Chronic Exertional Compartment Syndrome
Where is it painful for Chronic Exertional Compartment Syndrome?
Classical patient features for Chronic Exertional Compartment Syndrome
Age: More prominent in younger individuals (median age 20 years old)
Gender: Males and females are equally affected
Sport: High levels of participation in physical activity. Distance runners and endurance athletes have the highest prevalence
Area of symptoms for Chronic Exertional Compartment Syndrome
– 95% of presentations are in the anterior or lateral compartments of the lower limb
– Common for the patient to present with bilateral symptoms
– Symptoms isolated to the compartment of the leg that is implicated
– If the lateral compartment is implicated, may have paraesthesia to the dorsum of the foot (superficial peroneal nerve)
– Least common is the deep posterior leg compartment (symptoms will be in the posteromedial aspect of the lower limb)
Characteristics of symptoms for Chronic Exertional Compartment Syndrome
– No pain at rest
– Increase of aching +/- pain with exertion
– Symptoms come on at a relatively fixed point during exertion
– Patient reports “lower limb is cramping”
– Sensations of tightness and burning in the lower limb
– Symptoms will increase with higher intensity exercise and will reduce with lower intensity
– Is a constant pain if the activity is sustained // if warm up effect consider other differentials
– NSAIDs ineffective
– Rare: experience of motor weakness or paresthesia (if paraesthesias suspect the lateral compartment) (if motor weakness the implicated motor deficit will match the muscles in the compartment)
Typical activity capability/restriction for Chronic Exertional Compartment Syndrome
– Very little restriction in the early stages // main reason for the condition not being diagnosed earlier by therapists
– Most individuals are able to continue with their desired activity with modifications
– Therapists typically diagnose when the symptoms have progressed. By this stage, treatment may be difficult if irreversible tissue changes have occured within the fascia surrounding the compartment
Behaviour of symptoms for Chronic Exertional Compartment Syndrome
Aggravating:
– Exertion
– Relative increased lower limb demand compared to other body segments
– Comes on at the same time if regular completion of specific activity
No change
– Ground contact // differentiates from boney stress injury
Ease
– Resolution of symptoms after several minutes of stopping activity with rest
– Activity modification to redistribute lower limb load
24-hour pattern:
– Mechanical in nature.
– Low-level evidence to support night pain after prolonged activity and also second-day phenomena // not widely agreed upon in the literature
Typical history of a client with Chronic Exertional Compartment Syndrome
– Long term history of participation in physical activity
– Incidence has been reported as high as 14% of patients presenting with leg injuries
– Can be acute, chronic or develop into acute on chronic (similar to tendons)
– Diagnostic delay up to 2 years is common // can go undiagnosed also
– Patients regularly report symptoms for a long period of time that they have been independently managing // likely due to symptoms going away very quickly with cessation of the aggravating activity. People are hesitant to present for treatment
– Can occur in conjunction with lower limb stress fractures and MTSS
Pathobiological mechanisms underlying Chronic Exertional Compartment Syndrome
– Nociceptive pain mechanism
– The proposed mechanism is that repetitive overuse causes repeated inflammatory cascades.
– Leads to fibrosis of the tissues leading to a reduction of elasticity.
– When a patient tries to increase physiological demand with exercise the compartment is unable to expand causing a pressure build-up
Proposed pathology for Chronic Exertional Compartment Syndrome
– Unclear about the exact mechanism
– Hypothesised that it is an ischemic phenomenon secondary to the build-up in pressure in the implicated compartment
– This causes three possible things to happen that may explain the patient’s symptoms. 1. arterial spasm with an associated reduction in arterial flow. 2. The disruption of microcirculation to tissues. 3. arterial or venous collapse.
