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Basics ⬇

Author: BrianLowell, MD, CAQSM

Description

  • Chronic exertional compartment syndrome (CECS) is a rare condition that can cause significant pain to the lower extremity.
  • Cases have been reported in the forearm, thigh, and foot, but the majority are reported in the lower leg.
  • CECS is caused by an increase in interstitial pressure in a closed fascial compartment, which leads to ischemic pain that may be associated with paresthesias and muscular dysfunction.
  • CECS can be easily misdiagnosed due to the vague nature of symptoms experienced by the patient. Delayed diagnosis can increase severity of condition.
  • It is seen in a variety of sports, but most often those associated with lower extremity stresses:
    • Runners.
    • Soccer players.
    • Speed skaters.
    • Military populations (marching).
  • The anterior compartment is most commonly affected and consists of the tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius, and deep peroneal nerve. The other compartments of the lower extremity include the lateral (peroneal longus, peroneus brevis, and superficial peroneal nerve), the superficial posterior (gastrocnemius, soleus, plantaris, and tibial nerve), and the deep posterior (tibialis posterior, flexor hallucis longus, flexor digitorum longus, popliteus, and the tibial nerve).

Epidemiology

Incidence

  • CECS has an incidence reported at up to 27–33% in competitive athletes with pain related to exercise.
  • Described in athletic populations at a rate of approximately 0.49 cases per 1,000 person-years
  • Younger patients more likely to develop CECS. Mean age of presentation is in the late 20s.

Prevalence

  • The prevalence of CECS decreases with age.
  • Male > female (1)

Etiology and Pathophysiology

The etiology of CECS is unknown. The most described theory involves transient ischemia during exercise caused by an increase in intramuscular pressure which compromises blood supply to the affected compartment.

Risk-Factors

  • Rapid increase in repetitive activity
  • Participation in high-risk sport activities
  • Significant musculature of the lower extremity
  • Diabetes mellitus

Diagnosis ⬆ ⬇

History

  • Typically, no associated trauma or injury
  • Pain is described as fullness, cramp-like, or tightness.
  • Pain reoccurs consistently with specific amounts of exertion (time, distance, or intensity).
  • Pain is typically bilateral in nature.
  • Pain generally associated with neurologic abnormalities that include paresthesia or weakness (e.g., foot drop).
  • Symptoms generally resolve <30 min after cessation of inciting activity.

Physical Exam

  • Exam is usually normal at rest. A physical exam without abnormal findings largely assists in narrowing the differential.
  • Postexertional examination can greatly assist with diagnosis of CECS. Following exertion, pain may become present, muscle/facial tightness may be palpable, and neurovascular abnormalities may become present. Passive stretching of the muscles in the affected compartment may also cause pain.

Differential Diagnosis

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • Radiographs, magnetic resonance imaging (MRI), and computed tomography (CT) are not useful in diagnosis of CECS but are instead used to evaluate for other causes of lower extremity pain, such as stress reactions or tumors.
  • MRI/magnetic resonance angiography (MRA) is useful in identifying popliteal artery entrapment.

Diagnostic Procedures/Other

  • Needle manometry is currently the gold standard test of choice.
  • Intracompartmental pressure measurements before and after exercise are useful in validating the clinical diagnosis of CECS. Although scrutinized, most clinicians use the modified Pedowitz criteria to indicate a positive test (2)[C]:
    • Preexercise pressure ≥15 mm Hg
    • 1-min postexercise pressure ≥30 mm Hg
    • 5-min postexercise pressure ≥20 mm Hg (2)

Treatment ⬆ ⬇

General Measures

  • Conservative measures have largely been lacking evidence and include stretching, prolonged rest, decreasing activity levels, avoiding activities that exacerbate symptoms, and orthoses (2)[C].
  • Physical therapy to address any biomechanical predisposition

Medication

No evidence for benefit with pharmacologic intervention; specifically nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen

Additional Therapies

Nonsurgical therapeutic modalities have recently been studied in small number, some with promising results. These conservative therapies include the following:

