spent most of my career as a Royal Navy Commando Medical Officer working alongside the Royal Marines (RM). EILP, in all of its guises: shin pain, anterior knee pain, stress fractures, CECS and to a lesser extent Popliteal Artery Entrapment, is a well-documented problem blighting careers in military populations. As part of the medical team at the Commando Training Centre, home of the longest and most arduous initial infantry-training programme in the world, we saw a high volume of these overuse lower limb injuries on a daily basis. Consequently, this is a topic I have been interested in for many years. I wanted to improve the overall clinical service that can be offered to athletes and servicemen with EILP by trying to clarify the nature of the underlying pathology in CECS and identify the risk factors that might predispose to the condition. I wanted to investigate the effectiveness of the different treatment modalities and try to define, once and for all, the criteria by which a diagnosis of CECS should be made.

I first had to identify the most suitable host institution for this type of project so prior to commencing my PhD in 2012, I scoped several universities to establish which could provide the most relevant expertise and supervision. I decided on the UoS as it offered the perfect mix of research experience (UoS has one of the longest established biomechanics laboratories in the country), relevant ongoing research and quality of facilities with access to excellent academic supervision. I then had to successfully navigate the Defence Deanery Higher Degree Board, Ministry of Defence Ethics Committee and the UoS Higher Degree Panel. This required presenting a detailed background and rationale including assessments of potential clinical and financial benefits of both the work and myself. The whole application process took a year to complete after which I spent 3 years working in the gait laboratory at DMRC. I worked with a great team whilst learning a range of techniques including dynamic invasive intramuscular compartment pressure (IMCP) measurement, gait analysis with 3-dimensional kinematics, plantar pressure measurement and EMG as well as study design and statistical analysis. No mean feat for a mere GP!

All of these experiences informed my thesis, the abstract of which is below:

The Diagnosis and Management of Chronic Exertional Compartment Syndrome in the UK Military Population.

Background

CECS presents as EILP in the lower limb is presumed to be a result of elevated IMCP although this has never been proven. Doubt exists regarding the validity of the diagnostic criteria for CECS, the role of IMCP and the outcomes from surgical management[1]. An alternative biomechanical condition, Anterior Biomechanical Overload Syndrome (ABOS)[2], was proposed to account for the symptoms of CECS and a programme of gait re-education (GRE) was introduced although no primary research has been carried out to investigate the predisposing biomechanical and anthropometric factors for CECS or ABOS.

Methods

Case-control studies investigated the anthropometric, biomechanical and IMCP differences between CECS cases and asymptomatic controls. A post-surgical study evaluated the role of IMCP and a longitudinal study investigated the effectiveness of GRE and the nature of resultant biomechanical changes.

Results

Cases were significantly shorter than controls with specific biomechanical changes not akin to ABOS[3]. IMCP levels were significantly higher in cases than controls allowing for the extraction of diagnostic criteria for CECS[4]. Surgical responders had similar IMCP to controls but significantly lower than non-responders³. The biomechanical components of ABOS were not replicated. GRE made changes to gait but these did not correspond to those identified in the CECS case-control study³.

Conclusions

The intrinsic role of IMCP in CECS has been confirmed allowing for improved diagnostic criteria¹. Use of these criteria should allow for improved patient selection for surgery and improved outcomes. Novel insights to the biomechanical and anthropometric differences are provided allowing for the proposal of a new pathophysiological model whereby extrinsic training conditions impact upon intrinsic risk factors leading to CECS. These studies do not support the existence of ABOS or the use of GRE in the management of CECS.

Having completed my thesis, I have had time to reflect. From the outset of the application process to getting completed works published⁴, a PhD is an endurance challenge like no other. At times, it can seem like a near impossible and ill-defined mountain to climb; along the way there are setbacks, false-summits and hidden crevasses to traverse. You must tread carefully and determinedly, breaking it down into smaller, more manageable questions but never lose sight of the overall goal. A PhD teaches skills in every professional domain not just the specific area of interest. Learning how to formulate and investigate research questions and critically interrogate evidence and data is as challenging as it is rewarding.

I have been very fortunate to lead research projects that have provided significantly improved and more accurate diagnostic criteria for CECS as well as delineating many previously unknown risk factors for the condition. We have analysed the different treatment options using the same criteria for success and used this to inform the commissioning of services. Our results have allowed us to be more certain in our selection of patients for intervention and to better identify those treatment modalities that offer a good chance of success. However, only time will show if this translates into a meaningful change in wider practices and clinical effect. Overall, I would recommend getting involved in research to all in SEM as I think there are a host of clinical domains that could benefit from well structured research and the casting of light into the dark places in order to further improve and standardise care for our athletes and populations.

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David Roscoe is a Sport and Exercise Medicine (SEM) and Rehabilitation Medicine trainee currently posted at the Defence Medical Rehabilitation Centre (DMRC), Headley Court, Surrey.

Farrah Jawad is a Sport and Exercise Medicine registrar and co-ordinates the BJSM Trainee Perspective blog.

References

[1] Aweid et al., “Systematic Review and Recommendations for Intracompartmental Pressure Monitoring in Diagnosing Chronic Exertional Compartment Syndrome of the Leg.,” Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine 22, no. 4 (July 2012): 356–70, doi:10.1097/JSM.0b013e3182580e1d.

[2] Andrew Franklyn-Miller et al., “Biomechanical Overload Syndrome: Defining a New Diagnosis,” British Journal of Sports Medicine 0, no. 2012 (September 14, 2012): 201209124, doi:10.1136/bjsports-2012-091241.

[3] Papers in submission.

[4] David Roscoe, Andrew J Roberts, and David Hulse, “Intramuscular Compartment Pressure Measurement in Chronic Exertional Compartment Syndrome: New and Improved Diagnostic Criteria.,” The American Journal of Sports Medicine 43, no. 2 (November 18, 2014): 392–98, doi:10.1177/0363546514555970. http://ajs.sagepub.com/content/early/2014/11/17/0363546514555970.abstract