Exertional Compartment Syndrome

Aka: Exertional Compartment Syndrome, Chronic Compartment Syndrome, Chronic Exertional Compartment Syndrome, Nontraumatic exertional compartment syndrome

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II. Risk Factors

  1. Military
  2. Female gender
  3. Diabetes Mellitus
  4. Young athletes
  5. Most common associated sports
    1. Soccer
    2. Running
    3. Lacrosse or Field Hockey

III. Pathophysiology

  1. Predisposing factors
    1. Fascial defects and Herniation may contribute in more than one third of cases
    2. However, poor fascial compliance does not appear to be a contributing factor
  2. Increased intracompartmental pressure associated with Muscle overuse
    1. Muscle volume increases with Exercise as much as 20%
    2. Repetitive use results in Muscle hypertrophy and increased local Blood Volume
  3. Increased pressure results
    1. Decreased perfusion (arteriole compression, capillary Occlusion) with secondary ischemic pain
    2. Microvascular nutrient exchange
    3. Nerve compression

IV. Symptoms: General

  1. Characteristics
    1. Aching, burning or cramping pain
  2. Modifying Factors
    1. Exercise-induced pain and swelling relieved with rest
  3. Associated Symptoms
    1. Numbness
    2. Paresthesias
    3. Muscle Weakness
  4. Distribution
    1. Lower Leg (95% of cases)
      1. Anterior compartment (>42%) and Lateral Compartment (35%) are most often affected
      2. Foot "slap" while Running
        1. Anterior compartment dorsiflexor weakness
      3. First interdigital webspace numbness
        1. Anterior compartment deep peroneal nerve compression
      4. Lateral foot eversion weakness
        1. Lateral compartment Muscle Weakness
      5. Lateral leg and dorsal foot numbness
        1. Lateral compartment superficial peroneal nerve compression
    2. Forearm
    3. Thigh
    4. Gluteal region

V. Symptoms: Acute Exertional Compartment Syndrome

  1. See Compartment Syndrome
  2. Similar presentation as in Compartment Syndrome

VI. Symptoms: Chronic Exertional Compartment Syndrome

  1. Gradual aching extremity pain
  2. Bilateral extremity involvement in more than 75% of cases
  3. Sensation of fullness over involved compartment
  4. Pain begins predictably after Exercise start (e.g. exertional Leg Pain)
    1. Fixed time interval into Exercise routine or
    2. Specific intensity level
  5. Pain relieved with 20 minutes of rest
  6. Pain recurs on resuming Exercise and progresses in severity overtime
    1. Over time, symptoms occur with decreased amounts of Exercise with longer periods of pain

VII. Signs

  1. Perform exam immediately after Exercise
  2. See Compartment Syndrome

VIII. Exam

  1. Extremity neurovascular exam
  2. Musculoskeletal Exam for Muscle, tendon, bone injury

IX. Diagnosis

  1. See Intracompartmental Pressure Monitor
  2. Technique (typically in sports medicine or orthopedic clinic)
    1. Patient runs on treadmill or track to maximal symptoms
    2. Intracompartmental Pressure is measured immediately
  3. Intracompartmental Pressure Monitor Criteria (Pedowitz Criteria)
    1. Readings are only valid if Exercise reproduces symptoms
    2. Post-Exercise pressures are compared to pre-Exercise pressures
    3. Pre-Exercise resting pressure >=15 mmHg
    4. Post-Exercise pressure at 1 minute >= 30 mmHg
    5. Post-Exercise pressure at 5 minutes >= 20 mmHg
    6. Post-Exercise elevated pressure despite 15 minutes rest

X. Differential Diagnosis

  1. Stress Fracture
  2. Periostitis
  3. Deep Vein Thrombosis
  4. Posterior Tarsal Tunnel Syndrome
  5. Lumbar Radiculopathy
  6. Bone lesion or tumor
  7. Popliteal artery entrapment syndrome
  8. Medial Tibial Stress Syndrome
    1. Most common cause of exertional Leg Pain

XI. Imaging

  1. Extremity XRay
  2. Venous Ultrasound for DVT
  3. Triple phase bone scan
    1. Stress Fracture: Transverse linear pattern
    2. Shin Splint: Longitudinal linear uptake

XII. Precautions

  1. Diagnosis is often delayed (median time to diagnosis 28 months)

XIII. Management: Acute Exertional Compartment Syndrome

  1. See Compartment Syndrome
  2. Emergent evaluation and management as Compartment Syndrome
  3. Consideration for emergent Fasciotomy (within first 4 hours is critical)

XIV. Management: Chronic Exertional Compartment Syndrome

  1. Initial symptomatic management
    1. Avoid provocative activies
    2. Oral Analgesics
    3. Referral to sports medicine or orthopedics
  2. Modify extrinsic factors
    1. Training surface
    2. Athletic shoe
    3. Training intensity
  3. Modify Intrinsic Factors (e.g. hindfoot pronation)
    1. Physical therapy
    2. Ice
    3. Massage
    4. Strengthening Exercises
    5. StretchingExercises
    6. Orthotics
  4. Surgery for recurrent symptoms over 3 months
    1. Compartment-Release Fasciotomy (single or multi-compartment)
      1. Return to full activity within 3 months is typical
    2. Postoperative rehabilitation
      1. Week 0: Range of motion Exercises
      2. Week 1: Weight bearing
      3. Week 2: Stationary bike
      4. Week 3: Isokinetic strengthening Exercises
      5. Week 5: Running
      6. Week 8: Speed and agility training

XV. References

  1. Blythe, Gray and Delasobera (2018) Crit Dec Emerg Med 32(7):3-9
  2. Edwards (1996) Physician Sportsmed 24(4):31-46
  3. Abramowitz (1994) Orthop Rev 23(3):219-25 [PubMed]
  4. Detmer (1985) Am J Sports Med 13(3): 162-70 [PubMed]

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