BrJ7Sports Med 1997;31:21-27 2

Diagnosis and management of chroniccompartment syndromes: a review of the literature

Michael Barnes

Compartment syndromes may be acute or

chronic. Acute syndromes may complicatefracture, soft tissue trauma, burns, and drugoverdose. Very rarely is excessive exercise theunderlying cause.` Sportsmen and women

(particularly footballers) are perhaps more

prone to this condition than the general popu-

lation because of the high incidence of tibialfractures. Acute compartment syndromes are a

potentially limb threatening problem thatshould be dealt with urgently and hence are

more in the remit of orthopaedic and accidentand emergency departments than of sportsmedicine.

Chronic compartment syndromes are thedefinitive sports injury, being almost entirelydue to exercise and overuse. Diagnosis andmanagement are still a matter of debate anduncertainty.

Department of SportsMedicine, LeicesterGeneral Hospital,Gwendolen Road,Leicester LES 4 PW,UKM Barnes

Accepted for publication17 December 1996

Historical aspectsThe first case of a genuine chronic compart-ment syndrome was documented by Mavor in19566 as a case report of a professionalfootballer with bilateral lower leg pain causedby exercise. All earlier reports of exerciserelated compartment syndromes had beenacute syndromes induced by exercise, mostlyin military recruits.'-" It is interesting to notethat the clinical description and treatment inMavors' paper are very similar to current opin-ions and practice.

In the same volume of the journal, an edito-rial by Griffiths" cast doubt on Mavor's case

and questioned the existence of a chronic com-partment syndrome. However, over the past 40years there have been well over 1000 docu-mented cases (mostly confirmed by intracom-partmental pressure measurement and thesuccessful outcome of fasciotomy), so it wouldseem that Griffiths was wrong, and chroniccompartment syndrome is now a well recog-nised specific condition, with its own history,symptoms, and treatment.The correlation of the history and symptoms

with raised intracompartmental pressure was

first carried out by French and Price in 1 962'susing the needle method of Wells et al.'6When Reneman" published his series of 61

patients in 1975, there had been only nine pre-

viously reported cases. All 70 cases wereanterior/lateral. A chronic compartment syn-drome of the deep posterior compartment hadbeen suggested by Puranen'8 in 1974, but notconfirmed by pressure measurements until1981.'9 Even today there is still uncertaintyabout the causes of exercise related pain in andaround the deep posterior compartment.

DefinitionIn the broadest and simplest terms a chroniccompartment syndrome is defined as a condi-tion of pain on exercise that is relieved by rest.Over months the symptoms become worsewith progressively earlier onset. However, thisdefinition could cover several other conditions.Hence the need for measurements of intracom-partmental pressure.

AnatomySome 95% of chronic compartment syn-dromes occur in the lower leg. This is due to itsparticular anatomy and that intensive exerciseof the lower leg is part of virtually all sports.The remaining 5% are distributed between theforearm,202' thigh,222' hands,'4 and, very rarely,feet.25 26 What follows, therefore, will be limitedto the lower leg.

It is a generally accepted view that there arefour compartments in the lower leg; ananterior, deep posterior, lateral, and superficialposterior. Chronic compartment syndromeshave been diagnosed in all four, but it ispredominantly the anterior and deep posteriorcompartments that are most often involved.This is not a universally held belief. Davey eta!" suggested that the tibialis posterior muscleconstitutes a separate compartment making atotal of five compartments altogether. Detmeret a!'8 has taken this even further, stating thateach muscle should be regarded individually.They also describe seven functional compart-ments: in addition to the anterior and lateralcompartments, the deep posterior should bedivided into proximal and distal, and thesuperficial posterior should be subdivided intodistal, lateral, and medial. No work has beendone to confirm that these are discrete pressureunits. These additional subdivisions may berelevant for correct surgical decompression.

