Chronic Exertional Compartment Syndrome and Release

Brian R. Wolf, MD, MS

Jacqueline Baron, BA

Dr. Wolf or an immediate family member has received royalties from CONMED Linvatec; serves as a paid consultant to or is an employee of CONMED Linvatec; serves as an unpaid consultant to SportsMed Innovate; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from Arthrex, Inc., CONMED Linvatec, and Smith & Nephew; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association, the American Orthopaedic Society for Sports Medicine, and the Mid-America Orthopaedic Association. Neither Ms. Baron nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

This chapter is adapted from Wagstrom EA, Amendola A, Wolf BR: Chronic exertional compartment syndrome and release, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 541-543.

PATIENT SELECTION

Indications

The diagnosis of chronic exertional compartment syndrome (CECS) is made clinically. Patients with CECS are typically athletes participating in sports with a lot of running, but CECS can also be seen with jumping, cutting, and skating sports or military exercises.¹^,² CECS may also occur in less active individuals, older patients, or diabetics.³^,⁴^,⁵ Patients with CECS commonly present with pain that occurs following a certain amount of time exercising or after a certain intensity of exercise.⁶^,⁷^,⁸^,⁹ This leg pain usually dissipates with rest. CECS is often bilateral, but can also be unilateral, and may occur without a distinguishable cause or inciting event. Patients are frequently asymptomatic at the time of examination.

The cause of pain and exact pathophysiology of CECS is unclear. However, it is thought that the leg muscle compartments, which are each confined by tight fascia, do not allow sufficient muscle expansion during exercise, leading to relative ischemia.⁶ Pain symptoms result from muscle expansion and associated neurovascular function compromise due to elevated involved compartment pressures.

There are four muscle compartments in the leg: anterior, lateral, superficial posterior, and deep posterior. Each compartment contains one or more muscles and at least one neurovascular structure. The anterior compartment is the most commonly affected compartment, but it is not uncommon for multiple compartments to be involved.⁶^,⁸^,¹⁰

The diagnosis of CECS is typically confirmed using intracompartmental pressure measurement and the Pedowitz criteria.¹⁰ Multiple devices for testing intracompartmental pressures are available, but all require needle insertion into the leg compartments. Dynamic intramuscular compartment pressure recording during exercise has been proposed yet requires needle insertion into the intramuscular compartment and has been assessed only in the anterior compartment.¹¹ Traditionally, pressure testing is done at rest and after exercising until symptoms occur. A video of postexercise testing can be seen in the video supplement. Testing is considered confirmatory of CECS if preexercise resting compartment pressure is equal to or greater than 15 mm Hg. Confirmatory pressures after exercise are 1-min postexercise pressure equal to or greater than 30 mm Hg, and/or 5-min postexercise pressure equal to or greater than 20 mm Hg. Surgical treatment is indicated if the patient has failed nonsurgical management, typically lasting 3 to 6 months, and desires to continue with the associated activity.¹²^,¹³