Exertional compartment syndrome is often a diagnosis of exclusion and occurs secondary to increased pressures in a muscular compartment with resultant ischemia manifesting most commonly as pain. There are two distinct forms of exertional compartment syndrome, acute and chronic types.
Chronic exertional compartment syndrome (CECS) occurs in the setting of recurrent, reversible ischemic episodes following the cessation of activity resulting in the predictable decrease in fascial compartment pressures. Although benign, the refractory nature of CECS often results in a substantial portion of patients ultimately electing to proceed with fasciotomies.
Acute exertional compartment syndrome (AECS) is a rare entity that, unfortunately, its diagnosis often delayed. Just as in acute compartment syndrome (ACS), the diagnosis implies a surgical emergency requiring fasciotomies to help mitigate the risks of ensuing irreversible muscle ischemia and neurovascular injury, which can occur after just a few hours alone. ECS typically occurs in the lower leg but can also occur in other areas like the forearm, thigh, or hand. The article provides an overview of the hallmarks and diagnostic considerations surrounding both forms of ECS, including the importance of clinicians maintaining a high index of suspicion to avoid delays in diagnosis.
The major differentiating clinical variable separating the two forms of ECS from ACS is the absence of a specific traumatic event in the former. The literature consistently reports the clinical underappreciation of ECS types, particularly the acute subtype, given that there is most commonly an atraumatic presentation.
Multiple etiologies underlie CECS. During exercise, specific muscle compartments swell up to 20% secondary to increased blood flow and fluid volume. In the setting of CECS, there is ultimately a rise in the pressure within one or multiple musculofascial compartments which impedes further muscle expansion, eventually compromising blood flow once the volume and pressure reach a level that overrides the capillary perfusion pressure. This pressure buildup causes pain and sometimes subtle motor weakness and/or paresthesias in the corresponding neurovascular sensory and motor distributions. For example, CECS affecting the anterior and lateral compartment of the lower leg will often present with pain, tingling, and/or reduced sensation on the dorsum of the foot suggesting superficial peroneal nerve (SPN) involvement
The pathophysiologic cascade following this abnormal increase in intracompartmental pressure results in reduced myocyte oxygenation, and ultimately resulting in myonecrosis and neurologic damage . Depending on the compartment affected, symptoms will vary depending on the specific muscles and/or nerves affected during the pathophysiologic cascade.
Other etiologies of CECS include various overuse injuries or repetitive mechanisms where tissue degeneration or scar formation occurs as a result of microtrauma. Another predisposing risk factor may occur in individuals with inherently decreased elasticity of the fascia which predisposes to nerve entrapment and quicker rises in pathologic pressures overriding the capillary perfusion pressure of the corresponding compartment.. Amendola et al. in their study felt that CECS was secondary to increased fluid content, which impaired muscle or nerve function in a tight compartment.. Braver, in his review article, believed that CECS was secondary to “neurogenic claudication” where nerves were not getting appropriate perfusion secondary to compromised small capillary flow from the elevated pressures. Regardless of the exact mechanism, what is known is that the pathology is related to elevated intracompartmental pressures and it seems to affect those performing repetitive activities, i.e., runners, dancers, speed skaters, and those in military training.
Chronic exertional compartment syndrome is typically considered a rare cause of lower extremity pain, with a reported incidence rate in active patients presenting with exercise-induced leg pain to be 33%.
Waterman et al. in their retrospective study involving a military population showed an average annual incidence of 0.49 per 1000 at-risk person-years. CECS is relatively common, especially amount young adult athletes involved in running, endurance training, soccer, field hockey, and lacrosse. CECS predominantly affects the anterior compartment, representing up to 70% of cases in some series. Other reports cite the anterior and deep posterior compartments are the most frequently affected compartments (25% each), and simultaneous anterior and deep posterior involvement can happen in 8% to 10% of cases. There are reports of bilateral limb involvement in 37% to 82% of symptomatic athletes.
In a retrospective study, Brujin et al. looked at 1411 heterogeneous patients who had complaints of lower extremity pain and had dynamic intracompartmental pressures performed. Of the 1411 patients included in the study, 698 patients had a diagnosis of CECS. CECS demonstrated a peak prevalence at 20 to 25 years of age and a higher likelihood in males than females and was present bilaterally in the majority of cases. It occurred in patients that participated in sports like running or skating and higher activity intensities correlated with a higher likelihood of CECS. However, it is important to note that CECS may occur in patients not involved in sporting activity.
