How To Diagnose And Treat Chronic Exertional Compartment Syndrome
- Volume 22 - Issue 6 - June 2009
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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
One should ask patients to outline with a finger the exact borders to the area of pain they experience. Patients will often outline the entire muscular compartment. Patients experiencing anterior compartment syndromes may even experience transient low-grade foot drop with or without paresthesias.1 Upon initial examination, patients may complain of mild soreness to palpation. Muscle hernias may also occur but they are rare.
One must rule out all other possible diagnoses prior to further clinical considerations for compartment syndrome. Therefore, it is important to note that CECS is a diagnosis of exclusion. Differential diagnoses include stress fracture, Baker’s cyst, soft tissue mass, popliteal artery entrapment syndrome (PAES), medial tibial stress syndrome, adductor canal outlet syndrome, adventitial cystic disease, pes planus, muscle herniation or diffuse periostitis.2,10 One usually makes the definitive diagnosis with compartment pressure monitoring before and after exercise.
What The Literature Reveals About Diagnostic Testing
Researchers have described other means of diagnosis that include magnetic resonance imaging and near infrared spectroscopy (NIRS).12 Magnetic resonance imaging scans have shown an increase in T2-weighted signal in legs affected with chronic exertional compartment syndrome after exercise. The NIRS measures the hemoglobin saturation of tissues in a non-invasive manner.
A study by van den Brand et al., found the sensitivity of noninvasive NIRS to be clinically equivalent to that of invasive intracompartmental pressure measurements. Their study also found the diagnostic value of MRI to be disappointing in comparison to that of NIRS and intracompartmental pressure testing.12
Another non-invasive method of identifying an exertional compartment syndrome is testing leg pain with a sphygmomanometer following a period of exercise. After the patient completes a brief period of exercise, inflate the sphygmomanometer on the symptomatic calf region until the region is painful. Do this with the unaffected calf as well.
With chronic exertional compartment syndrome, the patient will exhibit pain at a much lower cuff pressure in the affected limb as opposed to the non-affected limb. Though it is non-specific for the exact compartment that is being affected, this test is a quick and inexpensive modality to aid in determining whether CECS is the culprit.
Intracompartmental pressure testing remains the gold standard for diagnosing CECS. Leversedge et al., defined CECS as a pre-exercise intracompartment resting pressure of more than 15 mmHg, a one-minute post-exercise pressure of more than 30 mmHg, a five-minute post-exercise pressure of more than 20 mmHg, or a combination, when one correlates these measurements with clinical symptoms.3
Physicians usually test the compartments with a wick or slit catheter. The literature shows that position of the lower extremity can affect pressure measurements and one needs to standardize this during testing. The patient is usually supine with the foot in neutral position.
We use a Stryker wick catheter (Stryker Corporation). This is a simple handheld device containing a transducer, amplifier and display that connects directly to a needle or slit-catheter. It is easy to handle, has a short learning curve, is relatively inexpensive and can produce reliable static measurements. In a large clinical study, Verleisdonk et al., noted sensitivity and specificity of 93 percent and 74 percent respectively with this device.9