Isolated Lateral Chronic Exertional Compartment Syndrome of the Leg: A New Entity?

Background: Chronic exertional compartment syndrome (CECS) mostly occurs in the anterior or deep posterior compartments (ant-CECS and dp-CECS, respectively) of the leg. It is generally accepted that CECS of the third or lateral compartment (lat-CECS) always occurs together with ant-CECS. However, whether exertional leg pain (ELP) can be caused by an isolated form of lat-CECS is unknown. Purpose: To determine the existence of isolated lat-CECS and study whether history taking and a physical examination aid in discriminating between different subtypes of CECS. Study Design: Case series; Level of evidence, 4. Methods: Patients were eligible for this single-center study, conducted between January 2013 and February 2018, if they reported anterolateral ELP and completed a questionnaire scoring the frequency and intensity of pain, tightness, cramps, muscle weakness, and paresthesia during rest and exercise. They were asked to mark areas of altered foot skin sensation, if present, on a drawing. All patients underwent a dynamic intracompartmental pressure (ICP) measurement of the anterior and lateral compartments simultaneously. The diagnosis of CECS was confirmed by elevated ICP (Pedowitz criteria). There were 3 patient groups: (1) isolated ant-CECS with elevated ICP in the anterior compartment and normal ICP in the lateral compartment, (2) isolated lat-CECS with elevated ICP in the lateral compartment but normal ICP in the anterior compartment, and (3) ant-/lat-CECS with elevated ICP in both the anterior and lateral compartments. Results: A total of 73 patients with anterolateral ELP fulfilled study criteria (isolated ant-CECS: n = 26; isolated lat-CECS: n = 5; ant-/lat-CECS: n = 42). Group differences were not observed regarding age (isolated ant-CECS: median, 26 years [range, 13-68 years]; isolated lat-CECS: median, 20 years [range, 17-63 years]; ant-/lat-CECS: median, 28 years [range, 17-57 years]; χ2 (2) = 0.466; P = .79), sex (isolated ant-CECS: 50% male; isolated lat-CECS: 40% male; ant-/lat-CECS: 62% male; P = .49), or bilateral symptoms (isolated ant-CECS: 54%; isolated lat-CECS: 80%; ant-/lat-CECS: 69%; P = .40). However, cramps at rest were present in a portion of the patients with isolated ant-CECS (38%) and ant-/lat-CECS (57%) but not in those with isolated lat-CECS ( P = .032). Patient drawings of altered foot skin sensation did not contribute to the diagnosis ( P = .92). ICP values after provocation were all lower in patients with isolated ant-CECS and isolated lat-CECS compared with those with ant-/lat-CECS ( P < .05). Conclusion: Seven percent of patients with CECS and anterolateral ELP who had symptoms due to isolated lat-CECS in the presence of normal muscle pressure in the anterior compartment.

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Fasciotomy for Lateral Lower-leg Chronic Exertional Compartment Syndrome

International Journal of Sports Medicine ◽

10.1055/a-0640-9104 ◽

2018 ◽

Vol 39 (14) ◽

pp. 1081-1087 ◽

Cited By ~ 4

Author(s):

Aniek van Zantvoort ◽

Johan de Bruijn ◽

Henricus Hundscheid ◽

Marike van der Cruijsen-Raaijmakers ◽

Joep Teijink ◽

...

Keyword(s):

Compartment Syndrome ◽

Lateral Compartment ◽

Lower Leg ◽

Leg Pain ◽

Success Rates ◽

Intracompartmental Pressure ◽

Surgical Success ◽

Chronic Exertional Compartment Syndrome ◽

Exertional Compartment Syndrome

AbstractExercise-induced lower leg pain may be caused by chronic exertional compartment syndrome (CECS). Anterior or deep posterior compartments are usually affected. Knowledge about CECS of the lateral compartment (lat-CECS) is limited and outcome after fasciotomy is unknown. The purpose of this study is to report on success rates of fasciotomy in patients with lat-CECS. Surgical success rates in patients with lat-CECS diagnosed with a dynamic intracompartmental pressure (ICP) measurement were studied using a questionnaire (success: excellent or good as judged by the patient; unsuccessful: moderate, fair or poor). We conducted ICP measurements in 247 patients for suspected lat-CECS, of whom 78 were positively diagnosed. Following exclusion (n=11), 30 of the eligible 67 patients completed the questionnaire. Bilateral (70%, n=21/30) exertional pain (97%, n=29) and a feeling of tightness (93%, n=28) were the most frequently reported symptoms. Four years after fasciotomy, severity and frequency of symptoms had dropped significantly. Long-term surgical success was reported by 33% (n=10; excellent n=4, good n=6). Seventy-three percent (n=22) had resumed sports activities (9 same level, 13 lower level). In conclusion, a fasciotomy for lat-CECS was successful in the long term in just one of three operated patients in this retrospective study.