Clinical aspectsMany chronic compartment syndromes can bediagnosed by history alone. The patientcomplains ofpain on exercise that is relieved byrest and has progressively worsened over aperiod ofmonths. The pain may be localised toa specific compartment or described as ageneral ache. There may be distal neurologicalsigns of paraesthesia in the foot. There are,however, several other conditions which maymimic these symptoms-for example, poplitealentrapment syndrome, medial tibial syndrome,or stress fracture. Most of these may be elimi-nated by other signs or routine investigations.Medial tibial syndrome always has associatedinner border tibial tenderness; stress fracturescan usually be confirmed by plain radiographs

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Table 1 Reported incidence of muscle hernias

No ofAuthors Year Patients Incidence (%)

Mavor6 1956 1 100French and Price'5 1962 2 100Reneman'7 1975 61 60Sudmann2 1979 51 Not mentionedPuranen and

Alavaikko'9 1981 10 Not mentionedMcDermott et al' 1982 9 45Qvarfordt et aP' 1983 108 40Martens et al12 1984 29 30Wallensten and

Eriksson"3 1984 12 Not mentionedDetmer et aP8 1985 50 OccasionalStyf and Korner'4 1986 80 See.textAllen and Barnes" 1986 110 None foundFronek et al6 1987 18 39 (<5 in normal

subjects)Turnispeed et al" 1989 209 Not mentionedPedowitz et al'8 1990 131 45.9 (12.9 in normal

subjects)Ambramowitz and

Schepsis"9 1994 28 25

and popliteal entrapment syndrome will affectfoot pulses (chronic compartment syndromenever affects the major vessels). However, noneof these conditions are mutually exclusive, sothe confirmation of one does not necessarilyrule out the existence of the others.On examination there is little or nothing to

see. Some authors suggest that swelling overthe anterior compartment can be felt in somepatients, particularly after exercise. This is asubjective finding and gives no indication as towhat might be happening in the deep posteriorcompartment. Swelling is of course, no indica-tion of raised compartmental pressure. It iscommon to find grossly swollen and tenselimbs with normal intracompartmental pres-sures (in patients with suspected acute com-partment syndrome).

Incidence ofmuscle herniasMuscle hernias may occur in association withanterior compartment syndrome (table 1).Some authors do not even mention them-others say that they are an occasional finding,others that they are a confirming diagnosticindicator.

In an earlier series of 1 10 consecutivepatients'5 we found no muscle hernias. In the10 years since, we have seen well over 1000patients with suspected compartment syn-drome and only 20 muscle hernias (anincidence <1 %) and these have been equallydistributed between patients with and withoutraised compartmental pressures. It has beenargued that a muscle hernia is a strong indica-tor of a longstanding compartment syndromeas the increased pressure within the compart-ment has caused the fascial defect." It has alsobeen suggested that the existence of a fascialdefect will prevent the build up of pressure'4 17implying that they should be a contraindicationfor increased pressure. Styf and Korner'4 foundmuscle hernias in five out of 19 patients withconfirmed anterior compartment syndrome onclinical examination, but then found a further12 in 30 limbs undergoing surgery. The differ-ences in the frequency of muscle herniasbetween normal subjects and patients with

Table 2 Evolution ofchronic compartment syndromepressure measurement techniques

Authors Year Technique

French and Price'" 1962 Wells et al'6 needleReneman" 1975 NeedleMubarak et al' 1976 WickD'Ambrosia et al" 1977 Needle with transducerSudmann" 1979 Needle and wickRorabeck et al'2 1980 SlitPuranen and Alavaikko'9 1981 WickMubarak et al" 1981 SlitMcDermott et alP 1982 STICRaether and Lutter" 1982 Whitesides et al44 needleChristenson et al5 1983 Epidural cathetersQvarfordt et al16 1983 WickRydholm et al" 1983 WickWallensten48 1983 WickMartens et al2 1984 WickDetmer et al'8 1985 Needle and wickStyf and Korner49 1986 Microcapillary infusionKutz et al' 1985 SlitAllen and Barnes2' 1986 SlitBell50 1986 Wick and slitFronek et al'6 1987 Wick and slitTurnispeed et al' 1989 StrykerPedowitz et al8 1990 Slit

compartment syndrome found by Pedowitz etaP'8 were reported as significant.The only conclusion that can be drawn from

such a diversity of findings is that preselectionof patients may influence the results whencomparing series.

