Chronic Exertional Compartment Syndrome of the Lower Extremity
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
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 .
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 . Distal paresthesias may be present and occasionally foot drop or other neurologic deficits occur.
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 . 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 .
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 . 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.
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.
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