Cambridge Sports Union has completed its on-line survey examining the prevalence of chronic exertional compartment syndrome (CECS) within the competitive nordic ski community in North America.
The purpose of the survey was to gauge the extent of CECS among cross-country skiers, and to collect data that contributes to understanding the etiology of CECS.
Fifty coaches responded to the survey, representing roughly 1,500 athletes. The teams represented include youth and regional clubs, the U.S. and Canadian national teams, and college and high school level teams. The geographic distribution of the respondents was New England (35 percent), New York (five percent), West (23 percent), Midwest (23 percent), Alaska (five percent) and Canada (10 percent).
56 percent of the coaches reported skiers with CECS, diagnosed by performing compartment pressure testing. There were a total of 39 cases of CECS reported. No coach had more than three cases of CECS on their team that required medical intervention.
90 percent of the teams had only one case of CECS. Of the 39 reported cases of CECS, 80 percent had surgery to correct it, and more than 90 percent had full recovery post-surgery. There were 3 cases that required a second surgery.
The percentage of woman and men diagnosed with CECS was 57 percent and 43 percent, respectively. The age distribution for women diagnosed with CECS was 14 to 30, with the average age being 19. The age distribution for men diagnosed with CECS was 16 to 30, with the average age being 19.
62 percent of those with CECS had pain in the front of the leg, 24 percent had pain in the side , and 14 percent had pain in the back. The teams that trained over 500 hours a year had a statistically significant (p value 0.06) higher prevalence of CECS than the teams that trained less than 500 hours a year. Those teams with a higher average vertical gain achieved during skate roller-ski workouts had a statistically significant (p value 0.04) increase in CECS. (The survey did not look at vertical gain during classic roller skiing.)
Few athletes were reported who were using the food supplement creatine. There was no correlation between CECS and the use of creatine in this study. The study size did not allow us to find statistical relevance in correlating CECS with geography, stretching, off-snow training or body type.
In summary, there appears to be a high prevalence of CECS in male and female competitive cross-country skiers, particularly among the teams that train at high hours with increased vertical gain during skate roller skiing. We hope that this small study encourages others to work toward understanding the etiology, prevention and treatment of CECS. We are encouraged by the many graduate students and researchers who contacted us and are initiating projects in this direction.
Peter Hoenig, MD David Brams, MD James Stock, PhD Cambridge Sports Union. Address questions to: P.Hoenig, 1073 Concord Road, Sudbury, MA 01776. phoenig@massmed.org.
7 comments
E
November 24, 2010 at 11:37 am
Curious about the training >500 hrs correlation with the vertical gain factor. I can imagine it could be the same skiers in both groups. If that were the case, how do you decide which component, or if both, or some unknown, are to blame for prevalence of CECS?
Would be interested to look at the survey- is it available somewhere?
Couple of points…
“there seems to be a high prevalence of CECS…” -Really? how do we know this? It seems like the survey return rate could easily be skewed in favor of coaches with experience with CECS athletes. How did you control for this? How random is your sample?
“The teams that trained over 500 hours a year had a statistically significant (p value 0.06) higher prevalence…” -Since when does 0.06 equal statistical significance?
Glad people are studying this and I hope we can find a solution to compartment syndrome affecting these young athletes.
T.Eastman
November 24, 2010 at 11:54 am
From my experience, skating seems to be involved in muscle and tendon issues in the lower leg. The “locking” of the range of motion and the concurrent contraction of both the shin and calf muscles could be part of the problem. Combine this skate related stress and hill bounding for classic training, and a recipe for lower leg issues seems likely for part of the population.
I am currently recovering from more achilles/bone spur surgery.
D. Diehl
November 24, 2010 at 2:18 pm
I contributed to the CECS survey. Beginning in 1987 I had a terrible case of CECS. Skiers were still using low top boots for skating. I had no clue what I had or what was causing it. I did learn I could classic ski without extreme pain,but skating was a different story. It got to the point where I would fall down in races and had no control over my lower legs. Pressing on the gas and brake pedals in a car was difficult. Slowly I started hearing through the grapevine skiers having the sheath cut in their lower legs to relieve the pressure. However I couldn’t go this route because I didn’t have insurance or savings to have the operation. I dealt with the symptoms for many years learning to ice the area which helped. When Salomon came out with the Energizer Cuff around 1995 it was like magic. It helped me learn to relax my lower legs. If you don’t know the cuff helps return the ski to a parrallel position and stabilize the tip. The icing on the cake was the introduction of the Pilot binding which inhanced the stabilization of the ski tip. Since the late 90’s I’ve had no symptoms of CECS. In hindsight I feeel it was learning to skate with low top boots which brought about my CECS. The constant lifting of the tip of the ski when aggressively climbing aggravated the Anterior Compartments in my legs. Interestingly I used a Alpina free floating cuff skate boot the last few seasons with no symptoms of CECS. I can only speculate I learned to skate with less tension in my lower legs and perhaps my lower legs had an opportunity to adapt while healing. Hope this helps anyone dealing with this painful injury.
sluggingsammy
November 24, 2010 at 3:09 pm
Thanks, D. Diehl.
Speaking strictly from my experience, I think CECS is correlated mostly to using a skate technique that includes tensing the legs while gliding. It would be interesting if the study captured the affected skiers’ technique approach.
D. Diehl
November 24, 2010 at 4:28 pm
Sluggingsammy. That is interesting because my CECS would be the worst during races on the Porter Mountain Trails at Mt. Van Hoevenberg in Lake Placid. If you haven’t skied there it probably has more vertical gain than any other 50km marathon course in the world. I’m sure T. Eastman would support this.
mygatt
November 25, 2010 at 3:52 pm
I have a hunch that there may be a component of core/hip strength and stability. Skating – and classic for that matter – are so much about balancing on one leg at a time, and if your abs/back/hips (big strong muscles) aren’t doing the job of keeping your weight above your ski, then that work goes to the smaller muscles in your lower legs.
Again, this is just a hunch, based on observations in one skier only. This person had compartment syndrome on one side, who could balance on the good foot for minutes, but was very unstable when trying to balance, single-legged, on the affected side. The skier’s upper leg strength, particularly abductor/adductor/vastus medialis was much weaker on the affected side than the good side.
Curious to hear what anyone thinks about my hypothesis.
D. Diehl
November 27, 2010 at 7:43 am
Interesting hypothesis. Again I could race classic with no problems at all and the next day do a skate race and would have to pull out. If you look at Kris Freeman’s history with CECS you see a skier with bomber core strength. Moreover two seasons ago he continued the WC classic events but stayed away from the freestyle events the remainder of the season when CECS reappeared. For me it was the continual stabilization of the ski tip. Lifting it up or ankling up the ski tip as I described on steep aggressive terrain. It’s not neccessary to ski this way, it’s just the way I learned on my own. However I’m just one skier expressing his history with CECS. I’m sure Chandra Crawford and Freeman’s experience with CECS have different reasons.