– This then creates an ischemic pain with blood unable to circulate to the tissues and cater for an increase in metabolic demand
– Supported by a study that did biopsies on surgical release. The muscle tissue had lower capillary density compared to normal tissue
Physical impairments & associated structure/tissue sources (ie P/E findings)
Local:
– Increased tension on palpation of lower limb compartments following exertion (wood type feeling)
– Pain on passive stretch of the affected compartment
– Obs: common to see bulges or herniations in the lower limb, also look for hypertrophy
– P/E at rest will often be unremarkable
– Neurological and neural tension required // especially if lateral compartment
– Vascular assessment: foot pulses (post tib, peroneal, dorsalis pedis, anterior tib) and capillary return (toenails) // at rest and under fatigue
– reduced strength of compartment muscles // only positive if symptoms progress
Remote
– Reduced distal pulses/refill with exertion
Note:
– Do a bony palpation assessment to rule out fracture or stress injury. Can also differentiate by physical activity that requires ground reaction forces (running) vs activity without (cycling)
Typical contributing factors to Chronic Exertional Compartment Syndrome
– Diabetes
– Presence of any metabolic conditions
– Inadequate nutritional intake
– Muscle hypertrophy
– Kidney Disease
– Fracture
– Lower limb trauma
Relevant precautions/ contraindications to P/E and treatment
– Severity and irritability
– Serious pathology needs to be excluded due to the overlapping nature of symptoms
– Acute compartment syndrome is considered a medical emergency and patients should be directed to the hospital
– Usually occurs with trauma (ie fracture or a crush injury) however it can happen secondary to exertion (20-30% of cases)
– Signs of this include pain, pallor, reduced or absent pulses, paraesthesia and change in temperature
Relevant diagnostic imaging for Chronic Exertional Compartment Syndrome
– Definitive diagnosis requires intracompartmental pressure measurements (Gold standard)
– Ultrasound, CT and MRI have a place in the exclusion of pathology however will often come back negative
– Consider imaging whilst the patient is in an exerted state
Typical prognosis for Chronic Exertional Compartment Syndrome
– With surgical intervention return to activity is estimated between 6-12 weeks
– Conservative is not reported // likely due to the diagnostic delay period of > 2 years, if symptoms are well controlled in early stages then continued play is a viable option
Management/treatment selection for Chronic Exertional Compartment Syndrome
Surgical (high-level evidence)
– fasciotomy or fasciectomy // most common form of release with relative success
– Fibulectomy has been attempted with some benefit reported however regarded by most as radical and unnecessary compared to the other surgical options
– Post-op recommendations:
1. Early mobilisation: Ambulation with 1-5 days with assistive devices.
2. AROM exercises at ankle and knee ASAP
3. Walking without an assistive device 5 days to 3 weeks. Commencement of strengthening and stretching at the same time.
4. 3-6 weeks resumptios of running.
5. Return to lower limb activity between 6-12 weeks
– Failure rate of 10-20% for the lateral and anterior compartments (due to post-op complications or return of pain/disability)
– Failure rate of 52% for a deep posterior compartment
Conservative
– Little has been completed on rehabilitation with conservative management // likely due to success with managing symptoms through activity modification
– Middle-level evidence for changing foot strike pattern from hindfoot to forefoot (Showed to reduce intracompartmental pressure and increase the distance before symptoms in military personal)
– Low-level evidence: Case series showed reduced pain following exercise however when collecting questionnaires the results were conflicting
– Low-level evidence for massage in the anterior compartment and deep posterior compartments // however short term benefit only
– Modalities mentioned (however no evidence to support): analgesics, physiotherapy, orthotics, biomechanics review, botox injections, ultrasound, strain counterstain
Differential diagnosis for Chronic Exertional Compartment Syndrome
Vascular symptoms (pulses, refill)
– Popliteal artery entrapment syndrome
– assess locally and distally
Bone Assessment (tuning fork, ground reaction forces, palpation)
– Stress fractures of the Tibia
– MTSS
– Periostitis of the tibia
Dynamic Assessment
– Tenosynovitis’
– muscle or tendon pathologies
Neurological and Lumbar spine Assessment
– Lumbar spine stenosis
– Lumbar spine referral
– CNS disorder (clear due to the bilateral nature)
– Cancer
Subjective examination (special questions)
– Infection
– Acute compartment syndrome
References
Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.
Blackman, Paul G 2000, ‘A review of chronic exertional compartment syndrome in the lower leg’, Medicine and Science in Sports and Exercise, vol. 32, pp. S4–S10.
Bong, M.R., Polatsch, D.B., Jazrawi, L.M. and Rokito, A.S., 2005. Chronic exertional compartment syndrome: diagnosis and management. Bulletin of the NYU Hospital for Joint Diseases, 62(3-4), pp.77-77.
Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.
Diebal, M.A.R., Gregory, R., Alitz, C.C. and Gerber, L.J.P., 2011. Effects of forefoot running on chronic exertional compartment syndrome: a case series. International journal of sports physical therapy, 6(4), p.312.
Kingdom. Clinical Journal of Sport Medicine, 16(3), pp.209-213.
Paik, R.S., Pepples, D. and Hutchinson, M.R., 2013. Chronic exertional compartment syndrome. Bmj, 346.
Palmer, E., Council, R.O. and Richman, S., 2021. Compartment Syndrome, Acute.
Tucker, A.K., 2010. Chronic exertional compartment syndrome of the leg. Current reviews in musculoskeletal medicine, 3(1-4), pp.32-37.
Tzortziou, V., Maffulower limbi, N. and Padhiar, N., 2006. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United
Zimmermann, W.O., Hutchinson, M.R., Van den Berg, R., Hoencamp, R., Backx, F.J. and Bakker, E.W., 2019. Conservative treatment of anterior chronic exertional compartment syndrome in the military, with a mid-term folower limbow-up. BMJ open sport & exercise medicine, 5(1), p.e000532.