How To Test And Treat Exertional Compartment Syndrome

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Why The ECS Diagnosis Is Often Missed

Be especially vigilant for ECS when patients come in with a history of shin splints. Sometimes, in these cases, ECS is the more accurate diagnosis.
It has been well established that shin pain is often caused by excessive pronation with eccentric contraction of the soleus muscle or traction of the soleus muscle away from the periosteum of the bone. This may cause injury to the muscle or disruption of the periosteal lining or Sharpey’s fibers where they insert into the bone. This may even eventually lead to micro- or stress fracture of the bone.
In my practice, I ask these patients if they have pain when walking. If their legs hurt while walking the day after the activity, then I look for a stress fracture with an X-ray and/or bone scan. Also keep in mind that the posterior tibial muscle tendon or other medial leg musculature are commonly involved with shin pain.
Patient may also have anterior muscle pains (possibly related to running uphill, sprinting, or overworking of the anterior tibial muscle against tight calf musculature) or are suffering from shock absorption issues. Shock absorption is particularly problematic for those who have rigid foot types (especially cavus feet). For these individuals, a change of playing surfaces or switching to more cushioned shoe gear is in order.
Yet you should also be on the lookout for more obscure causes of leg pain. For example, ECS and popliteal artery entrapment syndrome share very similar symptoms. For the latter condition, the pain is most prevalent during exercise activity, is severe and commonly occurs in the calf area. As with ECS, the intense pain subsides with rest.
Proceed with diagnostic testing, including arteriography and duplex scanning, to better evaluate the course and function of the popliteal artery. You may also want to perform non-invasive vascular testing to rule out claudication symptoms associated with the vascular pathology, especially in older athletes.
Another anomaly which causes ECS is an accessory soleus muscle or accessory peroneus quartus muscle. In my practice, I have seen many cases of recalcitrant posterior leg pain which mimics chronic Achilles tendonitis, but also mimics posterior compartment syndrome during activity.
I have identified several of these cases by looking at the overall contour of the distal calf and Achilles area. If you suspect hypertrophy or if the pains to the posterior leg are out of proportion to normal muscle soreness, order an MRI to determine if an accessory muscle is present. Obviously, an extra muscle within any compartment would cause increased pressures upon the adjacent soft tissues. When this is problematic, debulking or cutting of the surrounding fascia is often indicated.

When testing the deep posterior compartment with the Stryker intra-compartmental pressure monitor system, insert the needle just medial and posterior, staying relatively superficial within the posterior tibial muscle belly.
By Richard Braver, DPM

Performing The Corrective Fasciotomy For ECS
If you have established the ECS diagnosis and conservative care measures have failed, you should proceed to the corrective fasciotomy.
I prefer a single incisional approach for both the anterior and lateral compartments. Usually, you want to release both compartments, even when only one compartment is involved. Make a linear longitudinal incision approximately 15 cm. long midway up the leg between the tibia crest and fibular shaft. Sharply deepen the incision to the level of the subcutaneous tissues down to the layer of the overlying fascia. Proceed to incise the fascia. At this point, you should be able to identify the anterior intramuscular septum that divides the anterior and lateral compartments.
Make sure you identify and avoid the superficial peroneal nerve that lies in the lateral compartment, which usually runs alongside the intramuscular septum. Using a long Metzenbaum scissor, cut the anterior fascia compartment in a linear longitudinal manner. Direct the scissors along the anterior tibial muscle down toward the anterior aspect of the lateral malleolus distally and proximally toward the patella.
Release the lateral compartment by cutting the fascia with the scissors along the lateral aspect of the fibular shaft. Direct the scissors distally toward the posterior aspect of the lateral malleolus and proximally toward the fibular head. It is important to visualize and cut with the tips of the scissors so you only release the fascia and avoid the superficial peroneal nerve.
When it comes to releasing the deep posterior compartment, I recommend making a linear longitudinal incision approximately 2 cm. posterior to the palpated medial posterior margin of the tibia. Then deepen the incision down to the level of the fascia. It is important to separate the fascia from the subcutaneous tissues in order to identify the saphenous nerve and vein, which should be just medial-posterior to the tibia.
Retract the neurovascular structures anteriorly and cut the deep posterior compartment fascia in a linear longitudinal manner, aiming the scissors distally towards the posterior aspect of the medial malleolus and proximally straight up. If you want to release the superficial posterior compartment as well, you should release the soleus bridge of soft tissues distally. Then perform the fasciotomy more posterior and along the soleus muscle, directing it proximally toward the medial head of the gastrocnemius.
(During these procedures, you should identify the nerves, including the superficial peroneal nerve and the saphenous nerve, in order to make sure they are not entrapped or appear abnormal.)
Proceed to irrigate the surgical sites with saline. Do not suture the fascia. Re-unite the subcutaneous tissues and close with 2-0 absorbable suture in a simple interrupted technique. Then perform skin closure with a running subcuticular suture.

In Conclusion
Apply postoperative dressings along with a well padded posterior splint cast, which should be worn for three weeks to allow for soft tissue healing. After three weeks, the patient attends physical rehabilitation and usually progresses back to sports within five to six weeks after the surgery. Once you make the proper (albeit challenging) diagnosis for ECS, you’ll find that surgical results are very gratifying.

Dr. Braver (shown at right) is board certified in foot and ankle surgery by the American Board of Podiatric Surgery. A Fellow of the American College of Foot and Ankle Surgeons, he practices in Englewood, NJ.


1. Detmer D.E. Chronic compartment syndrome, American Journal of Sports Med. 1985; 13. May – June: 162-170.
2. Mubarak Scott J. Surgical Clinics of North America, 563 Number 3 June 1983, Page 539–555.
3. Amendola, A. The American Journal of Sports Medicine, Volume 18, Number 1 1990.
4. Stryker Corporation, Kalamazoo, MI.

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Anonymoussays: May 3, 2010 at 11:14 am Good Morning. I was looking for an update on procedures used to treat ECS. I have read a bit about arthroscopic procedures used to effect anterior/laterial releases, that do not require large 15cm incisions and 4-6 week recovery time. Can you please provide some detailed information about these procedures? Reply to this comment »
hmpadminsays: May 5, 2010 at 2:09 pm We are planning to publish a new feature article, "Current Concepts In Treating Exertional Compartment Syndrome," in our September 2010 issue. Sincerely, Jeff A. Hall Executive Editor Podiatry Today Reply to this comment »

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