Current Concepts In Treating Chronic Exertional Compartment Syndrome

Given the intricacies of the condition and varying etiologies, chronic exertional compartment syndrome can have a complex presentation. Accordingly, this author reviews the staging of the condition, keys to diagnosis and emerging insights on surgical treatment.

Chronic exertional compartment syndrome (CECS), also termed exercise induced compartment syndrome, has been a condition affecting both lower and upper extremities in patients who participate in exertional-type exercise.

   It appears that the early reports of exercise induced compartment syndrome were certainly acute in nature and required surgical intervention. (See “A Historic Perspective On The Emergence Of Chronic Exertional Compartment Syndrome” at top right.) The term that has been used more frequently in the recent literature is chronic exertional compartment syndrome. One of the main differences between exercise-induced compartment syndrome and CECS is the timeframe of pain and substantial symptoms. Chronic exertional compartment syndrome symptoms seem to resolve relatively quickly after the cessation of exercise. A small number of patients with exercise-induced compartment syndrome may have more acute and serious symptoms.

   In an athletic patient population, most of the reported diagnoses of exertional compartment syndrome are related to the leg. There are reports of exertional compartment syndrome in the erector spinae group of muscles as well as upper extremities. Researchers have also reported limited accounts of chronic exertional compartment syndrome of the foot.3

Differentiating Among The Types Of CECS

It appears that chronic exertional compartment syndrome has different levels of patient complaints that fall into three different types for patients who are participating in exercise.

   Type I. The first type is lower leg pain residing in a specific compartment at the beginning of exercise. This type of pain may be associated with a healing stress fracture or overuse injury.

   Type II. This is a classic chronic exertional compartment syndrome pain residing in a specific compartment during exercise. Pain is classically at the same levels of activity or distance with each exercise.

   Type III. With this type of pain, the patient experiences progressive compartment changes. The hallmark of these changes is pain that increases after activity and threatens both the vascular and neurologic function of the structures in the affected compartment.

   These three types have been useful in my practice to identify the severity of the athlete’s condition at a tissue plane level. The onset of pain in relationship to the time of the most recent exercise is very important and speaks to the level of tissue changes in the leg compartment. The condition does not follow a progression but previous injuries can affect the condition. This classification identifies the severity of the condition.

   The patients affected by chronic exertional compartment syndrome who can be classified by the aforementioned three types will in large number be the athletes participating in strenuous activities. The patient’s history will be the most important portion of the evaluation. Ascertaining when the patient’s pain began will be a critical question for the practitioner in order to stage this condition. When it comes to the segment of patients who have presented with a type III exertional compartment syndrome, it is important for the practitioner to identify those athletes with previous chronic leg pain.

   In addition, when it comes to patients presenting with type I exertional compartment syndrome pain, it is equally important to make sure the patients progress with healing of the overuse condition or stress fracture process. It is interesting to note that many patients who have overuse or classic shin splint pain with running activities will in many cases heal their injuries, but have additional bouts of pain with seasonal changes and sports. This may be due to repetitive scarring in the affected compartments of the lower leg. Additional research and monitoring of athletes with lower leg pain will continue to advance our treatments and result in earlier diagnosis of these conditions.

Salient Pointers On Making An Accurate Diagnosis

One initially makes the diagnosis of CECS from clinical history and the presentation of the patient. Most patients are athletic and will report pain in one or both legs after initiation of exercise. Runners are often the population of athletes who present with lower extremity CECS. Currently, the condition usually refers to mild neural ischemia from a reversible increase in tissue pressure within a myofascial compartment. However, athletes from sports disciplines other than running certainly can present with this problem.3 Recently, I have seen athletes with this syndrome participating in volleyball, lacrosse, soccer and even trampoline sports.

   Any athlete with endurance training requirements of the lower extremity could present with CECS. The patients will have pain in the affected compartment and may have had past diagnoses of shin splints, stress fracture, muscle strain and overuse injuries. Many of the patients will have unremarkable X-rays, vascular studies and neurologic studies at rest and while you are examining them in the office.

   The patients will report increased symptoms that occur at consistent levels of exercise intensity. Runners will complain that the symptoms occur at the same distance in each training session. Asking the athlete to reproduce her exercise intensity either by running or stationary exercise in many cases will increase symptoms of pain and tightness to the affected leg or legs.

   Diagnostic studies have been of value in ruling out other pathologies that may mimic chronic exertional compartment syndrome. Often post-exercise magnetic resonance imaging (MRI) is within normal limits. Nerve conduction velocity studies are often all normal. Peripheral examinations using Doppler ultrasound for arterial flow in many cases is normal as well. When it comes to the diagnosis of CECS, there is value in several special tests such as near infrared spectroscopy. Research has shown the sensitivity of near-infrared spectroscopy to be clinically equivalent to invasive intracompartmental pressure measurements.3

   I have used a non-invasive test in my office for several years that gives additional information as to the pain level of the patient with CECS. The test involves placing a sphygmomanometer circumferentially over the unaffected leg. One notes pressure measurements as the patient identifies perceived pain. The physician then performs the test again on the affected leg and asks the patient to report perceived pain. In many cases, the patient perceives the pain in the symptomatic leg at a much lower reading than the sphygmomanometer can detect.