Pressure measurementMeasurement of intracompartmental pressureis required to confirm the diagnosis and estab-lish exactly which compartments are involved.The techniques and equipment used haveevolved over time (table 2). The needle andmanometer techniques of Wells et al'6 andWhitesides et at4 have largely given way to wickor slit catheters and pressure transducers.These more recent methods are not necessarilymore accurate, but are much easier to use andmore versatile. With flexible catheters andtransducers the patient can exercise with thecatheters in place, thus making it possible tomeasure pressure during exercise and immedi-ately afterwards. This is obviously better thaninserting a needle after exercise because of thetime delay involved and the possibility that thelocalised trauma may give a falsely highpressure. Also, by using transducers andamplifiers an electrical signal is produced ena-bling a record of the fluctuations in pressure tobe made.Today most people use the slit catheter as it

is readily available (or simple to make) andreliable with an adequate frequency responsefor measuring pressure during exercise. Theolder method of needle and manometer israrely used, but does have the advantage ofneeding no specialised equipment so it can beused almost anywhere. The STIC (solid statetransducer intracompartmental catheter) ofMcDermott et al' and the microcapillary infu-sion technique of Styf and Korner49 are bothmore complex methods designed to improvefrequency response, but are both rather com-plicated for routine clinical use. The Strykerbox is a simple hand held device containing atransducer, amplifier, and display, that con-

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Table 3 Diagnostic criteria of intracompartmental pressure measurement

Authors Year Diagnostically relevant pressure values

French and Price" 1962 Postexercise fall time <30 min in normal subjects,> 100 min in patients

Reneman"7 1975 At six minutes postexercise pressure >15 cm H2O (11mm Hg) above resting pressure

Puranen" 1981 Mean pressure of 50 mm Hg during running. Restingof no value, but did observe slow postexercise fall

McDermott3' 1982 Mean pressure of 85 mm Hg during runningMubarak and Hargens5" 1982 Resting pressure >15 mm Hg. Exercise pressure >75

mm Hg. Pressure remains >30 mm Hg for >5 min afterexercise

Qvarfordt et al" 1983 Pressures raised before, during, and after exercise.Postexercise decline 40 min. Ti 6 min

Wallensten" 1983 No difference at rest, still raised 10 min postexercise(anterior), returned to normal <10 min (deep posterior)

Detmer et al" 1985 At rest, normal pressure < 15 mm HgStyf and Korner" 1986 Muscle relaxation pressureStyf and Korner34 1986 Postexercise pressure >35 mm Hg remained raised for >6

min (Also muscle relaxation pressure was raised duringexercise. >20 mins to return to normal)

Allen and Barnes" 1986 Exercise pressure >50 mm Hg anterior, >40 mm Hg deepposterior No difference in resting pressures

Fronek et al" 1987 Resting pressure .10 mm Hg and/or .25 mm Hg 5 minafter exercise

Rorabeck et al'2 1988 Pre-exercise pressure > 10 mm Hg and postexercise> 15 mm Hg for > 15 min

Styfs3 1988 Relaxation pressure >35 mm Hg, resting pressure >30mm Hg, postexercise return to normal >6 min

Turnispeed et al" 1989 > 20 mm Hg at rest (postexercise increase and slowdecline > 10 min)

Pedowitz et alr 1990 Pre-exercise pressure .15 mm Hg, or postexercisepressure .30 mm Hg at imin or .20 mm Hg at 5 min

nects directly to a needle or slit catheter. It wasprimarily designed for acute work, but itprovides a practical compromise between thecheap and simple techniques and the more

sophisticated and expensive ones.