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Factors Predicting Lower Leg Chronic Exertional Compartment Syndrome in a Large Population

International Journal of Sports Medicine ◽

10.1055/s-0043-119225 ◽

2017 ◽

Vol 39 (01) ◽

pp. 58-66 ◽

Cited By ~ 14

Author(s):

Johan de Bruijn ◽

Aniek van Zantvoort ◽

David van Klaveren ◽

Michiel Winkes ◽

Marike van der Cruijsen-Raaijmakers ◽

...

Keyword(s):

Compartment Syndrome ◽

Predictive Model ◽

Pressure Measurement ◽

Large Population ◽

Lower Leg ◽

Leg Pain ◽

Intracompartmental Pressure ◽

Discriminative Ability ◽

Chronic Exertional Compartment Syndrome ◽

Exertional Compartment Syndrome

AbstractKnowledge about lower leg chronic exertional compartment syndrome (CECS) is largely obtained from highly selected populations. Patient characteristics may therefore not be appropriate for the general population. Our purpose was to describe a heterogeneous population of individuals suspected of lower leg CECS and to identify predictors of CECS. Charts of individuals who were analyzed for exercise-induced lower leg pain in a referral center between 2001 and 2013 were retrospectively studied. Patients were included if history and physical examination were suggestive of CECS and if they had undergone a dynamic intracompartmental pressure measurement. Six hundred ninety-eight of 1411 individuals were diagnosed with CECS in one or more of three lower leg muscle compartments (anterior tibial, deep flexor, lateral). Prevalence of CECS peaked around the age of 20–25 years and decreased thereafter, although a plateau around 50 years was found. Age, gender, bilateral symptoms, previous lower leg pathology, sports (running and skating) and tender muscle compartments were identified as independent predictors of lower leg CECS. The proposed predictive model has moderate discriminative ability (AUC 0.66) and good calibration over the complete range of predicted probabilities. The predictive model, displayed as a nomogram, may aid in selecting individuals requiring an invasive dynamic intracompartmental muscle pressure measurement.

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Historic cohort: outcome of chronic exertional compartment syndrome-suspected patients

Journal of the Royal Army Medical Corps ◽

10.1136/jramc-2019-001290 ◽

2020 ◽

pp. jramc-2019-001290

Author(s):

Roy Maksymiak ◽

E Ritchie ◽

W Zimmermann ◽

N Maliko ◽

M van der Werve ◽

...

Keyword(s):

Surgical Treatment ◽

Compartment Syndrome ◽

Leg Pain ◽

Future Research ◽

Intracompartmental Pressure ◽

Chronic Exertional Compartment Syndrome ◽

Patient Demographics ◽

Military Recruits ◽

Exertional Compartment Syndrome ◽

Historic Cohort

IntroductionExercise-related leg pain (ERLP) may be caused by chronic exertional compartment syndrome (CECS), occurring mainly in athletes and military recruits. In military populations, the effectiveness of surgical treatment in CECS is debated. The purpose of this study is to assess the outcome of surgical treatment for CECS in Alrijne Hospital (the Netherlands), a civilian hospital with supraregional referral function.MethodsA historic cohort study was performed on patients with ERLP who were suspected for CECS and were referred for intracompartmental pressure measurement (ICPM) from 2013 to 2017 (n=160). Patient demographics, ICPM and survey response were analysed.ResultsThe mean delay before visitation was 29.0±30.3 months. When comparing surgical-treated patients with CECS with conservative-treated patients with ERLP, surgical-treated patients were more satisfied, reported better recovery towards former level of performance (2.8±2.0 vs 3.9±1.7 and 2.5±1.6 vs 3.2±1.4 on a 7-point Likert scale, respectively) and better subjective injury status (79.3±22.6 vs 63.5±27.4 using the Single Assessment Numeric Evaluation score). Treatment satisfaction was 75.0% in surgical-treated CECS versus 51.4% in conservative-treated ERLP.ConclusionCivilian patients report improved functional outcomes after fasciotomy for CECS. Future research should focus on non-invasive diagnostic options and methods to determine which treatment is the most appropriate for each individual patient.

