Current Concepts In Treating Chronic Exertional Compartment Syndrome

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What You Should Know About Predisposing Factors And CECS

Predisposing factors for chronic exertional compartment syndrome include trauma, strength training using eccentric contraction of muscles, using creatine as a supplement, hypertrophy and weakness of the compartment fascia.

   Increased intracompartmental pressure allows the capillary beds to undergo an increase in volume and size, leading to an increase in intracompartmental fluid. There is speculation as to the subsequent effects on muscle perfusion because of the increase in intracompartmental pressure. These effects include:

• arterial spasm;
• critical closing pressure changes because of pressure;
• microvascular occlusion beginning to decrease arterial flow; and
• arteriovenous gradient, which would lead to increased local venous pressure.

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Author(s): 
Robert J. Duggan, DPM, FACFAS

   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.

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