Diagnosis by pressure measurementMuch has been written about the advantagesand disadvantages of each particular method inregard to frequency response, reliability,reproducibility, accuracy, and cost. But themajor area of debate and point of greatestclinical importance is the diagnostic pressurevalue and when and how should it be measured(table 3).The first recorded pressure measurements of

a patient with chronic compartment syndromewere by French and Price in 1962," who foundthat the major difference in the pressurerecordings between patients with compartmentsyndrome and normal subjects was the time ittook the pressure to return to its resting valueafter exercise. This method had to be adoptedowing to the limitations in the technologyavailable at the time-it would have been verydifficult to measure the pressure duringexercise with a needle technique. Since thisfirst investigation the concept of postexercisepressure drop has largely remained the same

and is still the most widely used diagnostic cri-terion. However, each new investigator hasaltered or adapted the figures slightly, changingeither the time, the pressure value, or both.The physiological justification for this

method may be based on the 20% increase inmuscle volume that occurs during exercise.'4Patients are usually exercised until the onset ofsymptoms, which may take many minutes. Thevolume increase during this period then takestime to disperse, so the pressure remains raisedfor some time after the cessation of exercise.

Other authors have used different concepts.Puranen and Alavaikko" adopted a mean valueof 50 mm Hg during running and this figurewas also used by Allen and Barnes.21 McDer-mott et al 30 used a similar exercise protocol butadopted a higher threshold pressure of 85 mmHg. In addition they state that postexerciserecordings are so variable that they should notbe used for diagnosis. We agree with this state-ment, having found that the pressure dropsimmediately on the cessation of exercise. Wethink that a slow decline in postexercisepressure is more likely to be a blocked catheterrather than a finding of pathological relevance.The justification for using pressures recordedduring exercise is that this is when thesymptoms occur-the pain goes when theexercise stops.During exercise, as the muscles contract and

relax, a pulsatile pressure waveform is gener-ated, with the maximum pressure correspond-ing to the contraction and the minimum pres-sure occurring during relaxation. Styf et al" 55 56considered the muscle relaxation pressure tobe a more appropriate method of diagnosisthan mean exercise pressure. This is based onthe idea that if the exercise pressure dropsbelow 30 mm Hg during the relaxation phaseof exercise the muscle can still be adequatelyperfused. Styf et al also found a goodcorrelation between muscle relaxation pressureand postexercise fall, and dismissed meanexercise pressures as being unreliable, havingfound no significant differences between legswith and without compartment syndrome.This is explained by the effect of musclecontraction force on pressure.The clinical relevance of pressures measured

during exercise has been criticised on severalgrounds: the value being dependent on depthof catheter insertion and the strength of musclecontractions. Hargens et al'7 found strong cor-relations between the pressure and the depthinto the muscle and percentage maximum vol-untary contraction (MVC). Higher pressureswere recorded at greater depth and higher%MVC. This finding has been confirmed byAbramowitz and Schepsis.3

However, this work was done in the vastismedialis of the thigh which is anatomically verydifferent from the muscles in the lower legcompartments. In addition it is possible toavoid these criticisms by inserting the cathetersto a fixed depth and adopting a quantifiedexercise protocol.Some have used the pre-exercise resting

pressure for diagnosis (table 3), or at leasttaken it into account.2 3$353 However, aspointed out by Nkele et al'8 there is a range ofnearly 20 mm Hg in normal subjects, makingany use of this figure questionable, andsimilarly Allen and Barnes35 found a wide vari-ation in the resting pressures of patients withchronic compartment syndrome.Hence there is no real consensus on

definitive diagnostic values. This probablyreflects the lack of understanding about theunderlying pathophysiology.However, intracompartmental pressure

measurements remain the most direct and best

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objective method of diagnosis. Many othermethods have been used in the investigation ofchronic compartment syndrome, but thesehave largely been in an attempt to find outmore about the underlying causes, rather thanas practical diagnostic techniques.

