1. Chronic Exertional Compartment Syndrome
Sathish Rajasekaran, MD, Clinical Assistant Professor, Division of PM&R, University of Alberta

2. Disclosures
None

3. Choric Exertional Compartment Syndrome (CECS)
Outline
Objectives
Introduction
Anatomy
Pathophysiology
History and Physical Exam
Diagnostic Evaluation
Treatment
Have an approach to adding CECS to your differential diagnosis based on history and physical examination
Outline an approach to ordering the appropriate tests for patients where CECS is on the differential diagnosis
Outline conservative and surgical treatment options for CECS
Outline return to play guidelines for CECS
Have an approach to adding CECS to your differential diagnosis based on history and PE
Outline an approach to ordering the appropriate tests for patients where CECS is on the differential diagnosis
Outline conservative and surgical treatment options for CECS
Outline RTP guidelines for CECS

4. Clinical Case 24 year old female – J.M. History: Physical Examination
Classical symptoms?
Physical Examination
At rest vs. post-exertion
Diagnostic Testing
Compartment pressure testing vs. other imaging modalities
Other studies to exclude other diagnoses
Treatment options
Conservative (rehabilitation) vs. interventional options vs. surgery
Will discuss patients history, examination findings, pressure testing results and list topics I want audience to think about as I discuss case to foreshadow objectives of talk that I will be going through

5. First description of CECS and called “march gangrene in article” JBJS (Am) 1945

6. Epidemiology Incidence2,3 Age4-8 Association with sports4,9
General population (unknown)
Undiagnosed leg pain (14-27%)
Age4-8
Potential bimodal distribution (20 [before 30] vs. 48 years)
Association with sports4,9
Involved in sports (87%)
Running (69%)
Diabetic patients with exertional leg pain and normal vascular studies (90%)
Note bimodal distribution is reported because of older patient association with diabetes

7. Location Can present in various regions of the body10
Lower leg, thigh, foot, and forearm
Lower leg most common region affected (95%)10
Bilateral lower leg involvement (82%)4

8. Anatomy
40-60%4,5
12-35%4,5
32-60%4,5
CECS involves the anterior compartment in 40%-60% of patients
deep posterior compartment in 32%-60%
lateral compartment in 12%-35%
Superficial posterior compartment in 2%-20%
2-20%4,5
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):

9. Pathophysiology
↓Compliance → ↑Compartment pressure?

10. Pathophysiology Reduced microcirculatory capacity
Vascular congestion as a result of decreased venous return
Lower capillary denisity, lower number of cpillaries around muscle fibers, lower number of capillaries in relation to muscle fiber area

11. Pathophysiology
 This loss of flow reversal occurs in normal lower extremities with the vasodilatation that accompanies exercise, reactive hyperemia, or limb warming. The reverse flow component is also absent distal to severe occlusive lesions.
Loss of PDRF was not seen in ¾ CECS patients
Abstract presented at AMSSM 2013 (Rajasekaran and Aly)

12. Pathophysiology

13. History and Physical Examination
Pain with exertion
Dull → sharp pain
Neurological symptoms
Worsening over time
Pain with passive stretching of muscles in involved compartment

14. Diagnostic Evaluation
Pressure testing
Pre-exercise (15 mm Hg), 1 min post-exercise (≥30 mm Hg), 5 min post-exercise (≥20 mm Hg)
November and October 2012

15. Diagnostic Evaluation (Imaging)
The MRI protocol should consist of mainly fluid-sensitive sequences, such as STIR, T2, or proton density (PD). Fat saturation will increase conspicuity of edema. At least one T1-weighted image should also be included for better anatomic detail. The axial plane is the most important. The main finding is increased T2 signal intensity on postexercise images. Compartmental bulging, convex deep fascial margins, and effacement of the fascial planes may also be seen

16. Diagnostic Evaluation - Imaging
Bresler M, Mar W, Toman J. Diagnostic imaging in the evaluation of leg pain in athletes. Clinics in sports medicine. Apr 2012;31(2):
Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol. Skeletal radiology. Nov 2007;36(11):

17. Diagnostic Evaluation - Imaging
ATMG TP
Tib
Fib
Rajasekaran S, Beavis C, Aly AR, Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2013;23(4):

18. Treatment
Conservative
Interventional
Surgery

19. Treatment – Conservative

20. Treatment – Interventional
Abstract published in 16th European congress of PM&R (2008)

21. Treatment - Interventional

22. Treatment – Surgery Single incision (open) technique
One or two incision (subcutaneous) technique with or without endoscopic assistance with the removal of a strip of fascia

24. Treatment - Surgery
First two papers reports rates close to what is reported in various studies in the literature 80-95%
More recently Waterman published there retrospective level IV study with a success rate of: 55.3% (failure defined as needing revision surgery or medical discharge due to persistent LE symptoms)
-Cumulative surgery failure rate (medical discharge after first or second surgery) was 21.8%
-Things to consider they did not assess if pressures were done
-four compartment plus posterior included (21.6%)

25. Treatment - Surgery Complications (11-16%)28,29 Infection
Nerve or vascular injury
Deep vein thrombosis
Wound dehiscence
Complex regional pain syndrome
Scar hypersensitivity
Seroma/hematoma formation

