Page 93 - Journal of Special Operations Medicine - Winter 2016

early phases of training. Reducing loads will decrease Table 1 Summary of Symptoms and Signs, Etiology, Risk
the amount of compression on the toes and reducing Factors, Treatment, and Prevention of Rucksack Palsy and
load-carriage distance will reduce repetitive stress on the Digitalgia Paresthetica
foot and lower leg. More gradual progression of loads Rucksack palsy
and distances may enable more gradual adaptation of Symptoms Paresthesia, cramping, pain, and/or
lower-leg muscles to load, thus potentially reducing and signs weakness in the shoulder associated with
risks of overuse and tarsal tunnel syndrome. Footwear load carriage
should be examined to assure that lacing is not too tight, Symptoms may extend to neck, arms, hands
the toe box is adequate (i.e., not squeezing the toes), and Reduced pain after load is removed
that the fit is correct. Sensory deficits and muscle weakness
remain after load is removed
Scapular winging
Once symptoms have been experienced, a specialty con- Etiology Traction or compression injury of the upper
sultation by a physical therapist, podiatrist, or other brachial plexus due to rucksack shoulder
healthcare provider may be helpful to rule out entrap- straps
ment neuropathies such as tarsal tunnel syndrome that Risk factors Demonstrated: lower body mass index
might be contributing to the problem. If this is likely, Hypothetical: heavy loads and/or longer
39
the medical provider will be able to provide initial carriage distance
conservative treatment for the syndrome and refer the Treatment Reduce shoulder compression
Soldier for further diagnostic tests and possible tarsal Physical therapy
tunnel injections or decompression surgery if conserva- More effective use of rucksack hip belt
tive management does not fully resolve the problem. 39,41 Reduce rucksack load
The provider will also be able to advise on conserva- Improve shoulder straps (wider, more
padding)
tive management when the problem seems to be more
related to nerve compression under the foot. Conserva- Prevention Commanders encourage removal of packs
tive treatment will generally involve addressing inflam- during short rests where operationally
acceptable
mation and initial relief from loads and from heavy, Use of rucksack hip belt
repetitive ankle-muscle use, followed by exercises that Periodic shoulder strap adjustments while
mobilize the nerve tissue, and stretch and more gradu- carrying load
ally strengthen specific lower-leg and short foot muscles Wider shoulder straps
to reduce future risk of overuse injury and help maintain Improved shoulder strap padding
Strengthening of shoulder muscles
foot stability and arch structure. 39,41 These approaches
have potential to help alleviate nerve compression in Digitalgia paresthetica
both the tarsal tunnel and under the foot. Symptoms Paresthetica in the feet and/or toes that is
and signs associated with load carriage
Etiology Compression neuropathy of the foot
Conclusion associated with repetitive foot trauma
Table 1 provides a summary of the symptoms, signs, during prolonged load carriage and/or tight
or poor-fitting footwear
etiology, risk factors, and treatment and prevention
measures of rucksack palsy and digitalgia paresthetica. Risk factors Load carriage for a greater number of days
Though relatively rare, these conditions can cause se- Longer load carriage distance
vere symptoms and lead to longer-term disability in Sol- Treatment Physical therapy
diers. 9,32 Prevention should be the first consideration, Reduce rucksack loads
Examine and possibly replace footwear
but if the conditions manifest, early diagnosis and man- (check lacing tightness, toe-box size, and fit)
agement may be the key to recovery. If providers notice
the appropriate signs or symptoms, the Soldier should Prevention Gradually progressing loads and march
distances early in training
be removed from the load-carriage activity and be prop- Proper footwear – fit, toe box, lacing
erly diagnosed before being allowed to perform further
load carriage. Failure to appreciate symptoms and take
appropriate action may lead to a permanent profile 9,32 of meralgia paresthetica, another load-carriage–related
that could affect the individual Soldier’s career by reduc- injury.
ing his or her tactical mobility and the capacity to use
weapons and other equipment, in addition to compro- Disclaimer
mising unit effectiveness.
The views expressed in this presentation are those of the
Part 2 of this series will address the epidemiology, eti- authors and do not necessarily reflect the official policy
ology, symptoms, evaluation, diagnosis, and treatment of the Department of Defense, Department of the Army,

Load-Carriage Paresthesias: Part 1 77