Exertional Compartment Syndrome

Introduction

Increased compartment pressure with exercise
- anterior compartment most commonly affected (~70%)
- anterior and lateral compartment affected in 10%
- posterior compartment involvement associated with less predictable surgical outcomes
Epidemiology
- more common in males
- often seen in 3rd decade of life
Pathophysiology
- vascular, advanced imaging, and histologic experiments have not provided clear evidence of the mechanism and pathophysiology of this condition
- fascial hernias have been identified with decompression

Presentation

Symptoms
- aching or burning pain in leg
- paresthesias over dorsum of foot
- symptoms are reproduced by exercise and relieved by rest
  - symptoms begin ~ 10 minutes into exercise and slowly resolve ~30-40 minutes after exercise
Physical exam
- normal

Imaging

Radiographs
- useful to eliminate other pathology
MRI
- not very helpful in establishing diagnosis
- can help eliminate other pathology

Evaluation

Compartment pressure measurement
- required to establish diagnosis
- three pressure should be measured
  - resting pressure
  - immediate post-exercise pressure
  - continuous post-exercise pressure for 30 minutes
- diagnostic criteria
  - resting pressure > 15 mmHg
  - immediate post-exercise is > 30 mmHg and/or
  - continuous post-exercise failed to return to normal or remains > 15 mmHg at 15 minutes after cessation of exercise

Treatment

Nonoperative
- activity modification
  - indications
    - rarely effective
Operative
- two incision fasciotomy
  - indications
    - refractory cases
  - technique
    - two incision approach
      - lateral incision
        
        to release anterior and lateral incision
        
        12-15 cm above lateral malleolus
        
        identify superficial peroneal nerve and protect
        
        may see fascial hernia
      - medial incision
        
        used to release posterior compartments
        
        perform if needed based on measurements
        
        release at middle of tibia at posterior border
  - outcomes
    - not a "home run" procedure because symptoms are often multi-variable

TAG

(OBQ05.82) An 18-year-old girl has bilateral leg pain. It occurs shortly after she begins running and is improved with rest. When she tries to continue running, she gets paresthesias on the dorsum of the foot. She has normal x-rays. What is the next step in evaluation? Topic

Review Topic

1. MRI bilateral tibiae
2. Venous doppler ultrasound
3. Non-invasive arterial vascular studies
4. Compartment pressure measurement
5. Bone scan

PREFERRED RESPONSE ▶

DISCUSSION: The three most commonly affected areas of chronic exertional compartment syndrome (CECS) are the lower leg, thigh, and forearm. The lower leg consists of 4 compartments: anterior, lateral, superficial posterior, deep posterior. During strenuous exercise, muscle fibers can swell up to 20 times their resting size, leading to 20% increase in the muscle volume and weight. When the blood flow is insufficient to meet the requirements of the muscle, the patient experiences pain. Measuring the intracompartmental pressures at rest and post-exercise have been shown to be the best method of confirming the diagnosis of CECS. Pedowitz et al came up with the diagnostic criteria: 1) preexercise pressure = 15mm Hg, 2) a 1 minute postexercise pressure of =30 mm Hg, or 3) a 5 minute postexercise pressure = 20 mm Hg. Management includes stopping the activities that provoke the symptoms. However, if the patient is unwilling to modify their activities, the mainstay of treatment is subcutaneous fasciotomy.

REFERENCES:

1. Fraipont MJ, Adamson GJ: Chronic exertional compartment syndrome. J Am Acad Orthop Surg 2003;11:268-276. PMID:12889865 (Link to Abstract)

2. Pedowitz RA, Hargens AR, Mubarak SJ, et al: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Meds 1990;18:35-40. PMID:2301689 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Fraipont MJ, Adamson GJ: Chronic exertional compartment syndrome. J Am Acad Orthop Surg 2003;11:268-276. PMID:12889865 (Link to Abstract)
Pedowitz RA, Hargens AR, Mubarak SJ, et al: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Meds 1990;18:35-40. PMID:2301689 (Link to Abstract)

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