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Diagnosis of chronic exertional compartment syndrome by post-exercise MRI

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117s00001 ◽

2017 ◽

Vol 5 (1_suppl) ◽

pp. 2325967117S0000

Author(s):

Vicente Paús ◽

Ariel Graieb ◽

Federico Torrengo ◽

Francisco Villalba

Keyword(s):

Compartment Syndrome ◽

Gold Standard ◽

Leg Pain ◽

Intracompartmental Pressure ◽

Post Exercise ◽

Chronic Exertional Compartment Syndrome ◽

Hyperintense Signal ◽

Exertional Compartment Syndrome ◽

Attractive Option ◽

Post Stress

Objective: Chronic exertional compartment syndrome (CECS) is the cause of 27% of anterior leg pain in athletes. The source of pain in this condition is still debated. Measurement of intracompartmental pressure is the gold standard diagnosis, albeit an invasive study. The development and interpretation of new MRI sequences has provided a non-invasive alternative to CECS diagnosis. Post-exercise MRI is an attractive option, which is currently undergoing its validation process. Methods: 22 patients with a clinical diagnosis of CECS were included, with a median follow-up of 5 years (1-10 years). All the patients were evaluated by clinical examination, pre- and post-exercise MRI and pre-and post-exercise intracompartmental pressure measurement. Pressure was measured with Whitesides technique, and diagnosis was carried out by Pedowitz criteria. Results: Out of the total 22 patients, 19 had positive intracompartmental measurement (15 male, 4 female) and 3 had negative measurement. All the patients had a normal MRI at rest. The three patients who had negative intracompartmental measurement had a normal post-stress MRI. Out of the remaining 19 patients, the MRI detected hyperintense signal in T2 and STIR weighted in 15 of them (78,95%). Conclusions: MRI could be relevant for diagnosis, for which case the sensitivity of this method should be improved. Nevertheless, pre- and post-stress intracompartmental measurement continues to be the gold standard.

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Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study

Foot & Ankle International ◽

10.1177/1071100718811632 ◽

2018 ◽

Vol 40 (3) ◽

pp. 343-351 ◽

Cited By ~ 3

Author(s):

Johan A. de Bruijn ◽

Aniek P. M. van Zantvoort ◽

Henricus Pieter Hubert Hundscheid ◽

Adwin R. Hoogeveen ◽

Joep A. W. Teijink ◽

...

Keyword(s):

Compartment Syndrome ◽

Nerve Injury ◽

Peroneal Nerve ◽

Case Series ◽

Superficial Peroneal Nerve ◽

Anterior Compartment ◽

Chronic Exertional Compartment Syndrome ◽

Sensory Deficits ◽

Clinical Series ◽

Exertional Compartment Syndrome

Background: Up to 8% of patients who underwent a fasciotomy for leg anterior chronic exertional compartment syndrome (ant-CECS) report sensory deficits suggestive of iatrogenic superficial peroneal nerve (SPN) injury. In the current study we aimed to thoroughly assess the risk of SPN injury during a semiblind fasciotomy of the anterior compartment using 2 separate approaches. Methods: A modified semiblind fasciotomy of the anterior compartment was performed via a longitudinal 2-cm skin incision 2 cm lateral of the anterior tibial crest halfway along the line fibular head-lateral malleolus both in cadaver legs and in patients with ant-CECS. In the cadaver legs, the skin was removed after the procedure and possible SPN injuries and spatial relationships between the SPN and the opened fascia were studied. Between January 2013 and December 2016, 64 ant-CECS patients who underwent a fasciotomy of the anterior compartment were prospectively followed. Iatrogenic SPN injuries were assessed using questionnaires and physical examinations. Results: Macroscopic SPN nerve injury was not observed in any of the 9 cadaver legs. In 8 specimens, the SPN was located at least 5 mm posterolateral to the opened fascia. In 1 specimen, an undamaged SPN branch crossed the operative field in a ventral plane. De novo sensory deficits suggestive for iatrogenic SPN injury were not observed in any of the 64 patients (120 legs; 36 females; median age, 22 years) who underwent a fasciotomy of the anterior compartment. Conclusion: The proposed semiblind fasciotomy for treatment of ant-CECS was not associated with SPN injury in either the cadaveric study or our clinical series. Level of Evidence: Level IV, case series.

