summary Exertional compartment syndrome is an exercise-induced condition of the extremity 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 volar forearm less commonly encountered, but occurs in sports requiring repetitive gripping volar forearm compartment most commonly affected 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 login to view 4 more bullets 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 login to view 1 more bullet 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 login to view 1 more bullet anti-inflammatories attempt these treatments for 3 months prior to operating Operative two incision fasciotomy indications login to view 1 more bullet technique login to view 12 more bullets outcomes login to view 4 more bullets 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