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Chronic Exertional Compartment Syndrome

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Other Names

  • Chronic Exertional Compartment Syndrome
  • CECS
  • CECS Lower Extremity
  • CECS Upper Extremity
  • Pediatric CECS
  • March Gangrene
  • Chronic Exertional Compartment Syndrome of the Forearm
  • Chronic Exertional Compartment Syndrome of the Leg

Background

  • This page refers to Chronic Exertional Compartment Syndrome (CECS)

History

  • First described in 1912 (need citation)
  • Also reportedly first described in 1945 by Vogt (need citation)

Epidemiology

  • Reported incidence of 27-33%[1]
  • Mean age 26 to 28 years

Introduction

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Chronic Exertional Compartment Syndrome
Cross-section of the lower leg depicting the 4 compartments and select key structures[2]

General

  • Complex pathology associated with overuse seen in young and athletic populations[3]
  • Can affect upper and lower extremities, although most commonly occurs in the leg
  • Characterized by reversible exercise-induced tightness, cramping, weakness, paresthesia and pain[4]
  • Symptoms rapidly improvement with rest, typically without permanent sequelae
  • Diagnosis is frequently made clinically, gold standard is intra-compartment pressure measurements

Pathophysiology

  • Not well understood
  • Occurs due to decreased blood flow as a result of increased compartment pressures
  • Cause is likely multifactorial[5]
    • Muscle hypertrophy
    • Decreased venous return
    • Microtrauma
    • Myopathies
    • Noncompliant fascia
  • Most commonly accepted theory
    • Exercise-induced increase in blow flow to muscle
    • The muscle then expands beyond the elastic capacity of the local osteofascial compartment
    • As the intramural pressure rises, it compresses the surrounding neurovascular structures
  • Elevated intramuscular pressure in CECS[6]
    • Remains higher in affected than unaffected individuals
    • This is true even in patients who are post fasciotomy
  • Other implicated factors
    • Improper training
    • Limb malalignment
    • Leg-length discrepancy
    • Running technique
    • Uncoordinated muscle control

Pathoanatomy of CECS

Risk Factors

General

Upper Extremity

Lower Extremity

Differential Diagnosis

Upper Extremity

Lower Extremity

Clinical Features

History

  • Pain that can be sever and in a specific location
  • Usually localizes to a compartment and is worse with exercise
  • Described as fullness or cramping sensation
  • Some patients will have paresthesia, numbness
    • Transient nerve palsy including foot drop can occur
  • Symptoms predictably become worse with increased exercise intensity and duration
  • Symptoms usually relieved within minutes to hours of discontinuation of activity
  • Patients usually deny history of trauma or direct injury
  • Report recurrence of symptoms after resuming activity
  • Symptoms are bilateral up to 82% of the time[10]
  • Over time, patient may note a longer duration of time post-exertion until symptoms subside

Physical Exam

  • Often normal/ unremarkable
  • Patients with long standing or server CECS may have point tenderness or atrophy
  • Muscle fascial herniation may be present
    • Especially with contraction of the affected muscle groups within the compartment
    • Fascial defects occur 4-5x greater in CECS than asymptomatic individuals[11]
  • Passive stretching of the muscles may be painful

Special Tests

  • Needs to be updated

Evaluation

Post-exercise STIR imaging shows increased signal in the deep and superficial posterior compartments which corresponds with increased region of interest measurements of signal intensity in these compartments.[12]
Compartment pressure measurement of the four compartments (A) anterior, (B) lateral, (C) deep posterior and (D) deep posterior

