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Updated: 12/7/2022

Exertional Compartment Syndrome

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  • 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
  • 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
      • may 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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(SBQ16SM.36) A 17-year-old male hurdler presents with burning pain and paresthesias in bilateral legs. He reports symptoms predictably after 10 minutes of running and training. The pain is localized over the dorsum of the foot and anterior leg. He denies any associated back pain. On exam, there is no apparent motor weakness and peripheral pulses are 2+ and symmetric with ankle plantar flexion and dorsiflexion. The patient undergoes surgical treatment of this condition. Which of the following would place the patient at risk for recurrence?

QID: 211502

Four-compartment fasciotomy using two-incision technique



Age < 23 years



Isolated anterior and lateral compartment releases



Higher pre-operative post-exertion compartment pressures



Bilateral leg involvement



L 3 B

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(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?

QID: 968

Resting MRI bilateral tibiae



Venous doppler ultrasound



Non-invasive arterial vascular studies



Post-exercise compartment pressure measurement



Bone scan



L 1 D

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Evidence (9)
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