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:
• 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
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
Why Fasciotomy Is The Gold Standard
The first approach to treatment is conservative care. Conservative options include modification of activity, prolonged rest, anti-inflammatory drugs, stretching, bracing, massage, orthotics, diuretics and physiotherapy.1,7 The literature notes the majority of these conservative modalities tend to be less effective in alleviating exertion-induced pain.
The second option and mainstay of treatment is the fasciotomy. Common techniques include open fasciotomy, subcutaneous release and endoscopically assisted fasciotomy.6 Fasciotomy is generally reserved for recurrent episodes of CECS. Studies have shown that endoscopically assisted fascial release reduces the risk of superficial peroneal nerve injury in comparison to blind percutaneous release.10
In Hutchinson’s study of percutaneous versus endoscopically assisted fasciotomy, four of six specimens undergoing the percutaneous procedure had complete transection of the superficial peroneal nerve.10 Detmer et al., found that 90 percent of the 70 patients treated with subcutaneous fasciotomy had significant improvement.2 Verleisdonk and colleagues had a similar success rate of 87 percent for 53 patients treated with fasciotomy.9
Potential complications of fasciotomy include infection, nerve injury, recurrence secondary to incomplete release, cosmetically unacceptable scarring, muscle fascia adhesions and postoperative hematoma.10
How To Perform An Endoscopically Assisted Fasciotomy For Anterior/Lateral CECS
Prep the left leg and drape it in normal sterile fashion. After performing Esmarch exsanguination, inflate a thigh tourniquet to 300 mmHg to maintain hemostasis. Make a 2 cm vertical incision, the center of which is 12 cm proximal to the lateral malleolus and 5 cm lateral to the tibial crest. Dissect down to the fascia.
Place a 30-degree endoscope into the incision and identify the anatomy within the fascial incision. Then place Metzenbaum scissors into the incision. Under endoscopic visualization, use the scissors to release the fascia both proximally and distally until you can perform a complete fasciotomy. Take care to visualize and protect the superficial peroneal nerve throughout the entire procedure.
It is not uncommon to perform both an anterior and lateral compartment release at the same time. Incise the anterior compartment fascia sharply and insert the endoscope. Using the same technique one would employ with the lateral compartment, incise the anterior compartment fascia under endoscopic visualization proximally and distally. Then irrigate the incision and deflate the tourniquet. After confirming hemostasis, close the incision in a running subcuticular pattern.
Pertinent Postoperative Pearls
The literature describes varying postoperative protocols following fasciotomy. Patients should elevate the extremity for the first 48 to 72 hours to prevent edema. We advocate non-weightbearing for two weeks. One would subsequently emphasize protected weightbearing in a fracture boot and the initiation of formal physical therapy.
At four weeks postoperatively, patients may ambulate in regular shoe gear and resume their normal daily activities. Some high performance athletes may return to training regiments as soon as eight to 10 weeks postoperatively if tolerated.
Chronic exertional compartment syndrome is an activity-induced pathological elevation of tissue pressures within an osteofascial envelope that results in debilitating symptoms of pain and neurological dysfunction. The etiology of this process is unclear but it appears to be a combination of vascular, neurological and muscular sequelae.6 The diagnosis is often difficult due to the differential diagnoses that involve the neurological, vascular and musculoskeletal systems. A high level of clinical suspicion, a thorough history and measurement of the intracompartmental pressures can help accurately diagnose CECS.
There a few different methods to diagnose CECS in the lower leg. Sphygmomanometer testing, magnetic resonance imaging and near-infrared spectroscopy are reasonable non-invasive methods for identifying this pathology, although sensitivity and specificity vary. The gold standard today remains intracompartmental pressure testing following a brief period of exertion.
Surgical treatment for CECS remains the treatment of choice for patients with elevated intracompartmental pressures.4 Today surgeons perform compartment decompression either by open fasciotomy or by subcutaneous fascial division.3
Endoscopically assisted release improves visualization and minimizes the risk of incomplete compartment decompression and inadvertent neurovascular injuries, subsequently improving patient outcomes.1,3 Endoscopically assisted fasciotomy for CECS in the anterior and lateral compartments of the lower leg is a safe and reliable technique with excellent outcomes and patient satisfaction.6,13
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.
Dr. MacGill is the Chief Resident of Foot and Ankle Surgery at Florida Hospital East Orlando.
Dr. Reeves is an Attending Physician with the Florida Hospital East Orlando Residency Training Program. He is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery.
Dr. Goldstein is an Associate of the American College of Foot and Ankle Surgeons. He practices in Ocala, Fla.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is a Past President of the American Academy of Podiatric Sports Medicine.
For further reading, see “How To Detect And Treat Chronic Compartment Syndrome” in the December 2002 issue of Podiatry Today.
To access the archives or get information on reprints, visit www.podiatrytoday.com.
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