26. Treatment - Surgery POD 1-2 POD 3-4 Weeks 1-4 Weeks 4-6 Weeks 6+
Gentle active and passive range-of-motion, weight bearing as tolerated, edema control measures, basic activities of daily living, protect the healing incision at all times
POD 3-4
Achieve independence with activities of daily living, and begin unassisted ambulation
Weeks 1-4
Add stair climbing and increase walking distance
Weeks 4-6
Begin non-impact lower extremity aerobic exercise
Weeks 6+
Initiate unrestricted impact lower extremity activities
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):

27. Clinical Case 24 year old female – J.M.
Trialed forefoot running technique
Symptoms resolved
Repeat pressures were not done
Patient continues to be asymptomatic (7 months)

28. Rajasekaran S, Kvinlaug K, Finnoff JT
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):

29. Choric Exertional Compartment Syndrome (CECS)
Outline
Objectives
Introduction
Anatomy and Pathophysiology
History and Physical Exam
Diagnostic Evaluation
Treatment
Return-to-Play Guidelines
Have an approach to adding CECS to your differential diagnosis based on history and physical examination
Outline an approach to ordering the appropriate tests for patients where CECS is on the differential diagnosis
Outline conservative and surgical treatment options for CECS
Outline return to play guidelines for CECS

30. References
Horn C. Acute ischaemia of the anterior tibial muscle and the long extensor muscles of the toes. J Bone Joint Surg Am. 1945;27(4):
Qvarfordt P, Christenson JT, Eklof B, Ohlin P, Saltin B. Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clinical orthopaedics and related research. Oct 1983(179):
Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. The American journal of sports medicine. Mar-Apr 1988;16(2):
Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. The American journal of sports medicine. May-Jun 1985;13(3):
Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. The American journal of sports medicine. Jan-Feb 1990;18(1):35-40.

31. References
Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. The Journal of bone and joint surgery. American volume. Dec 1983;65(9):
Wallensten R. Results of fasciotomy in patients with medial tibial syndrome or chronic anterior-compartment syndrome. The Journal of bone and joint surgery. American volume. Dec 1983;65(9):
Styf JR, Korner LM. Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. The Journal of bone and joint surgery. American volume. Dec 1986;68(9):
Edmundsson D, Toolanen G. Chronic exertional compartment syndrome in diabetes mellitus. Diabetic medicine : a journal of the British Diabetic Association. Jan 2011;28(1):81-85.
Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med. Mar 1997;31(1):21-27.

32. References
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R : the journal of injury, function, and rehabilitation. Dec 2012;4(12):
Hurschler C, Vanderby R, Jr., Martinez DA, Vailas AC, Turnipseed WD. Mechanical and biochemical analyses of tibial compartment fascia in chronic compartment syndrome. Annals of biomedical engineering. May-Jun 1994;22(3):
Dahl M, Hansen P, Stal P, Edmundsson D, Magnusson SP. Stiffness and Thickness of Fascia Do Not Explain Chronic Exertional Compartment Syndrome. Clinical orthopaedics and related research. Sep
Edmundsson D, Toolanen G, Thornell LE, Stal P. Evidence for low muscle capillary supply as a pathogenic factor in chronic compartment syndrome. Scandinavian journal of medicine & science in sports. Dec 2010;20(6):
Birtles DB, Rayson MP, Casey A, Jones DA, Newham DJ. Venous obstruction in healthy limbs: a model for chronic compartment syndrome? Medicine and science in sports and exercise. Oct 2003;35(10):

33. References
Aweid O, Del Buono A, Malliaras P, et al. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2012;22(4):
Roberts A, Franklyn-Miller A. The validity of the diagnostic criteria used in chronic exertional compartment syndrome: A systematic review. Scandinavian journal of medicine & science in sports. Sep
McDonald S, Bearcroft P. Compartment syndromes. Seminars in musculoskeletal radiology. Jun 2010;14(2):
Bresler M, Mar W, Toman J. Diagnostic imaging in the evaluation of leg pain in athletes. Clinics in sports medicine. Apr 2012;31(2):
Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol. Skeletal radiology. Nov 2007;36(11):

34. References
Rajasekaran S, Beavis C, Aly AR, Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2013;23(4):
Kirby RL, McDermott AG. Anterior tibial compartment pressures during running with rearfoot and forefoot landing styles. Archives of physical medicine and rehabilitation. Jul 1983;64(7):
Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. International journal of sports physical therapy. Dec 2011;6(4):
Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome. The American journal of sports medicine. Mar
Isner-Horobeti ME, Dufour SP, Blaes C, Lecocq J. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study. The American journal of sports medicine. Nov 2013;41(11):

35. References
Wittstein J, Moorman CT, 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. The American journal of sports medicine. Aug 2010;38(8):
Packer JD, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. The American journal of sports medicine. Feb 2013;41(2):
Waterman BR, Laughlin M, Kilcoyne K, Cameron KL, Owens BD. Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. The Journal of bone and joint surgery. American volume. Apr ;95(7):
Brennan FH, Jr., Kane SF. Diagnosis, treatment options, and rehabilitation of chronic lower leg exertional compartment syndrome. Current sports medicine reports. Oct 2003;2(5):

36. Acknowledgments
Dr. Jonathan Finnoff