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Surgical outcomes for chronic exertional compartment syndrome following improved diagnostic criteria

BMJ Military Health ◽

10.1136/jramc-2019-001171 ◽

2019 ◽

Vol 166 (E) ◽

pp. e17-e20 ◽

Cited By ~ 2

Author(s):

Christopher Simpson ◽

D Roscoe ◽

S Hughes ◽

D Hulse ◽

H Guthrie

Keyword(s):

Compartment Syndrome ◽

Diagnostic Criteria ◽

Clinical Symptoms ◽

Diagnostic Testing ◽

Rank Test ◽

Anterior Compartment ◽

Chronic Exertional Compartment Syndrome ◽

Significant Difference ◽

Exertional Compartment Syndrome ◽

The Impact

IntroductionChronic exertional compartment syndrome (CECS) presents with pain during exercise, most commonly within the anterior compartment of the lower limb. A diagnosis is classically made from a typical history and the measurement of intramuscular compartmental pressure (IMCP) testing. Improved, more specific diagnostic criteria for IMCP testing allow clinicians to now be more certain of a diagnosis of CECS. Outcomes following surgical treatment in patients diagnosed using these more robust criteria are unknown.MethodsAll patients undergoing fasciectomy for anterior compartment CECS at a single rehabilitation unit were identified between 2014 and 2017. Wilcoxen signed-rank test was used to compare military fitness grading and paired t-test was used to compare Foot and Ankle Ability Measure, FAAM Sport Specific and Exercise-Induced LimbPain-G outcome measures, presurgery and postsurgery.ResultsThere was a significant difference in fitness grading between presurgical and postsurgical intervention (Z = −2.68, p < 0.01) with 46 % of patients improving their occupational medical grading. All secondary measures of outcome, looking at clinical symptoms, also improved.ConclusionAlmost half of the patients undergoing fasciectomy, following diagnosis using more specific criteria, will have an improvement in occupational medical grading. These outcomes represent the lower end of those reported in civilian populations. This is likely a result of a combination of factors, most notably the different diagnostic criteria followed and the more stringent criteria applied to military occupational grading, compared with civilian practice. Further work is now required to evaluate the impact of differing rehabilitation regimes on postoperative patients identified through this more specific diagnostic testing.

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Chronic exertional compartment syndrome: diagnosis, investigation, management and return to training

Journal of The Royal Naval Medical Service ◽

10.1136/jrnms-104-124 ◽

2018 ◽

Vol 104 (2) ◽

pp. 124-128

Author(s):

R L Thomas ◽

R Hemingway ◽

A Keenan ◽

A Wood

Keyword(s):

Compartment Syndrome ◽

Lower Limbs ◽

Leg Pain ◽

Military Recruit ◽

Chronic Exertional Compartment Syndrome ◽

Military Recruits ◽

Exertional Compartment Syndrome ◽

Poor Outcomes ◽

Exercise Induced ◽

The Military

AbstractExercise-induced leg pain is a frequent presenting complaint in military recruits. This has several causes, including chronic exertional compartment syndrome (CECS). The pathophysiology of CECS is debated, but it involves pressure increases in particular compartments and reduced compliance in the epimyseal fascia. Its morbidity and poor outcomes with conservative management lead to extended rehabilitation times, and ultimately to a loss of recruits from training. It has been described in various compartments of the upper and lower limbs, but is most frequently encountered in the leg. It is a condition often encountered in the military recruit, and within this demographic is less common than other causes of exertional lower leg pain. However, its debilitating nature and complicated investigative pathway can cause difficulties, and have notable occupational consequences. This article aims to review the evidence surrounding its diagnosis, treatment, prognosis and the implications for the military patient.

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