How To Diagnose And Treat Chronic Exertional Compartment Syndrome

Robert J. Duggan, DPM, Alan A. MacGill, DPM, Christopher L. Reeves, DPM, and Scott P. Goldstein, DPM

   Evaluating and treating exercise-induced lower leg pain can be a difficult task for the foot and ankle physician. Chronic exertional compartment syndrome (CECS) is commonly misdiagnosed and often patients go though an exhaustive trial of treatments that fail to alleviate their pain.

   There is a plethora of differential diagnoses for this syndrome. However, one can diagnose it accurately with a thorough history and following up on strong clinical suspicion. Physicians can subsequently treat the condition surgically with a high rate of success.

   Chronic exertional compartment syndrome is also known as “exercise-induced compartment syndrome,” “recurrent compartmental syndrome” or “subacute compartment syndrome.” The syndrome is an effort induced condition in which tissue pressures within an osteofascial envelope are elevated well above physiologic levels. This results in inadequate perfusion and ischemic-related symptoms.1-3

   Mavor was the first to describe CECS of the leg and offered insight into this increase in compartmental pressure. He noted “it is unlikely that the so-called ‘open’ lower end of the compartment is anything more than a potential opening well occupied by tendons and thus unsatisfactory as a ‘safety-valve.’ With increasing tension in the compartment, ‘circulation within the intramuscular vascular networks is embarrassed.’”4

   Collagen tissue under a prolonged stretch will respond by aligning its fibers to increase in density and strength. These increases in density and strength likely account for the increased progression in symptoms that many patients describe. Detmer et al., found this to be the case in 75 percent of the patients in their study.1

   Chronic exertional compartment syndrome is more often bilateral with a strong male predisposition.5 This condition is more common in younger athletes as they are more prone to return to activity despite residual pain.6 In their study, Detmer et al., found that 87 percent of their patients with lower leg chronic exertional compartment syndrome were involved in some type of sport.1

Essential Anatomical Insights

   Researchers have reported that 95 percent of CECS occurs in the lower leg.7 This is due to the fact that intensive exercise in most sports usually includes the anatomic structures of the lower leg. When it comes to the lower leg, the anterior compartment is most commonly affected. This is followed by the lateral compartment. The deep and superficial posterior compartments are much less commonly involved.8,9

   Anatomic textbooks describe four compartments in the lower leg. These compartments include the anterior, lateral, deep posterior and superficial posterior compartments. Detmer et al., believed the lower leg to contain seven functional compartments. These compartments include the:

   • anterior;
   • lateral;
   • posterior superficial medial (medial head of the gastrocnemius);
   • posterior superficial lateral (lateral head of the gastrocnemius);
   • posterior deep proximal;
   • posterior deep distal (flexor digitorum longus, flexor hallucis longus, posterior tibialis); and
   • posterior superficial distal (soleus) compartments.1

   The superficial peroneal nerve has variable branching patterns and is particularly at risk during lateral compartment fasciotomy. The nerve is most frequently at risk at the junction of the middle and distal thirds of the calf, where it pierces the fascia and begins to course more obliquely.10

A Guide To Key Clinical Features

   The most common clinical feature of CECS is the relationship of the pain to exertion. Patients often complain of lower leg pain during exercise and describe it as easing with cessation of activity. Following exercise, patients often describe mild tenderness, aching pain, tightness, weakness of the muscles in the affected compartment and/or sensory abnormalities of the involved nerve.11

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