December 6, 2020
Chronic Exertional Compartment Syndrome

Chronic Exertional Compartment Syndrome of the Lower Extremity

Chronic exertional compartment syndrome (CECS) is an uncommon presentation for the general population, but much more common in sports medicine. It was first described in 1956 in a professional football player [1]. The incidence in the general population is unknown, but certain subpopulations of athletes have rates of 0.5 per 1,000 persons [2]. This is also challenging because many athletes or runners will change their habits to curb symptoms. Approximately 90-95 percent of cases involve the lower legs [3]. It is also common to occur bilaterally (up to 82% of cases). There is no gender predilection and chronic exertional compartment syndrome sometimes occurs in conjunction with other diagnosis such as medial tibial stress syndrome, vascular insufficiency and nerve entrapment. The anterior compartment is most common, followed by the deep posterior, lateral and then superficial posterior compartments [4].

Case Question

An 18 year old male collegiate soccer player presents to your training room about one week into the soccer season. He complains of bilateral anterolateral leg pain that gets worse with running. His pain is worse with jogging for more than 5 minutes or sprinting. He described a pressure sensation in his legs and when he tries to push through the pain he starts to notice a slapping sensation of his right foot along with some mild numbness at the top of his foot. The pain seems to be relieved with rest. His physical examination is unremarkable with normal pulses and muscular strength. His pulses were checked in passive ankle dorsiflexion and also in active ankle plantarflexion and were also normal. What is the most likely diagnosis?

A) Medial tibial stress syndrome
B) Anterior tibialis strain
C) Popliteal artery entrapment syndrome
D) Chronic exertional compartment syndrome

Muscle Compartments of the Leg

Image 1. Muscle Compartments of the Leg (adopted from 3d4medical.com)

Although debate exists in regards to etiology, the pathology is thought to arise from transient muscular ischemia and progressive neurovascular dysfunction due to the increased intramuscular pressures experienced during endurance. Normal muscle will hypertrophy with exertion but return to baseline within a few minutes; intracompartmental pressures follow a similar pattern. In documented cases of CECS, muscles expand up to 20% in volume against inelastic fascia and intracompartmental pressures rise in accordance with Laplace’s law. Resultant microvascular compromise and reduced venous return lead to ischemic pain, ultimately manifesting as workload intolerance and loss of function. Symptoms resolve completely between periods of activity and recur once the activity is resumed. Patients with lower-extremity CECS have higher intracompartmental pressures at rest as well as with exercise compared with normal individuals, although this has not been specifically reported for CECS of the forearm [4].

 

As with most things in sports medicine, a thorough history and physical examination are very important in the diagnosis of CECS. Patients typically present with atraumatic exercise-induced pain, cramping and tightness in the involved compartment or compartments. Onset and severity of the pain often becomes predictable, recurring at similar durations or with certain intensities of exercise. Many running athletes will present within 5 minutes of full exercise, although it may be much longer with endurance runners. Symptoms sometimes will persist after the inciting exercise and will typically improve with rest. Static physical examination is many times normal or unrevealing. Muscle fascial herniations may be present on inspection of the limb and become more obvious with activation of the affected muscle group. Rarely, point tenderness may be present in the involved compartment along with atrophy if symptoms are longstanding. Provocative signs for peripheral compressive neuropathies are typically normal. Dynamic examination of the involved compartments during training is essential for diagnosis and they may be firm, taut and tender to palpation [5]. Distal paresthesias may be present and occasionally foot drop or other neurologic deficits occur.

Differential Diagnosis of Chronic Exertional Compartment Syndrome

Image 2: Differential Diagnosis of Chronic Exertional Compartment Syndrome

The patient’s clinical history is the most important factor for diagnosis. Thorough static and dynamic physical examination aids in eliminating other etiologies. Intracompartmental pressure measurements before, during, and after exercising are standard for the diagnosis of CECS of the lower extremity. The diagnostic criteria for CECS in the lower extremity published by Pedowitz et al include resting pressure greater than 15 mm Hg, pressure one minute after exercise > 30 mm Hg, and/or pressure 5 minutes after exercise greater 20 mm Hg [5]. These criteria have been used for over two decades, although controversy remains about the role and validity of this criteria. Hutchinson suggested the use of a change of 10 mm Hg in intracompartmental pressure as diagnostic, independent of baseline measurements [6]. 