A strong index of clinical suspicion is needed to rule out ACS and AECS; it is particularly crucial given the latter condition occurs in the absence of a traumatic injury or fracture. AECS is essentially a hybrid of ACS and CECS and is often overlooked or diagnosed in a delayed fashion. AECS patients often present following sport-related activity or exertion with nonspecific leg pain during and often persisting after strenuous or repetitive activity. CECS clinically differentiates in that symptoms will predictably abate following activity cessation. While CECS is often a diagnosis of exclusion, AECS should be ruled out first before considering other diagnoses, which one accomplishes by measuring the patient's compartments in question.
The diagnosis of CECS has its basis in a thorough clinical history, paying particular attention to a patient's characterization of pain during strenuous activity, well-localized to a specific compartment and the pain/symptoms disappear quickly after the cessation of activity. Patients will generally complain of discomfort that they describe as squeezing, cramping, aching or burning that typically begins within 15 to 20 minutes of an exertional type activity, i.e., running, marching, etc. The discomfort resolves completely with rest, although the duration may vary.
In 70 to 95% of cases, the pain is bilateral. Generally, the physical examination is unremarkable as patients do not undergo evaluation during or immediately after exercise. If this condition is suspected, a physical examination should take place pre- and immediately post-exercise. After exercise, the affected compartment may be tender, bulge, or feel tight. Passive stretching of the involved compartment may elicit pain. Additionally, there may be focal neurological findings, i.e., decreased sensation, paresthesias, or weakness.
Formal CECS testing following stress-testing gets confirmed by compartment pressure measurements before and after exercise utilizing the Stryker pressure monitoring system as described previously. Upon obtaining baseline measurements with the patient resting supine, the patient is often asked to perform a period of exercise activity in a controlled environment to facilitate later post-testing. A common exercise period consists of running on a treadmill with a minimal degree of incline until the onset of severe symptoms. At that time, the patient rests for 5 minutes, followed by the measurement of compartment pressures.
History is key to suspecting this diagnosis as this condition is easy to overlook or fail to consider. Once CECS is suspected, diagnosis is confirmed by dynamic intra-compartmental pressure measurement at rest and then after exercise.
The Pedowitz criteria are often used to obtain or rule out a diagnosis of CECS in each compartment of interest:
Just as in the setting of ACS, emergent fasciotomies must be performed in a patient presenting with AECS. Otherwise, CECS is typically managed nonoperatively for a one- to three-month duration and surgical management may often be delayed and/or electively performed after having a discussion with the patient (or athlete) regarding the ideal timing given the athletes current sport-specific requirements.
Conservative management consists of rest, activity modification, stretching, orthotics, and physical therapy, but these measures are generally ineffective. Nonoperative modalities include, but are not limited to:
In refractory cases, or following at least a multiple month trial of nonoperative management modalities, operative management is discussed keeping in mind the patient/athlete's expectations for return to baseline activity and/or sport.
Open fasciotomy is the predominant technique. However, other minimally invasive endoscopic techniques are also options. The latter may include a smaller incision; by comparison, however, complication rates are reportedly similar in the literature
In general, for the lower leg:
The differential diagnosis for CECS can be quite broad. Most commonly, CECS initially gets misdiagnosed as shin splints or medial tibial stress syndrome (MTSS).
Other considerations include:
In general, patients with isolated anterior and/or lateral compartment (over 80%) involvement generally report superior outcomes compared to their deep posterior compartment counterparts (60%).
Campano et al. in his systematic review of 24 articles showed a 66% success rate and an 84% satisfaction rate (short and mid-term follow up) after surgical repair. Beck et al. in his retrospective study of 155 pediatric patients showed a 79.5% return to sports rate with 18.8% requiring additional surgical revision. Prognosis also depends on the involved compartment as the anterior compartment (the most common location) has better outcomes. Additionally, a single compartment CECS has a better surgical success rate than CECS involving multiple compartments.