Other methods of investigationBONE SCANSRadioisotope imaging is a useful technique inthe diagnosis of lower leg pain; in particular,bone scans are the best method to confirmstress fractures. Several authors8 33 36 haveattempted to use bone scanning to diagnosecompartment syndrome, but the results havebeen inconclusive. This is not an appropriatetechnique for the diagnosis of chronic com-partment syndrome, but is necessary for theelimination of other diseases.

METHOXY ISOBUTYL ISONITRILEMethoxy isobutyl isonitrile has been used toimage ischaemic heart muscle for some time.Recently, this technique has been applied toskeletal muscle in the hope that it candistinguish between normal and pathologicalcompartments.5960 The disadvantages of thistechnique are that it subjects the patient toradiation, the radiopharmaceutical is veryexpensive, and it requires 3D imaging tech-niques. Should it prove to be reliable it has theadvantage of being more widely available thanpressure measurements and is less invasive.

ELECTROPHYSIOLOGYThere are two types of investigation that maybe applied to chronic compartment syndrome.Electromyography (EMG) can be used to givean indication of the strength of musclecontractions, and hence may be useful in shed-ding light on the causes of compartmentsyndrome. Nerve conduction velocity (NCV)may show neurological changes due to raisedintracompartmental pressure either directlyexerting pressure on the nerves or affectingthem by disrupting the blood supply. Both maybe useful research tools, but it is rare for intra-compartmental pressures to become suffi-ciently elevated that the nerves are affected, sothe diagnostic use is limited.

MAGNETIC RESONANCE IMAGING

Magnetic resonance imaging (MRI) has beenused to investigate chronic compartment syn-dromes.596' It has the obvious advantages ofbeing non-invasive, producing an image of allthe compartments at the same time, andperhaps providing additional information as tothe causes. At present it is still a very expensivediagnostic technique, and rather an indirectmethod of diagnosis.

ULTRASOUND IMAGINGGershuni et a16' have used ultrasound to meas-ure changes in the size of the anterior compart-ment after exercise. This has the advantages ofbeing totally non-invasive and widely available,but is not really a valid diagnostic technique. Itcan only be used on the anterior compartment,and there is no evidence to suggest that an

increase in the compartment volume is relatedto an increase in the compartment pressure. Itcould be argued that the compartment pres-sure increases because there is no increase inthe compartment volume.

MUSCLE BLOOD FLOWThis technique has been used for many years.'5Styf et ar5 correlated muscle relaxation pres-sure with muscle blood flow during exercise.Qvarfordt et al' found that muscle blood flowdecreased during exercise in patients withraised pressures. These findings may shed lighton the underlying pathology, but are againmore a research than clinical tool.

TreatmentDO NOTHINGThe real incidence of chronic compartmentsyndromes in the population at large isunknown. This is because it is a self limitingcondition, the pain occurs during exercise andgoes with rest. Many potential patients willsimply give up their activity rather than seekmedical treatment. This attitude may unfortu-nately be adopted by some members of themedical profession who recommend that "if ithurts don't do it". Only a small percentage ofpotential patients may ever progress to reach adefinitive diagnosis.Many patients can trace the earliest symp-

toms back to an increase in or a change ofactivity. Reducing activity back to previous lev-els often prevents the pain, and some patientsconsider this to be the best option.There is one potential danger with this

method of treatment. There is a small amountof evidence to suggest that a chronic compart-ment syndrome may, under certain circum-stances (excessive overuse), become acute andtherefore potentially limb threatening. Thiscan only be inferred from the very few cases ofexercise induced acute compartment syn-dromes which sometimes list chronic symp-toms in the history.7"3263 There is no direct evi-dence.