Another proposal was to continuously monitor the dynamic intramuscular compartment pressures with a threshold of 105 at 5 minutes being diagnostic [7]. Achieving accurate and reproducible intracompartmental pressure measurements during exercise is technically demanding, whether it is done at specified intervals or in a continuous fashion. The level of catheter placement, position of the catheter within the compartment, and variation in the position of the extremity all affect pressure measurements and can be challenging for inexperienced providers. More recently, dynamic magnetic resonance imaging (MRI) has shown potential to aid in the diagnosis of CECS. It has been shown that a significant increase in T2 signal intensity in the involved compartments when compared with controls. This resolved after decompression fasciotomy [9]. Dynamic MRIs are mainly limited to academic institutions currently.
The recommended initial treatment for CECS is conservative management with cessation of causative activities. This can be difficult, as most athletes will be unwilling to stop their desired activity and other factors may be present such as scholarship or compensation. Rajasekaran and Hall performed a systematic review of nonoperative management of CECS, including massage, gait changes, chemodenervation, and ultrasound-guided fascial fenestration. Although their study reported that all the nonoperative management strategies had few to no adverse effects, the authors concluded that there was a lack of robust data regarding their effectiveness [10]. This is because the data available comes primarily from case series and case reports. One small study enrolled ten patients that were signed up for fasciotomy in a forefoot strike running program and symptoms and lower leg intracompartmental pressures improved. This was maintained for one year and surgery was avoided [11]. This was then repeated in additional studies [12-13].
Taping has increased in popularity and shows some promise with medial tibial stress syndrome, but no studies evaluated the role in CECS. Botulinum toxin A (Botox) injections have also been evaluated and one study in sixteen patients showed a decrease in intracompartmental pressures but around seventy percent showed some loss in muscle strength [14]. Resolution of CECS symptoms following Botox injections was also reported in two recent reports [15,16].
compartment pressure measurement for chronic exertional compartment syndrome

Image 3. Illustration of compartment pressure testing approach (courtesy of orthobullets)

When symptoms persist despite nonsurgical management, surgical fasciotomy is considered for symptom relief and return to athletic capacity. Athletes are counseled that not all patients experience full symptom resolution after fasciotomy. When compared to nonoperative management, operative management appears to have better patient satisfaction and favorable functional outcomes in the general population, as well as elite athletes [17-18]. Surgical techniques for lower-extremity CECS include traditional open fasciotomy, endoscopy-assisted compartment release, single minimal-incision fasciotomy, percutaneous fasciotomy under local anesthesia, and ultrasound-guided fasciotomy. Packer et al. found that patients aged <23 years had improved outcomes after fasciotomy [19]. It is believed that younger patients have a thicker/stiffer fascia, and thus decompression tends to provide favorable results in this patient population. Lower success rates after fasciotomy have been reported in older patients (mean age 39 years), likely secondary to chronic changes to muscle, nerves, fascia, and vasculature with age. 

Slimmon et al. found that patients who had compartment releases within 12 months of symptoms had improved outcomes. Those with statistically longer duration of symptoms had lower satisfaction scores [20]. Some use a less invasive, endoscopy-assisted technique, particularly in pediatric patients. The endoscopic, minimally invasive technique has resulted in an overall 79.5% return-to-sports rate in the pediatric population. However, 18.8% of legs treated had recurrent CECS requiring reoperation at a median of 1.3 years after initial compartment release [21]. The single minimal-incision technique, percutaneous fasciotomy under anesthesia and ultrasound guided fasciotomy are less studied but have generally favorable results. Overall, a systematic review found primary operative management of lower-extremity CECS was successful in approximately two-thirds of all young athletic patients, and 84% were satisfied with their surgical outcomes at short- to mid-term follow-up. Open fasciotomy remains the predominant surgical technique, although its comparative efficacy relative to newer endoscopic or other minimally invasive techniques is not currently known [22].

In summary, chronic exertional compartment syndrome of the lower extremity is uncommon in the general population but is a common diagnosis for athletes complaining of claudication symptoms. A thorough history is imperative for diagnosis and providers must have suspicion in certain populations. Diagnosis is usually done by manometry of the lower extremity compartments before and after exercising or provocative maneuvers. It is also very important to be aware that CECS occurs in conjunction with other conditions and these may need to be ruled out. Most begin with non operative measures and a forefoot running program and Botox have shown promise in limited studies. Fasciotomy is the more definitive treatment and results are generally favorable. More studies are needed to more definitively treat and diagnose CECS.

Case Answer

The correct answer is D. Chronic exertional compartment syndrome (CECS) typically occurs in runners or athletes. The majority of cases occur within 5 minutes of vigorous running activity or other strenuous activities, though there are many exceptions. Many cases can occur bilaterally and it is more common for CECS to occur bilaterally than it would be for popliteal artery entrapment syndrome (PAES). Symptoms sometimes will persist after the inciting exercise and will typically improve with rest. Static physical examination is many times normal or unrevealing. Medial tibial stress syndrome will typically have tenderness over the medial tibia on examination. His pulses were checked in passive ankle dorsiflexion and also in active ankle plantarflexion and were also normal, making PAES unlikely, as these pulses many times will diminish with this diagnosis.

References

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  5. Bong, Matthew R., et al. “Chronic Exertional Compartment Syndrome.” Bulletin of the NYU Hospital for Joint Diseases 62 (2005).
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  17. Pasic N, Bryant D, Willits K, Whitehead D. Assessing outcomes in individuals undergoing fasciotomy for chronic exertional compartment syndrome of the leg. Arthrosc J Arthrosc Relat Surg. 2015;31(4):707–713.e5. doi:10.1016/j.arthro.2014.10.018
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  19. Packer JD, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Am J Sports Med. 2013;41(2):430–436.
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