   I then ask the patient to exercise either in the office or outside the office with a short run. Then I redo this test on both legs. The affected leg in most cases will have as much as a 50 percent decrease in the sphygmomanometer measurement of mmHg when the patient reports perceived pain in comparison with the unaffected side. Further research is warranted to correlate these measurements with preoperative intracompartmental pressure measurements or near-infrared spectroscopy measurements.

   A delay in identifying CECS can lead to local tissue necrosis and permanent changes to both the musculoskeletal component and the neurologic component of the lower leg.4

Weighing Conservative Versus Surgical Treatment

Treatment for CECS focuses on decreasing pain and limiting any chronic tissue damage to the fascial compartment that is involved. Physical therapy and modalities geared toward decreasing inflammation seem to be of some value in those patients who have mild symptoms. When it comes to patients with persistent CECS, symptoms will limit activity enough that these patients will seek additional pain relief in the form of surgical intervention.

   For those patients failing conservative care, surgeons have used several approaches for fascial decompression. In the early history of this condition, treatment was in most cases an open fasciotomy of the compartment involved.5 More recent reports are focusing on incisional fascial decompression of the involved compartments with a significant shift toward the use of endoscopic techniques.3,6,7 These procedures have been very effective in decreasing symptomatology as well as shortening the postoperative time to healing.

   A large portion of the patients presenting with chronic exertional compartment syndrome have involvement in the anterior or anterior-lateral lower leg compartment. There have been significant advances in the surgical treatment of these two compartments with the use of endoscopic procedures, which we have used in my practice with good success. Research has shown that the procedure described by Stein and Sennett is safe and effective.7

Step-By-Step Surgical Insights

Prep and drape the affected lower leg in the usual manner. Place a pneumatic tourniquet at the thigh and set it for the appropriate level for hemostasis. Place the surgical incision 5 cm lateral to the crest of the tibia and 12.5 cm proximal from the distal aspect of the fibula. The incision is approximately 2 to 3 cm in length and the surgeon deepens it to expose the fascia. Make a linear incision in the fascia below the skin incision. Using a switching stick from the arthroscopy instrumentation, make a tunnel and move proximal to accommodate long Metzenbaum scissors.

   Introduce the arthroscopy camera subcutaneously and as the camera moves proximally, use it to visualize the fasciotomy. This allows for direct arthroscopic visualization of the fascial incision, the perforating vessels, the underlying musculature and the portions of the peroneal nerve that may be presenting to the wound area. Then free the switching stick, remove the arthroscopic camera and free the fascia distally. This completes the procedure.

   Withdraw the instrumentation, place simple sutures in the skin and apply a wound dressing. Apply a bandage of half-stretch Coban (3M) over the compartment from distal to proximal to create a mild compression dressing. Follow-up occurs between three and five days postoperatively. The patient is able to actively dorsiflex and plantarflex to toleration but with no weightbearing on the affected side for the first three to five days. The patient then slowly progresses to full activity as tolerated.

What The Literature Says About Subcutaneous Fasciotomies

Several authors have reported excellent or good results in the majority of their patients who have undergone subcutaneous fasciotomies.8-10 In those patients with less than excellent results, hematoma was the most common postoperative complication.

   When performing this procedure, the surgeon must pay special attention to the superficial peroneal nerve because of the risk for muscle injury and excessive bleeding. Post-op management of the patient and wound is similar to any other type of open fasciotomy and one must monitor the patient’s gradual return back to activity as well as local healing of the leg wound and the patient’s general health.

   Dr. Duggan is an Attending Physician with the Florida Hospital East Orlando Residency Training Program in Orlando, Fla. He is a Fellow of the American College of Foot and Ankle Surgeons.

   For further reading, see “How To Diagnose And Treat Chronic Exertional Compartment Syndrome” in the June 2009 issue of Podiatry Today, “How To Test And Treat Exertional Compartment Syndrome” in the May 2002 issue or “How To Detect And Treat Chronic Compartment Syndrome” in the December 2002 issue.

References:

1. Vogt PR. Ischemic muscular necrosis following marching. Presented to the Oregon State Medical Society, Sept. 4, 1943. 2. Sirbu AB, Murphy MJ, White AS. Soft tissue complications of fractures of the leg. Cal West Med 1944; 60(2):53-56. 3. Pandhiar N, Allen M, King J. Chronic exertional compartment syndrome of the foot. Sports Med Arthroscopy Rev 2009; 17(3):198-202. 4. Uzel AP, Lebreton G, Socrier ML. Delay in diagnosis of acute on chronic exertional compartment syndrome of the leg. Chir Organi Mov 2009 Dec; 93(3):179-82. 5. Blandy J, Fuller R. March gangrene. J Bone Joint Surg 1957; 39(4):679-93. 6. Wittstein J, Moorman CT 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. Am J Sports Med 2010; 38(8):1661-6. 7. Stein DA, Sennett BJ. One-portal endoscopically assisted fasciotomy for exertional compartment syndrome. Arthroscopy 2005; 21(1):108-112. 8. Fronek J, Mubarak SJ, Hargens AR, et al. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop 1987; 220:217-227. 9. Micheli LJ, Solomon R, Solomon J, et al. Surgical treatment for chronic lower-leg compartment syndrome in young female athletes. Am J Sports Med 1999; 27(2):197-201 10. Howard JL, Mohtadi NG, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin J Sports Med 2000; 10(3):176-184.