Current Diagnosis and Management of Chronic Exertional Compartment Syndrome

Sports Medicine Rehabilitation (B Liem and BJ Krabak, Section Editors)
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  1. Topical Collection on Sports Medicine Rehabilitation

Abstract

Purpose of Review

The goal of this paper is to review the current evidence on diagnosis and management of chronic exertional compartment syndrome (CECS) of the lower leg. We sought to answer the question of whether recent research and innovations have demonstrated diagnostic alternatives or adjuncts to intramuscular compartment pressure testing and whether there are effective treatment options other than surgical fasciotomy.

Recent Findings

Research has shown promising outcomes with non-operative management including targeted alterations to running biomechanics. There is also research demonstrating efficacy in the use of botulinum injection as well as ultrasound-guided fascial fenestration and fasciotomy.

Summary

Innovations in the diagnosis of CECS include the use of continuous compartment pressure monitoring during exercise as well as some early research on the use of musculoskeletal ultrasound and particular MRI protocols of the lower leg. Non-surgical management includes intervention to improve running biomechanics, botulinum toxin injection, and ultrasound-guided fasciotomy. Future research is needed on alternative diagnostic modalities including musculoskeletal ultrasound and exercise MRI protocols and on alternative management strategies including botulinum toxin injection and ultrasound-guided fascial fenestration or fasciotomy.

Keywords

Chronic exertional compartment syndrome CECS Fasciotomy Gait retraining Running medicine 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently have been highlighted as: • Of importance