CONSERVATIVE MEASURESPreventiveIt is widely believed, although there can be noreal objective scientific evidence, that inappro-priate training may be a major contributingfactor to the development of a chroniccompartment syndrome. Such factors as incor-rect or worn out footwear, running on hardsurfaces, and changing or increasing activityhave all been suggested as possible causes.There is also the suggestion that chronic com-partment syndrome may be caused by bio-mechanical abnormalities64 and in particularexcessive pronation. If this is the case then cor-recting the gait by the use of orthotics shouldprevent the symptoms. As yet this theory andthe effectiveness of orthotics have neither beenproved nor disproved.

CurativeAs well as restricting activity to withincomfortable limits, total rest has also been sug-gested as a treatment. It is our experience that

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rest has no effect at all on genuine cases. Evenwhen patients do nothing more strenuous thaneveryday walking for several months, thesymptoms return within days of recommenc-ing to run. This contradicts the theory thatmuscle hypertrophy is a contributing factor, asmuscle will waste very quickly with this level ofinactivity.Many other conservative treatments have

been tried. Anti-inflammatory drugs, pain kill-ers, ice, heat, ultrasound, physiotherapy, andsteroid injections have all been used at somestage. Most of these treatments are effective atalleviating the symptoms to a degree, but theydo not cure the underlying problem. In theseries of 80 patients described by Styf andKorner56 all had tried a range of conservativemeasures, including diuretics, without success.Martens et alP treated nine patients conserva-tively with prolonged rest, physiotherapy, anti-inflammatory drugs, and stretching exercise ofthe flexor muscles, but this could not beconsidered successful as all the patients had toreduce their sports activity to some extent.Fronek et alP6 initially treated 18 patientsconservatively with rest, stretching, and modi-fication of activity. However, 13 of 18 foundthis unsatisfactory and went on to surgery. Theremaining five did not improve, but continuedto restrict their activity.Hence all have found conservative measures

to be unsuccessful.

SURGERYIt is generally accepted that surgery is the onlyreally effective treatment for a chronic compart-ment syndrome. Various different fasciotomytechniques have been described," 27 28 34 36 37 48 51 65but all have the same effect-to divide therestricting envelope of the fascia and thuseffectively increase the size of the compartment.The underlying cause of chronic compart-

ment syndrome is still unknown. One of thepossible causes may be due to changes in themechanical properties of the fascia-for exam-ple, reduced compliance due to increasedthickness.66 If, as seems most likely (as longterm rest and all conservative measures areineffective), these changes are irreversible, thensurgery must be the only effective treatment.

OutcomesThe outcome of surgery is generally very goodwith some success rates reaching 100%. A suc-cessful result can vary from an increased exer-cise tolerance to complete absence of symp-toms. Several authors have also measuredpostoperative pressures for confirmation, 1921 33 34

although these can be difficult to interpretowing to the presence of scar tissue. There aresome poorer results, particularly with the deepposterior compartment. Ambramowitz andSchepsis"9 found that all 16 patients whounderwent anterior compartment fasciotomyhad good results. However, only 13 out of 20had satisfactory results in the deep posteriorcompartment. Similarly Rorabeck et al5 ob-

tained complete success in the anterior com-partment but in only 10 out of 12 with thedeep posterior compartment. Both these au-thors suggest that the failures were due toincomplete fasciotomy, a theory supported byPuranen and Alavaikko'9 who went on to redohis failures with more extensive surgery,obtaining successful outcomes.

In one of the largest series Turnispeed et alr7decompressed 209 patients, 100 with a subcu-taneous fasciotomy and 109 with the unusualmethod of open fasciectomy. The success ratewas higher (98%) with the open procedurethan with the closed (89%). However, no men-tion was made of recurrence rates in specificcompartments.The comparatively low success rate of

surgery in the deep posterior compartmentmay result from several reasons. The possibilityof incomplete fasciotomy has already beenmentioned, and some authors are cautiousabout excessive dissection in an athlete,possibly leading to muscle weakness. A furtherreason may be incomplete decompression ofthe tibialis posterior, if as suggested by Davey etal'7 it is a separate compartment. There is alsothe possibility of multiple diseases with similarpresentations. Detmer67 has subdivided pa-tients with exercise pain in the deep posteriorcompartment into three distinct groups, whichare not all treatable by surgery and may wellcoexist.

