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Updated: Jun 20 2024

Exertional Compartment Syndrome

  • summary
    • Exertional compartment syndrome is an exercise-induced condition of the leg characterized by reversible ischemia to muscles within a muscular compartment.
    • Diagnosis is made by obtaining compartment pressures at rest, during exercise and post-exercise.
    • Treatment generally involves surgical fasciotomies of the compartments involved. 
  • Epidemiology
    • Incidence
      • second most common exercise induced leg syndrome
        • behind medial tibial stress syndrome
    • Demographics
      • males >females
      • often seen in 3rd decade of life
      • runners or those who run a lot for their sport
    • Anatomic location
      • anterior leg compartment most commonly affected (~70%)
      • anterior and lateral leg compartment affected in 10%
      • posterior leg compartment involvement associated with less predictable surgical outcomes 
        • more frequently associated with popliteal artery entrapment syndrome (PAES)
          • most common cause is the presence of an accessory head of the medial gastrocnemius muscle
  • Etiology
    • Pathophysiology
      • biochemistry
        • the local metabolism of the musculature cannot go fast enough to clear the metabolic waste products
      • pathoanatomy
        • vascular, advanced imaging, and histologic experiments have not provided clear evidence of the pathoanatomy of this condition
          • may have lower density of capillaries compared to asymptomatic individuals
          • fascial hernias have been identified with decompression
            • 40% of people with exertional compartment syndrome have these facial defects, only 5% of asymptomatic people have such defects
            • most common location is near the intramuscular septum of the anterior and lateral compartments, where the superficial peroneal nerve exits
  • Presentation
    • Symptoms
      • aching or burning pain in leg
        • patients can often predict how long the pain will last for after they stop exercise
      • 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
      • most likely to be normal
      • decreased sensation 1st web space
      • decreased active ankle dorsiflexion
  • Imaging
    • Radiographs
      • useful to eliminate other pathology
    • MRI
      • not very helpful in establishing diagnosis
      • can help eliminate other pathology
  • Evaluation
    • Compartment pressure measurement
      • limb should be in relaxed and consistant position
      • required to establish diagnosis
      • three pressure should be measured
        • resting pressure
        • 1 minute post-exercise pressure
        • 5 minutes post-exercise pressure
          • some authors advocate for an additional measurement point 15 minutes post-exercise
      • diagnostic criteria
        • resting (pre-exercise) pressure > 15 mmHg
        • immediate (1 minute) post-exercise is >30 mmHg and
        • post-exercise pressure >20mmHg at 5 minutes
        • post-exercise pressure >15 mmHg at 15 minutes
    • Near-infrared spectroscopy
      • can show deoxygenation of muscle
        • showed return to normal within 25 minutes of exercise cessation
  • Treatment
    • Nonoperative
      • activity modification 
        • indications
          • rarely effective
      • anti-inflammatories
      • attempt these treatments for 3 months prior to operating
    • Operative
      • two incision fasciotomy
        • indications
          • refractory cases
        • technique
          • two incision approach
            • lateral incision
              • release anterior and lateral compartments
              • 12-15 cm above lateral malleolus
              • identify and protect superficial peroneal nerve
              • 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
            • endoscopic
              • smaller incisions, similar complications
        • outcomes
          • not a "home run" procedure because symptoms are often multi-variable
          • no studies directly comparing operative to non-opertative treatment options
          • surgery is successful in >80% of cases for the anterior compartment
            • deep posterior compartment success is lower (around 60%)
  • Complications
    • Nerve injury
      • most commonly the SPN
    • DVT
    • Recurrence
      • up to 20% at a mean of 2 years after fasciotomy
      • because of fibrosis/scar formation
      • risk factors:
        • isolated compartment release
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