  1. 1.
    Mavor GE. The anterior tibial syndrome. J Bone Joint Surg Br. 1956;38:513-7.Google Scholar
  2. 2.
    Campano D, Robaina JA, Kusnezov N, Dunn JC, Waterman BR. Surgical management for chronic exertional compartment syndrome of the leg: a systematic review of the literature. Arthroscopy. 2016;32:1478–86.CrossRefPubMedGoogle Scholar
  3. 3.
    Dunn JC, Waterman BR. Chronic exertional compartment syndrome of the leg in the military. Clin Sports Med. 2014;33:693–705.CrossRefPubMedGoogle Scholar
  4. 4.
    Davis DE, Raikin S, Garras DN. Characteristics of patients with chronic exertional compartment syndrome. Foot Ankle Int. 2013;34:1349–54.CrossRefPubMedGoogle Scholar
  5. 5.
    Zantvoort APV, Bruijn JAD, Winkes MB, Dielemans JP, Cruijsen-Raaijmakers MVD, Hoogeveen AR, et al. Isolated chronic exertional compartment syndrome of the lateral lower leg. Orthop J Sports Med. 2015;3:232596711561772.CrossRefGoogle Scholar
  6. 6.
    Beck JJ, Tepolt FA, Miller PE. Surgical treatment of chronic exertional compartment syndrome in pediatric patients. Am J Sports Med. 2016;44:2644–50.CrossRefPubMedGoogle Scholar
  7. 7.
    Van der Wal WA1, Heesterbeek PJ, Van den Brand JG, Verleisdonk EJ. The natural course of chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):2136-41.Google Scholar
  8. 8.
    Waterman BR, Liu J, Newcomb R, Schoenfeld AJ, Orr JD, Belmont PJ. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med. 2013;41:2545–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Roberts A, Hulse D, Bennett AN, Dixon S. Plantar pressure differences between cases with symptoms of clinically diagnosed chronic exertional compartment syndrome and asymptomatic controls. Clin Biomech. 2017;50:27–31.CrossRefGoogle Scholar
  10. 10.
    • Roberts A, Roscoe D, Hulse D, Bennett AN, Dixon S. Biomechanical differences between cases with suspected chronic exertional compartment syndrome and asymptomatic controls during running. Gait Posture. 2017;58:374–9. Provided an analysis of biomechanical differences associated with CECS CrossRefPubMedGoogle Scholar
  11. 11.
    Breen DT, Foster J, Falvey E, Franklyn-Miller A. Gait re-training to alleviate the symptoms of anterior exertional lower leg pain: a case series. Int J Sports Phys Ther. 2015;10(1):85-94.Google Scholar
  12. 12.
    Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35–40.CrossRefPubMedGoogle Scholar
  13. 13.
    Tiidus PM. Is intramuscular pressure a valid diagnostic criterion for chronic exertional compartment syndrome? Clin J Sport Med. 2014;24:87–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Pasic N, Willits K, Bryant D. Assessing long-term outcomes in individuals undergoing fasciotomy for chronic exertional compartment syndrome of the lower leg (SS-44). Arthroscopy. 2015;29:707–13.CrossRefGoogle Scholar
  15. 15.
    Nilsson A, Zhang Q, Styf J. Using the amplitude of pulse-synchronous intramuscular pressure oscillations when diagnosing chronic anterior compartment syndrome. Orthop J Sports Med. 2014;2:232596711455644.CrossRefGoogle Scholar
  16. 16.
    Dharm-Datta S, Minden DF, Rosell PA, Hill PF, Mistlin A, Etherington J. Dynamic pressure testing for chronic exertional compartment syndrome in the UK military population. J R Army Med Corps. 2013;159:114–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Roscoe D, Roberts AJ, Hulse D. Intramuscular compartment pressure measurement in chronic exertional compartment syndrome. Am J Sports Med. 2014;43:392–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Aweid O, Buono AD, Malliaras P, Iqbal H, Morrissey D, Maffulli N, et al. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clin J Sport Med. 2012;22:356–70.CrossRefPubMedGoogle Scholar
  19. 19.
    Winkes MB, Tseng CM, Pasmans HL, Cruijsen-Raaijmakers MVD, Hoogeveen AR, Scheltinga MR. Accuracy of palpation-guided catheter placement for muscle pressure measurements in suspected deep posterior chronic exertional compartment syndrome of the lower leg. Am J Sports Med. 2016;44:2659–66.CrossRefPubMedGoogle Scholar
  20. 20.
    Ringler MD, Litwiller DV, Felmlee JP, Shahid KR, Finnoff JT, Carter RE, et al. MRI accurately detects chronic exertional compartment syndrome: a validation study. Skelet Radiol. 2012;42:385–92.CrossRefGoogle Scholar
  21. 21.
    Sigmund EE, Sui D, Ukpebor O, et al. Stimulated echo diffusion tensor imaging and SPAIR T2-weighted imaging in chronic exertional compartment syndrome of the lower leg muscles. J Magn Reson Imaging. 2013;38:1073–82.CrossRefPubMedGoogle Scholar
  22. 22.
    Sigmund EE, Novikov DS, Sui D, et al. Time-dependent diffusion in skeletal muscle with the random permeable barrier model (RPBM): application to normal controls and chronic exertional compartment syndrome patients. NMR Biomed. 2014;27:519–28.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Rajasekaran S, Beavis C, Aly A-R, Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome. Clin J Sport Med. 2013;23:305–11.CrossRefPubMedGoogle Scholar
  24. 24.
    Packer JD, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Am J Sports Med. 2013;41:430–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Agresta C, Brown A. Gait retraining for injured and healthy runners using augmented feedback: a systematic literature review. J Orthop Sports Phys Ther. 2015;45:576–84.CrossRefPubMedGoogle Scholar
  26. 26.
    Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40:1060–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Diebal AR, Gregory R, Alitz C. Effects of forefoot running on chronic exertional compartment syndrome: a case series. Int J Sports Phys Ther. 2011;6:312–21.PubMedPubMedCentralGoogle Scholar
  28. 28.
    • Helmhout PH, Diebal AR, Kaaden LVD, Harts CC, Beutler A, Zimmermann WO. The effectiveness of a 6-week intervention program aimed at modifying running style in patients with chronic exertional compartment syndrome. Orthop J Sports Med. 2015;  https://doi.org/10.1177/2325967115575691. (Very important) This study prospectively looked at 19 patients with CECS and utilized a 6-week intervention to change to a forefoot strike pattern. They found improvements in running distance and in ICPs. This study highlights that CECS can be successfully treated non-operatively by modifying running mechanics
  29. 29.
    Zimmermann WO, Helmhout PH, Beutler A. Prevention and treatment of exercise related leg pain in young soldiers; a review of the literature and current practice in the Dutch Armed Forces. J R Army Med Corps. 2016;163:94–103.CrossRefPubMedGoogle Scholar
  30. 30.
    Helmhout PH, Diebal-Lee MA, Poelsma LR. Modifying marching technique in military service members with chronic exertional compartment syndrome: a case series. Int J Sports Phys Ther. 2016;11:1106–24.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Isner-Horobeti M-E, Dufour SP, Blaes C, Lecocq J. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg. Am J Sports Med. 2013;41:2558–66.CrossRefPubMedGoogle Scholar
  32. 32.
    • Baria MR, Sellon JL. Botulinum toxin for chronic exertional compartment syndrome. Clin J Sport Med. 2016;  https://doi.org/10.1097/jsm.0000000000000289. This case report demonstrates a durable effect of botulinum toxin injection in improving symptoms of CECS
  33. 33.
    • Finnoff JT, Rajasekaran S. Ultrasound-guided, percutaneous needle fascial fenestration for the treatment of chronic exertional compartment syndrome: a case report. Pm&r. 2016;8:286–90. (Very important) This was the first report to our knowledge of an ultrasound-guided procedure targeting the muscle fascia for the management of CECS CrossRefGoogle Scholar
  34. 34.
    • Balius R, Bong DA, Ardèvol J, Pedret C, Codina D, Dalmau A. Ultrasound-guided fasciotomy for anterior chronic exertional compartment syndrome of the leg. J Ultrasound Med. 2016;35:823–9. Very important) This is the first study describing ultrasound-guided fasciotomy and showed excellent results CrossRefGoogle Scholar
  35. 35.
    Irion V, Magnussen RA, Miller TL, Kaeding CC. Return to activity following fasciotomy for chronic exertional compartment syndrome. Eur J Orthop Surg Traumatol. 2014;24:1223–8.CrossRefPubMedGoogle Scholar
  36. 36.
    Tjeerdsma J. Outcome of a specific compartment fasciotomy versus a complete compartment fasciotomy of the leg in one patient with bilateral anterior chronic exertional compartment syndrome: a case report. J Foot Ankle Surg. 2016;55:1027–34.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopedic Surgery, Division of Physical Medicine and RehabilitationWashington UniversityChesterfieldUSA

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