POSTOPERATIVE MANAGEMENTThe successful outcome of surgery may alsodepend on the immediate postoperative man-agement. The earliest possible mobilisation isrequired to maximise the effect of the fasci-otomy. If the patient remains inactive in bed forseveral days after surgery, then the fascia maywell heal back to its original size and make thesurgery ineffective.Rorabeck et at5 encouraged patients to walk

as much as possible on the first postoperativeday; Bell50 kept his patients in bed for five days,but encouraged them to perform active footdorsiflexion one day after surgery; Detmer et al 28kept the legs raised for 48 to 72 hours to reduceoedema and hence speed recovery, whereas Wal-lensten48 allowed his patients to walk immediatelyafter surgery.

Styf and Korner'4 kept the patient's legsraised for 12 hours and then encouraged walk-ing.

COMPLICATIONSSome authors have admitted to surgicalcomplications. Detmer et al'8 in a series of 100patients had a total of 1. These included onearterial injury repair, five haematomas, fourwound infections, three nerve injuries, and onedeep venous thrombosis. Fronek et al6 re-ported only one wound infection in a series of18 patients. The published complication ratesare not sufficiently high to consider thatsurgery may be too risky; but there are otherpossible contraindications which should beconsidered.

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POSSIBLE DETRIMENTAL EFFECTS OF SURGERY

There is some speculation concerning the pos-sible detrimental effects of surgery. As hasalready been mentioned there are concernsabout excessive surgical dissection causingmuscle weakness. Garfin et al68 found thatmuscle force decreased with fasciotomy, whichmay be a problem for athletes. This work wascarried out on dogs so it only shows an imme-diate effect; there was no long term follow up.No measurements have been done to see if thisis a genuine long term problem. A more recentstudy69 has shown that preoperatively patientswith compartment syndrome have weakermuscles than normal subjects. Our currentresearch shows that patients with chronic com-partment syndrome have greater power but lessendurance than normal subjects.

It is widely thought that fasciotomy issuccessful because it increases the size of thecompartment, thereby increasing the volumeand reducing the pressure generated by exer-cise. However, if the cause of increasedpressure is stronger muscle contractions, thenperhaps the effect of fasciotomy is to reducethe power of the contractions and thus toreduce the pressure. This theory correlateswith the work of Hargens et al,57 who foundthat intracompartmental pressure was relatedto muscle contraction force.

REPEAT SURGERYAs mentioned earlier there have been somefailures of surgery. Many of these have thenbeen successfully treated by a second moreextensive operation. It is important to distin-guish between patients who have never hadrelief of symptoms and those who have had arecurrence months or even years later. Bell50had five patients who still had symptoms andelevated pressures after fasciotomy. These weresuccessfully treated by fasciectomy. In theseries of Detmer et a!'8 of 100 patientsundergoing surgery, five had had a recurrenceof symptoms within two months. All five werethen cured by a second operation. We havefound a small but important group of patientswho were free of symptoms for several yearsbefore the symptoms returned. These patientshave also responded well to a second opera-tion, but it is difficult to explain why the symp-toms returned. This may cast doubt on thelong term effects of fasciotomy. No compre-hensive long term follow up studies have yetbeen done.

ConclusionChronic compartment syndrome of the lowerleg is a relatively common sports injury. It isusually easy to confirm the diagnosis from his-tory alone, but in more difficult cases, intra-compartmental pressure measurement is re-quired. The treatment of choice is fasciotomy,which has a very high success rate. Despite theabundance of literature on the subject over thepast 40 years, there are still several areas of

disagreement, principally that of an exact diag-nostic pressure value. This may become cleareras more work is done to establish the underly-ing cause.

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