Chronic Exertional Compartment Syndrome: A Review

Written by admin on July 15, 2013 – 10:00 pm -

Active individuals, including athletes or people with highly active jobs, have a risk of sustaining an orthopedic condition. While a lot of the focus remains on the traumatic, or acute, injuries, a vast majority of conditions may result from overuse. The body can only take so much before these overuse injuries begin to create dysfunctions and inflammation in the body, thus causing chronic pain syndromes. One syndrome that results due to overuse is a condition to the lower legs called chronic exertional compartment syndrome.
Chronic exertional compartment syndrome (CECS) is the direct result of increased pressure within one or more of the four compartments of the lower leg. These compartments include the anterior, lateral, superficial posterior, and deep posterior. This increase in pressure causes compression of the muscular and neurovascular structures located in each compartment. The anterior compartment is the most common compartment for this syndrome to occur in, however, any or all compartments may be involved (Blackman, 2000). The condition is activity related as symptoms are generally felt only during activity. These symptoms may include a deep aching pain, tightness, and swelling of the involved compartments. These same symptoms will resolve fairly quickly with rest.
One such case involving CECS involved a 22 year old male soccer athlete who reported to clinic with insidious, yet sudden, onset of bilateral lower leg tightness. This pain was felt consistently about 50 minutes into soccer activities and would resolve within 15 minutes of rest. Examination of lower legs revealed firmness to the bilateral anterior and lateral compartments which is a common finding in this condition. To confirm that CECS is present, the best method is by measuring the compartment pressure. Compartment pressure measurements were taken in this patient. These measurements revealed resting compartment pressures well above average in bilateral anterior and lateral compartments. It was determined that this patient was suffering from CECS.
Once CECS is identified, treatment and management of the condition is the next barrier that needs to be addressed. This patient was given options for both non-operative and operative interventions. Upon consideration, the patient elected to receive bilateral anterior and lateral compartment release by fasciotomy.
Surgical intervention involving fasciotomy compartmental release remains the main form of management for this condition, particularly in younger, athletic individuals such as the soccer player described above. The American Journal of Sports Medicine recently published an article that investigated functional outcomes and patient satisfaction after fasciotomy for CECS. In this investigation, the authors identified patients between 1998 and 2008 that presented with CECS that had failed non-operative management and presented them with the option of either continuing to receive non-operative treatment or to receive referral to orthopedic surgeon for fasciotomy release. Patients with a minimum 2-year follow-up were provided a questionnaire describing their pre-treatment and post-treatment conditions. This questionnaire included quality and duration of symptoms, analog pain scale, symptomatic and functional responses to treatment, and satisfaction with treatment. All medical records and patient outcomes were then reviewed. After interventions were implemented, the operative group had a much higher rate of success and patient satisfaction rate at 81% in both categories compared to the non-operative group with success and satisfaction rates of 41% and 56%, respectively. Patients that received combined anterior and lateral compartment release had a much higher failure rate (31%) than those receiving an isolated anterior compartment release (0%). Also, the data analyzed revealed that those patients who were college-aged or younger had a higher satisfaction rating when compared to patients post-college. The authors concluded that patients 23 years old or younger with isolated anterior compartment syndrome are excellent candidates for fasciotomy release. Furthermore, they conclude that lateral compartment release should be avoided unless clearly indicated by symptoms and compartment pressure measurements (Packer, Day, Nguyen, Hobart, Hannafin & Metzl, 2013).
In the case of this 22 year old soccer player, he elected to receive bilateral anterior and lateral compartment fasciotomy for CECS. Despite the conclusions of Packer et. al., this particular patient responded favorably to both anterior and lateral compartment releases. Factors that likely attributed to the success of this individuals surgery were the fact that he was younger and fell into the group of people that respond more favorably. The athlete was able to return to soccer activities and has not had any recurrence of symptoms.
Additional studies supporting the use of compartment fasciotomy include one study published in 2010 that concluded compartment release is a cosmetic, safe, and effective means of treating CECS (Wittstein, Moorman & Levin 2010). Another study later concluded that, for athletes, a meticulous surgical intervention for CECS will yield good outcomes and return to play can be expected in as quickly as 8-12 weeks (Murray & Heckman, 2012).
Despite the overall support for the implementation of surgical intervention for patients suffering from CECS, many patients wish to avoid surgical interventions by means of more conservative management. For athletes, particularly those involved in intense aerobic activities such as soccer or track athletes, conservative management is a realistic option to pursue.
One key component that must be addressed is analyzing the athletes running mechanics to identify a possible cause for why the condition became a problem. In 2012, the American Journal of Sports Medicine published an article investigating the effects of forefoot running on pain and disability associated with CECS. The investigators identified 10 individuals that were clinically indicated for surgical compartment release. Once these individuals were identified, surgical intervention was postponed and conservative management was implemented in the form of a six week forefoot strike running intervention. Multiple variable were measured before and after the six week intervention including compartment pressures at rest and post-running, running distance, and reported pain. The results showed that after the six-week intervention, mean post-run anterior compartment pressures significantly decreased from 78.0 ± 32.0 mm Hg to 38.4 ± 11.5 mm Hg. Additionally, running distance significantly increased and reported pain while running decreased. No subject involved in the study needed surgical intervention (Diebal , Gregory, Alitz & Gerber, 2012).
Based on the results of this study, any high caliber athlete wishing to avoid surgical intervention should strongly consider a running gait analysis from a qualified professional to determine if forefoot running is a viable option to remain off the operating table.
While the surgical intervention of the 22-year old soccer athlete was a success, the question must be raised: would the athlete have been able to avoid a surgery by altering his running gait? Future research and clinical trials must be implemented in order to draw more support towards successful non-operative interventions for CECS. For some patients, this may be viable substitute to surgical intervention.

Sources:

Blackman, P. (2000). A review of chronic exertional compartment syndrome in the lower leg. Medicine and Science in Sports and Exercise, 32(3 Suppl), S4-10. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10730989
Diebal , A., Gregory, R., Alitz, C., & Gerber, J. (2012). Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. The American Journal of Sports Medicine, 40(5), 1060-1067. Retrieved from http://ajs.sagepub.com/content/40/5/1060.short
Murray, M., & Heckman , M. (2012). Chronic exertional compartment syndrome: Diagnostic techniques and management. Techniques in Orthopaedics, 27(1), 75-78. Retrieved from http://journals.lww.com/techortho/Abstract/2012/03000/Chronic_Exertional_Compartment_Syndrome__.15.aspx
Packer, J., Day, M., Nguyen, J., Hobart, S., Hannafin, J., & Metzl, J. (2013). Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. The American Journal of Sports Medicine, 41(2), 430-436. Retrieved from http://ajs.sagepub.com/content/41/2/430.short
Wittstein, J., Moorman, C., & Levin, L. (2010). Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. The American Journal of Sports Medicine, 38(8), 1661-1666. Retrieved from http://ajs.sagepub.com/content/38/8/1661.short

Matt Rongstad is a nationally Certified, state Licensed Athletic Trainer and post-graduate Resident in training at The Galland Orthopaedics and Sports Medicine Athletic Training Residency– a 12 month immersional program allowing ATCs to maintain and hone clinical skills while developing those talents necessary to be effective in the clinical setting as an ATC/physician extender. Find out more at www.atcfellowship.com.


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