Current Concepts In Treating Chronic Exertional Compartment Syndrome

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A Historical Perspective On The Emergence Of Chronic Exertional Compartment Syndrome

In regard to chronic exertional compartment syndrome, Voght and Severin originally referred to the condition as march gangrene in 1943.1 They noted that march gangrene occurred in fit young soldiers who were undergoing training.

   Cerumen and colleagues described the condition again in 1944.2 They discussed the assumption that the condition was due to the cumulative affects of multiple microtrauma rather than a single injury. These authors noted the condition “ … stimulated a march fracture and could be called march myositis. This in fact was a misnomer since the pathology was not that of inflammation of muscle but of infarction.”2

   Physicians reported diagnosing the condition in the lower extremities, most often the anterior tibial compartment, with signs and symptoms of pain, swelling and local heat. When physicians utilized electronic diagnostic testing, the muscle showed no symptoms. There was often evidence of peripheral nerve injury and an inability for the patient to move her digits. Patients have also experienced numbness in the first interdigital space of the foot.

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Robert J. Duggan, DPM, FACFAS

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.

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