Review Question - QID 220060

This college athlete is presenting with symptoms of exertional compartment syndrome. Although radiographs and MRI may be utilized to rule out other pathologies, diagnosis is ultimately confirmed with serial compartment pressure measurements, with various measurements as described below considered diagnostic (Answer 4).

Exertional compartment syndrome is an exercise-induced condition, most commonly affecting the anterior compartment of the leg. It is the second most common cause of exercise-induced leg pain behind medial tibial stress syndrome and is typically seen in male runners or athletes in their third decade of life. The condition often presents as aching or burning pain, sometimes with paresthesia, that begins roughly 10 minutes into exercise and resolves 30–40 minutes after stopping. Diagnosis is made by measuring compartment pressures at rest, immediately after exercise, and at 5 and 15 minutes post-exercise, with specific criteria indicating abnormally elevated pressures. While conservative treatment like activity modification can be attempted, surgical intervention via a two-incision fasciotomy, particularly for the anterior and lateral compartments, may be required for lasting relief, with success rates varying based on the compartment involved. Although generally successful, complications from surgery may include nerve injury, DVT, and recurrence.

Pedowitz et al. reviewed the records of 131 patients referred for evaluation of chronic exertional leg pain, 45 of whom were diagnosed with chronic compartment syndrome (CCS), to establish modified, objective criteria for the diagnosis of CCS based on intramuscular pressure measurements. They found that the only significant difference between patients with and without CCS was a higher incidence of muscle herniae in the CCS group, and that one-third of patients with CCS and over half without CCS reported persistent pain at follow-up. They concluded that in the presence of appropriate clinical findings, one or more of the following intramuscular pressure criteria are diagnostic of CCS: a pre-exercise pressure ≥ 15 mmHg, a 1-minute postexercise pressure of ≥ 30 mmHg, or a 5-minute postexercise pressure ≥ 20 mmHg.

Mangan et al. reviewed the outcomes and return to sport (RTS) rates in 59 patients (63 procedures) who underwent open fasciotomy for chronic exertional compartment syndrome (CECS) of the lower extremity, confirmed by pre- and post-exercise compartment pressure testing. They found significant postoperative improvement in Foot and Ankle Ability Measure-Sport Subscale (FAAM-Sport), FAAM-Sport Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS) for pain, with 93.2% of patients able to return to sport, and 78.1% returning at the same level of sport. They concluded that lower extremity fasciotomy for CECS results in improved patient-reported outcomes and allows many athletes to return to sport, suggesting it is an effective treatment for this condition.

Figures A and B demonstrate normal anteroposterior (AP) and lateral radiographs of the right tibia and fibula, respectively.

Incorrect Answers:
Answer 1: This finding is consistent with an infectious process such as an intramuscular abscess. The relation of the patient’s symptoms around exercise are more suggestive of exertional compartment syndrome.
Answer 2: This finding is suggestive of osteogenic neoplasm, such as osteosarcoma. Radiographic changes would be expected, and symptoms would be unlikely to be related to exercise, as in this patient.
Answer 3: This compartment pressure measurement would not meet criteria for a diagnosis of exertional compartment syndrome.
Answer 5: This finding is suggestive of a tibial shaft stress fracture. Although this condition early on may present similarly as exertional compartment syndrome, both clinically and with normal radiographs, patients often have pain directly over their fracture site on exam. Furthermore, in patients with prolonged symptoms such as in this question stem, symptoms often progress to persistent pain despite the cessation of physical activity.