Where CECS is a relatively benign condition characterized by resolution of symptoms with rest, AECS is a true surgical emergency where the symptoms do not resolve. Like CECS, AECS correlates with repetitive type activities such as endurance sports, military training, and not associated with acute trauma. This condition typically affects adolescent and young men. Some believe that this population is at risk secondary to the developing muscle mass in a restrictive fascial space. Like CECS, there are elevated compartment pressures, but in AECS, it can result in irreversible myonecrosis and nerve injury. Treatment is surgical intervention with fasciotomy. Unfortunately, because this entity is rare, and there is a lack of familiarity with this diagnosis, intervention is typically delayed. The key to making the diagnosis is awareness of this entity. The examination is significant for pain out of proportion, and pain with passive stretch. Tenderness remains generally isolated to the affected compartment. Pressure measurement can confirm the diagnosis. Normal pressures are between 0 and 8mmHg. An intracompartmental pressure of 30mmHg or a delta pressure less than 30mmHg (delta pressure = diastolic blood pressure - compartment pressure) is an indication for fasciotomy. It is worth mentioning that if a Stryker intracompartmental pressure monitor is unavailable, an 18g or 20g needle or catheter can be attached to an arterial line monitor to determine pressures.
Knowledge is key. In the setting of an underdiagnosed and easily missed clinical entity, educating providers and patients is paramount. Any patient that with a history of exertional extremity pain which resolves with rest should trigger consideration of CECS and seek medical attention. Additionally, any patient with atraumatic extremity pain with findings of the pain out of proportion, pain on a passive stretch, and tender compartments merits consideration of AECS and should seek care.
Exertional compartment syndrome (ECS) requires awareness by a multitude of providers in various fields. Physical therapists, advanced providers, nurses, and physicians may all encounter this entity in fields like primary care, emergency medicine, sports medicine, and orthopedics. These various disciplines need to work collaboratively across interprofessional lines to help bring about optimal outcomes for these patients. [Level V] Ultimately, once suspected, the condition would need confirmation and definitive management with surgical fasciotomy by a specialist like an orthopedic surgeon. Primary care and emergency medicine practitioners must be especially aware of the limb-threatening form of acute exertional compartment syndrome (AECS).
|||Varacallo M,Shirey L,Kavuri V,Harding S, Acute compartment syndrome of the hand secondary to propofol extravasation. Journal of clinical anesthesia. 2018 Jun [PubMed PMID: 29476968]|
|||Drexler M,Rutenberg TF,Rozen N,Warschawski Y,Rath E,Chechik O,Rachevsky G,Morag G, Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications. Archives of orthopaedic and trauma surgery. 2017 Jan [PubMed PMID: 27670876]|
|||de Bruijn JA,van Zantvoort APM,Hundscheid HPH,Hoogeveen AR,Teijink JAW,Scheltinga MR, Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study. Foot & ankle international. 2019 Mar [PubMed PMID: 30466306]|
|||Livingston K,Glotzbecker M,Miller PE,Hresko MT,Hedequist D,Shore BJ, Pediatric Nonfracture Acute Compartment Syndrome: A Review of 39 Cases. Journal of pediatric orthopedics. 2016 Oct-Nov [PubMed PMID: 26019026]|
|||Chatterjee R, Diagnosis of chronic exertional compartment syndrome in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners. 2015 Aug; [PubMed PMID: 26212853]|
|||Gill CS,Halstead ME,Matava MJ, Chronic exertional compartment syndrome of the leg in athletes: evaluation and management. The Physician and sportsmedicine. 2010 Jun; [PubMed PMID: 20631472]|
|||McKinney B,Gaunder C,Schumer R, Acute Exertional Compartment Syndrome with Rhabdomyolysis: Case Report and Review of Literature. The American journal of case reports. 2018 Feb 8; [PubMed PMID: 29415981]|
|||Puranen J, The medial tibial syndrome: exercise ischaemia in the medial fascial compartment of the leg. The Journal of bone and joint surgery. British volume. 1974 Nov; [PubMed PMID: 4452718]|
