Chronic Exertional Compartment Syndrome Sathish Rajasekaran,
MD, Clinical Assistant Professor, Division of PM&R, University
of Alberta
Slide 2
None Disclosures
Slide 3
Introduction Anatomy Pathophysiology History and Physical Exam
Diagnostic Evaluation Treatment Outline Have an approach to adding
CECS to your differential diagnosis based on history and physical
examination Outline an approach to ordering the appropriate tests
for patients where CECS is on the differential diagnosis Outline
conservative and surgical treatment options for CECS Outline return
to play guidelines for CECS Objectives Choric Exertional
Compartment Syndrome (CECS)
Slide 4
Clinical Case 24 year old female J.M. History: Classical
symptoms? Physical Examination At rest vs. post-exertion Diagnostic
Testing Compartment pressure testing vs. other imaging modalities
Other studies to exclude other diagnoses Treatment options
Conservative (rehabilitation) vs. interventional options vs.
surgery
Slide 5
Slide 6
Epidemiology Incidence 2,3 General population (unknown)
Undiagnosed leg pain (14-27%) Age 4-8 Potential bimodal
distribution (20 [before 30] vs. 48 years) Association with sports
4,9 Involved in sports (87%) Running (69%) Diabetic patients with
exertional leg pain and normal vascular studies (90%)
Slide 7
Location Can present in various regions of the body 10 Lower
leg, thigh, foot, and forearm Lower leg most common region affected
(95%) 10 Bilateral lower leg involvement (82%) 4
Slide 8
Anatomy 40-60% 4,5 32-60% 4,5 12-35% 4,5 2-20% 4,5 Rajasekaran
S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM
& R. Dec 2012;4(12):985-1000.
Slide 9
Pathophysiology Compliance Compartment pressure?
Slide 10
Pathophysiology Reduced microcirculatory capacity Vascular
congestion as a result of decreased venous return
Slide 11
Pathophysiology Abstract presented at AMSSM 2013 (Rajasekaran
and Aly)
Slide 12
Pathophysiology
Slide 13
History and Physical Examination Pain with exertion Dull sharp
pain Neurological symptoms Worsening over time Pain with passive
stretching of muscles in involved compartment
Slide 14
Diagnostic Evaluation Pressure testing Pre-exercise (15 mm Hg),
1 min post-exercise (30 mm Hg), 5 min post-exercise (20 mm Hg)
Slide 15
Diagnostic Evaluation (Imaging)
Slide 16
Diagnostic Evaluation - Imaging Bresler M, Mar W, Toman J.
Diagnostic imaging in the evaluation of leg pain in athletes.
Clinics in sports medicine. Apr 2012;31(2):217-245. Litwiller DV,
Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome
of the lower extremities: improved screening using a novel dual
birdcage coil and in-scanner exercise protocol. Skeletal radiology.
Nov 2007;36(11):1067-1075.
Slide 17
Diagnostic Evaluation - Imaging Tib Fib TP ATMG Rajasekaran S,
Beavis C, Aly AR, Leswick D. The utility of ultrasound in detecting
anterior compartment thickness changes in chronic exertional
compartment syndrome: a pilot study. Clinical journal of sport
medicine : official journal of the Canadian Academy of Sport
Medicine. Jul 2013;23(4):305-311.
Slide 18
Treatment Conservative Interventional Surgery
Slide 19
Treatment Conservative
Slide 20
Treatment Interventional
Slide 21
Treatment - Interventional
Slide 22
Treatment Surgery Single incision (open) technique One or two
incision (subcutaneous) technique with or without endoscopic
assistance with the removal of a strip of fascia
Slide 23
Slide 24
Treatment - Surgery 24
Slide 25
Treatment - Surgery Complications (11-16%) 28,29 Infection
Nerve or vascular injury Deep vein thrombosis Wound dehiscence
Complex regional pain syndrome Scar hypersensitivity
Seroma/hematoma formation
Slide 26
Treatment - Surgery POD 1-2 Gentle active and passive
range-of-motion, weight bearing as tolerated, edema control
measures, basic activities of daily living, protect the healing
incision at all times POD 3-4 Achieve independence with activities
of daily living, and begin unassisted ambulation Weeks 1-4 Add
stair climbing and increase walking distance Weeks 4-6 Begin
non-impact lower extremity aerobic exercise Weeks 6+ Initiate
unrestricted impact lower extremity activities Rajasekaran S,
Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM
& R. Dec 2012;4(12):985-1000.
Slide 27
Clinical Case 24 year old female J.M. Trialed forefoot running
technique Symptoms resolved Repeat pressures were not done Patient
continues to be asymptomatic (7 months)
Slide 28
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in
the athlete. PM & R. Dec 2012;4(12):985-1000.
Slide 29
Introduction Anatomy and Pathophysiology History and Physical
Exam Diagnostic Evaluation Treatment Return-to-Play Guidelines
Outline Have an approach to adding CECS to your differential
diagnosis based on history and physical examination Outline an
approach to ordering the appropriate tests for patients where CECS
is on the differential diagnosis Outline conservative and surgical
treatment options for CECS Outline return to play guidelines for
CECS Objectives Choric Exertional Compartment Syndrome (CECS)
Slide 30
References 1.Horn C. Acute ischaemia of the anterior tibial
muscle and the long extensor muscles of the toes. J Bone Joint Surg
Am. 1945;27(4):615-622. 2.Qvarfordt P, Christenson JT, Eklof 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. Oct
1983(179):284-290. 3.Styf J. Diagnosis of exercise-induced pain in
the anterior aspect of the lower leg. The American journal of
sports medicine. Mar-Apr 1988;16(2):165-169. 4.Detmer DE, Sharpe K,
Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis,
management, and outcomes. The American journal of sports medicine.