Radiographs

  • Findings
    • Typically normal
    • Useful to exclude other pathology

Bone Scintigraphy

  • Needs to be updated

MRI

  • Needs to be updated

Electromyography

  • Needs to be updated

Compartment Pressure Measurement

  • AKA needle manometry
  • Considered diagnostic gold standard
  • Measurement can be performed statically or dynamically
  • Static
    • Takes a single measurement at a single instance of time
    • Thought to be less accurate because it does not reflect pressures following exercise/exertion
  • Dynamic
    • Measures before and after a provocative event (e.g. running on a treadmill)
    • Can also be monitored continuously depending on equipment available
  • Pedowitz Criteria[13]
    • 1) pre-exercise pressure ≥ 15 mmHg
    • 2) 1-minute postexercise pressure ≥ 30 mmHg
    • 3) 5-minute postexercise pressure ≥ 20 mmHg
    • Note: if at-rest measurements or 1-minute postexercise measurements are confirmatory, further sequential testing is not required
  • Upper Extremity
    • Rare condition
    • Currently no consensus on diagnosing forearm CECS based only on compartment pressure

Classification

  • Not applicable

Management

Algorithm for offering nonoperative treatment for patients presenting with ELP that have a diagnosis of CECS.[1]

Nonoperative

  • Indications
    • Vast majority of cases
  • Re-training running style
    • First described by Kirby and McDermott (13) in 1983[14]
    • Emphasis on forefoot running
    • Diebal et al found that a 6 week course of therapy could provide long-lasting symptom relief in patients with anterior or anterolateral CECS[15]
  • Deep Tissue Massage
    • One small study found it was effective in decreasing symptoms, increasing the amount of exertion[16]
  • Activity modification/ Prolonged rest
    • Avoid or eliminate symptom-inducing activities[17]
    • Note: this may not always be possible
  • NSAIDS
  • Physical Therapy
  • Botulinum Toxin
    • Case series by Isner-Horobeti et al demonstrated patients with complete resolution of symptoms within 5 months[18]
      • This study only looked at anterolateral CECS
      • Decreased strength needs to be considered, especially in competitive athletes
    • Should be considered after the patient has tried gait modifications
  • Ultrasound Guided Fascial Fenestration
    • Case report published by Finoff details success of bilateral anterolateral compartment USG percutaneous needle fenestration[19]

Operative

  • Indications
    • Failure of conservative management
  • Technique
    • Traditional open fasciotomy
    • Endoscopy-assisted compartment release
    • Single minimal-incision fasciotomy
    • Percutaneous fasciotomy under local anesthesia
    • Ultrasound-guided fasciotomy

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Post operative return to play protocol from Blackman et al[20]
    • Immediately: mobilization exercises of knee, ankle to minimize scar tissue and adhesions
    • 3-5 days: limited weight bearing with crutches, full weight bearing as tolerated
    • 10-14 days: as soon as wound is healed, dynamic strength training, cycling, swimming
    • 4-6 weeks: gradual return to low intensity jogging
    • 8 weeks: return to sports training if one compartment was released
    • 12 weeks: return to sport training if multiple compartments/ both legs released
    • 90% pain free: return to performance and full sports participation

Prognosis and Complications

Prognosis

  • Minimally invasive fasciotomy
    • Croutzet et all describes good results in 16 motorcyclists with return to competition by 6 weeks[21]
  • Wide open versus mini open fasciotomy
    • Barrerra et al compared them at mean 45 months follow up with no differences between groups[22]
  • Surgical success rate
    • Success rates for anterior compartment CECS range from 81% to 100% at 5.2 years after surgery[23]
    • Success rate for deep posterior compartment CECS is lower (30% to 65% at varying follow-up periods, 3 to 89 months) for unknown reasons[24]