|||Braver RT, Chronic Exertional Compartment Syndrome. Clinics in podiatric medicine and surgery. 2016 Apr; [PubMed PMID: 27013413]|
|||Joubert SV,Duarte MA, Chronic Exertional Compartment Syndrome in a Healthy Young Man. Journal of chiropractic medicine. 2016 Jun; [PubMed PMID: 27330517]|
|||Hope MJ,McQueen MM, Acute compartment syndrome in the absence of fracture. Journal of orthopaedic trauma. 2004 Apr [PubMed PMID: 15087965]|
|||Amendola A,Rorabeck CH,Vellett D,Vezina W,Rutt B,Nott L, The use of magnetic resonance imaging in exertional compartment syndromes. The American journal of sports medicine. 1990 Jan-Feb; [PubMed PMID: 2301688]|
|||Waterman BR,Liu J,Newcomb R,Schoenfeld AJ,Orr JD,Belmont PJ Jr, Risk factors for chronic exertional compartment syndrome in a physically active military population. The American journal of sports medicine. 2013 Nov; [PubMed PMID: 23911700]|
|||Breen DT,Foster J,Falvey E,Franklyn-Miller A, Gait re-training to alleviate the symptoms of anterior exertional lower leg pain: a case series. International journal of sports physical therapy. 2015 Feb [PubMed PMID: 25709867]|
|||Davis DE,Raikin S,Garras DN,Vitanzo P,Labrador H,Espandar R, Characteristics of patients with chronic exertional compartment syndrome. Foot & ankle international. 2013 Oct [PubMed PMID: 23669162]|
|||Qvarfordt P,Christenson JT,Eklöf B,Ohlin P,Saltin B, Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clinical orthopaedics and related research. 1983 Oct [PubMed PMID: 6617028]|
|||Martens MA,Moeyersoons JP, Acute and recurrent effort-related compartment syndrome in sports. Sports medicine (Auckland, N.Z.). 1990 Jan [PubMed PMID: 2408118]|
|||Detmer DE,Sharpe K,Sufit RL,Girdley FM, Chronic compartment syndrome: diagnosis, management, and outcomes. The American journal of sports medicine. 1985 May-Jun [PubMed PMID: 4014531]|
|||Schepsis AA,Gill SS,Foster TA, Fasciotomy for exertional anterior compartment syndrome: is lateral compartment release necessary? The American journal of sports medicine. 1999 Jul-Aug [PubMed PMID: 10424211]|
|||de Bruijn JA,van Zantvoort APM,van Klaveren D,Winkes MB,van der Cruijsen-Raaijmakers M,Hoogeveen AR,Teijink JAW,Scheltinga MR, Factors Predicting Lower Leg Chronic Exertional Compartment Syndrome in a Large Population. International journal of sports medicine. 2018 Jan; [PubMed PMID: 29126337]|
|||Tucker AK, Chronic exertional compartment syndrome of the leg. Current reviews in musculoskeletal medicine. 2010 Sep 2 [PubMed PMID: 21063498]|
|||Pedowitz RA,Hargens AR,Mubarak SJ,Gershuni DH, Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. The American journal of sports medicine. 1990 Jan-Feb; [PubMed PMID: 2301689]|
|||Diebal AR,Gregory R,Alitz C,Gerber JP, Effects of forefoot running on chronic exertional compartment syndrome: a case series. International journal of sports physical therapy. 2011 Dec [PubMed PMID: 22163093]|
|||[PubMed PMID: 22427621]|
|||Beck JJ,Tepolt FA,Miller PE,Micheli LJ,Kocher MS, Surgical Treatment of Chronic Exertional Compartment Syndrome in Pediatric Patients. The American journal of sports medicine. 2016 Oct; [PubMed PMID: 27365374]|
|||Vajapey S,Miller TL, Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature. The Physician and sportsmedicine. 2017 Nov; [PubMed PMID: 28952402]|
|||Campano D,Robaina JA,Kusnezov N,Dunn JC,Waterman BR, Surgical Management for Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature. Arthroscopy : the journal of arthroscopic [PubMed PMID: 27020462]|
|||[PubMed PMID: 30137811]|
|||Mostafa E,Varacallo M, Anatomy, Bony Pelvis and Lower Limb, Leg Posterior Compartment . 2019 Jan [PubMed PMID: 30726025]|
|||Lohrer H,Malliaropoulos N,Korakakis V,Padhiar N, Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. The Physician and sportsmedicine. 2019 Feb; [PubMed PMID: 30345867]|
|||Livingston KS,Meehan WP 3rd,Hresko MT,Matheney TH,Shore BJ, Acute Exertional Compartment Syndrome in Young Athletes: A Descriptive Case Series and Review of the Literature. Pediatric emergency care. 2018 Feb; [PubMed PMID: 27248777]|
|||Boody AR,Wongworawat MD, Accuracy in the measurement of compartment pressures: a comparison of three commonly used devices. The Journal of bone and joint surgery. American volume. 2005 Nov; [PubMed PMID: 16264116]|