May-Jun 1985;13(3):162-170. 5.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. Jan-Feb 1990;18(1):35-40.
Slide 31
References 6.Rorabeck CH, Bourne RB, Fowler PJ. The surgical
treatment of exertional compartment syndrome in athletes. The
Journal of bone and joint surgery. American volume. Dec
1983;65(9):1245-1251. 7.Wallensten R. Results of fasciotomy in
patients with medial tibial syndrome or chronic
anterior-compartment syndrome. The Journal of bone and joint
surgery. American volume. Dec 1983;65(9):1252-1255. 8.Styf JR,
Korner LM. Chronic anterior-compartment syndrome of the leg.
Results of treatment by fasciotomy. The Journal of bone and joint
surgery. American volume. Dec 1986;68(9):1338-1347. 9.Edmundsson D,
Toolanen G. Chronic exertional compartment syndrome in diabetes
mellitus. Diabetic medicine : a journal of the British Diabetic
Association. Jan 2011;28(1):81-85. 10.Barnes M. Diagnosis and
management of chronic compartment syndromes: a review of the
literature. Br J Sports Med. Mar 1997;31(1):21-27.
Slide 32
References 11.Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional
leg pain in the athlete. PM & R : the journal of injury,
function, and rehabilitation. Dec 2012;4(12):985-1000. 12.Hurschler
C, Vanderby R, Jr., Martinez DA, Vailas AC, Turnipseed WD.
Mechanical and biochemical analyses of tibial compartment fascia in
chronic compartment syndrome. Annals of biomedical engineering.
May-Jun 1994;22(3):272-279. 13.Dahl M, Hansen P, Stal P, Edmundsson
D, Magnusson SP. Stiffness and Thickness of Fascia Do Not Explain
Chronic Exertional Compartment Syndrome. Clinical orthopaedics and
related research. Sep 24 2011. 14.Edmundsson D, Toolanen G,
Thornell LE, Stal P. Evidence for low muscle capillary supply as a
pathogenic factor in chronic compartment syndrome. Scandinavian
journal of medicine & science in sports. Dec
2010;20(6):805-813. 15.Birtles DB, Rayson MP, Casey A, Jones DA,
Newham DJ. Venous obstruction in healthy limbs: a model for chronic
compartment syndrome? Medicine and science in sports and exercise.
Oct 2003;35(10):1638-1644.
Slide 33
References 16.Aweid O, Del Buono A, Malliaras P, et al.
Systematic review and recommendations for intracompartmental
pressure monitoring in diagnosing chronic exertional compartment
syndrome of the leg. Clinical journal of sport medicine : official
journal of the Canadian Academy of Sport Medicine. Jul
2012;22(4):356-370. 17.Roberts A, Franklyn-Miller A. The validity
of the diagnostic criteria used in chronic exertional compartment
syndrome: A systematic review. Scandinavian journal of medicine
& science in sports. Sep 13 2011. 18.McDonald S, Bearcroft P.
Compartment syndromes. Seminars in musculoskeletal radiology. Jun
2010;14(2):236-244. 19.Bresler M, Mar W, Toman J. Diagnostic
imaging in the evaluation of leg pain in athletes. Clinics in
sports medicine. Apr 2012;31(2):217-245. 20.Litwiller DV, Amrami
KK, Dahm DL, et al. Chronic exertional compartment syndrome of the
lower extremities: improved screening using a novel dual birdcage
coil and in-scanner exercise protocol. Skeletal radiology. Nov
2007;36(11):1067-1075.
Slide 34
References 21.Rajasekaran S, Beavis C, Aly AR, Leswick D. The
utility of ultrasound in detecting anterior compartment thickness
changes in chronic exertional compartment syndrome: a pilot study.
Clinical journal of sport medicine : official journal of the
Canadian Academy of Sport Medicine. Jul 2013;23(4):305-311.
22.Kirby RL, McDermott AG. Anterior tibial compartment pressures
during running with rearfoot and forefoot landing styles. Archives
of physical medicine and rehabilitation. Jul 1983;64(7):296-299.
23.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. Dec
2011;6(4):312-321. 24.Diebal AR, Gregory R, Alitz C, Gerber JP.
Forefoot Running Improves Pain and Disability Associated With
Chronic Exertional Compartment Syndrome. The American journal of
sports medicine. Mar 16 2012. 25.Isner-Horobeti ME, Dufour SP,
Blaes C, Lecocq J. Intramuscular pressure before and after
botulinum toxin in chronic exertional compartment syndrome of the
leg: a preliminary study. The American journal of sports medicine.
Nov 2013;41(11):2558-2566.
Slide 35
References 26.Wittstein J, Moorman CT, 3rd, Levin LS.
Endoscopic compartment release for chronic exertional compartment
syndrome: surgical technique and results. The American journal of
sports medicine. Aug 2010;38(8):1661-1666. 27.Packer JD, Day MS,
Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes
and patient satisfaction after fasciotomy for chronic exertional
compartment syndrome. The American journal of sports medicine. Feb
2013;41(2):430-436. 28.Waterman BR, Laughlin M, Kilcoyne K, Cameron
KL, Owens BD. Surgical treatment of chronic exertional compartment
syndrome of the leg: failure rates and postoperative disability in
an active patient population. The Journal of bone and joint
surgery. American volume. Apr 3 2013;95(7):592-596. 29.Brennan FH,
Jr., Kane SF. Diagnosis, treatment options, and rehabilitation of
chronic lower leg exertional compartment syndrome. Current sports
medicine reports. Oct 2003;2(5):247-250.