  • Massage: no change in postexercise compartment pressure, but decrease in postexercise pain (3)[C]
  • Gait changes: Forefoot training led to a significant change in compartment pressure postintervention (3)[C].
  • Chemodenervation: treatment via botulinum toxin A assisted with pain relief; however, there were concerns with lower extremity weakness associated with such therapies (3)[C].
  • Ultrasound-guided fascial fenestration: no significant surgical risks. Full return to sport without reoccurring pain. Case report; further research needed (3)[C]

Surgery/Other Procedures

  • Surgery is the definitive treatment. The gold standard is decompressive fasciotomy (4)[C].
  • Surgery consists of a fasciotomy of the affected compartment or compartments; open or endoscopic. Endoscopic release is hypothesized to decrease surgical healing time and minimize risk for dehiscence. There is no evidence for improvement in postsurgical fibrosis formation.
  • Studies report satisfactory results in 60–80% of patients. Greater successes were seen with anterior compartment intervention, whereas less favorable outcomes were seen with intervention to the other three compartments.
  • Common surgical complications include infection, wound dehiscence, bleeding, hematoma, nerve injury (peroneal neuritis), venous injury (saphenous), and inadequate release of fascia during initial surgical intervention and postsurgical fibrosis.
  • Reoccurring symptoms are seen in approximately 20–30% of postsurgical patients and typically occur from localized muscle constrictions secondary to fibrosis (4).
  • Special considerations:
    • Acute compartment syndrome and acute exertional compartment syndrome are different from CECS:
      • Acute compartment syndrome: typically associated with fracture or crush injury
      • Acute exertional compartment syndrome: commonly associated with significant increase in activity
    • Remember pain out of proportion to physical exam along with neurovascular abnormalities on physical exam at rest.
    • The acute compartment syndromes are surgical emergencies that must be treated with emergent fasciotomy to avoid muscle necrosis (5).

Ongoing Care ⬆ ⬇

  • Very little literature on rehabilitation after fasciotomy
  • Small study rehabilitation protocol includes:
    • Crutches for ambulation immediately postfasciotomy.
    • Remove crutches when one can bear weight without significant limp.
    • Control swelling with ice, elevation, and compression.
    • Gait training and progression to full weight-bearing.
    • Progressive strengthening of the lower extremity with goal of sport-specific training between 6 and 8 wk (6).
  • >80% of elite athletes return to previous sports participation in 8 to 12 wk.

Additional Reading ⬆ ⬇

Roscoe D, Roberts AJ, Hulse D. Intramuscular compartment pressure measurement in chronic exertional compartment syndrome: new and improved diagnostic criteria. Am J Sports Med. 2015;43(2):392–398.

References ⬆ ⬇

  1. de Bruijn JA, van Zantvoort APM, van Klaveren D, et al. Factors predicting lower leg chronic exertional compartment syndrome in a large population. Int J Sports Med. 2018;39(1):58–66.
  2. Vajapey S, Miller T. Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature. Phys Sportsmed. 2017;45(4):391–398.
  3. Rajasekaran S, Hall MM. Nonoperative management of chronic exertional compartment syndrome: a systematic review. Curr Sports Med Rep. 2016;15(3):191–198.
  4. Campano D, Robaina JA, Kusnezov N, et al. Surgical management for chronic exertional compartment syndrome of the leg: a systematic review of the literature. Arthroscopy. 2016;32(7):1478–1486.
  5. Livingston KS, Meehan WP III, Hresko MT, et al. Acute exertional compartment syndrome in young athletes: a descriptive case series and review of the literature. Pediatr Emerg Care. 2018;34(2):76–80.
  6. Irion V, Magnussen RA, Miller TL, et al. Return to activity following fasciotomy for chronic exertional compartment syndrome. Eur J Orthop Surg Traumatol. 2014;24(7):1223–1228.

Clinical Pearls ⬆

  • Typical presentation is a young athlete who has recurrent lower extremity pain that is aggravated with repetitive activity and alleviated with rest.
  • A high index of suspicion if athletes endorse symptoms, but physical exam findings on exam are benign
  • The diagnosis of CECS is clinical. Needle manometry assists with diagnosis.
  • Surgical treatment via fasciotomy is the gold standard, but successful treatment of pain may be achieved with nonsurgical interventions.
  • Surgical treatment success rates are high, but complications and postsurgical reoccurrences are seen.