Complications

  • Needs to be updated

See Also

Internal

External

References

  1. ↑ 1.0 1.1 Rajasekaran, Sathish, and Mederic M. Hall. "Nonoperative management of chronic exertional compartment syndrome: a systematic review." Current sports medicine reports 15.3 (2016): 191-198.
  2. ↑ Pechar, Joanne, and M. Melanie Lyons. "Acute compartment syndrome of the lower leg: a review." The Journal for Nurse Practitioners 12.4 (2016): 265-270.
  3. ↑ Tucker, Alicia K. "Chronic exertional compartment syndrome of the leg." Current reviews in musculoskeletal medicine 3.1 (2010): 32-37.
  4. ↑ Dunn, John C., and Brian R. Waterman. "Chronic exertional compartment syndrome of the leg in the military." Clinics in sports medicine 33.4 (2014): 693-705.
  5. ↑ Fronek, J., et al. "Management of chronic exertional anterior compartment syndrome of the lower extremity." Clinical Orthopaedics and Related Research® 220 (1987): 217-227.
  6. ↑ Reneman, Robert S. "The anterior and the lateral compartmental syndrome of the leg due to intensive use of muscles." Clinical Orthopaedics and Related Research (1976-2007) 113 (1975): 69-80.
  7. ↑ Shah, Steven N., Bruce S. Miller, and John E. Kuhn. "Chronic exertional compartment syndrome." American Journal of Orthopedics (Belle Mead, NJ) 33.7 (2004): 335-341.
  8. ↑ Liu, Betty, Gustavo Barrazueta, and David E. Ruchelsman. "Chronic exertional compartment syndrome in athletes." The Journal of hand surgery 42.11 (2017): 917-923.
  9. ↑ Mavor GE. The anterior tibial syndrome. J Bone Joint Surg Br. 1956;38-B(2):513–517. doi: 10.1302/0301-620X.38B2.513.
  10. ↑ Detmer, Don E., et al. "Chronic compartment syndrome: diagnosis, management, and outcomes." The American journal of sports medicine 13.3 (1985): 162-170.
  11. ↑ Fraipont, Michael J., and Gregory J. Adamson. "Chronic exertional compartment syndrome." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 11.4 (2003): 268-276.
  12. ↑ Wasserman, Paul L., et al. "MR diagnosed chronic exertional compartment syndrome successfully treated by endoscopically-assisted fasciotomy." Radiology Case Reports 16.6 (2021): 1378-1383.
  13. ↑ Pedowitz, Robert A., et al. "Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg." The American journal of sports medicine 18.1 (1990): 35-40.
  14. ↑ Kirby RL, McDermott AG. Anterior tibial compartment pressures during running with rearfoot and forefoot landing styles. Arch. Phys. Med. Rehabil. 1983; 64: 296–9.
  15. ↑ Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am. J. Sports Med. 2012; 40: 1060–7.
  16. ↑ Blackman PG, Simmons LR, Crossley KM. Treatment of chronic exertional anterior compartment syndrome with massage: a pilot study. Clin. J. Sport Med. 1998; 8: 14–7.
  17. ↑ Vogels, Sanne, et al. "Chronic exertional compartment syndrome in the leg: comparing surgery to conservative therapy." International journal of sports medicine 42.06 (2021): 559-565.
  18. ↑ Isner-Horobeti, Marie-Eve, et al. "Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study." The American journal of sports medicine 41.11 (2013): 2558-2566.
  19. ↑ Finnoff JT, Rajasekaran S. Ultrasound-guided, percutaneous needle fascial fenestration for the treatment of chronic exertional compartment syndrome: a case report. PM R. 2016; 8: 286–90.
  20. ↑ Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. 2000;32(3 Suppl):S4-10.
  21. ↑ Croutzet, Pierre, Romain Chassat, and Emmanuel H. Masmejean. "Mini-invasive surgery for chronic exertional compartment syndrome of the forearm: a new technique." Techniques in hand & upper extremity surgery 13.3 (2009): 137-140.
  22. ↑ Barrera-Ochoa, Sergi, et al. "Surgical decompression of exertional compartment syndrome of the forearm in professional motorcycling racers: comparative long-term results of wide-open versus mini-open fasciotomy." Clinical Journal of Sport Medicine 26.2 (2016): 108-114.
  23. ↑ Packer JD, Day MS, Nguyen JT, et al. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Am. J. Sports Med. 2013; 41: 430–6.
  24. ↑ Winkes MB, Hoogeveen AR, Scheltinga MR. Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review. Br. J. Sports Med. 2014; 48: 1592–8.
Created by:
John Kiel on 24 June 2019 14:00:26
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Last edited:
11 November 2024 00:18:47
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