Chronic Exertional Compartment Syndrome

NewsBot · Jul 26, 2020

Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg
Sanne Vogels Ewan D. Ritchie Thijs T. C. F. van Dongen Marc R. M. Scheltinga Wes O. Zimmermann Rigo Hoencamp
11 June 2020

Objective
Surgery is the gold standard in the management of chronic exertional compartment syndrome (CECS) of the lower extremity, although recent studies also reported success following gait retraining. Outcome parameters are diverse, and reporting is not standardized. The aim of this systematic review was to analyze the current evidence regarding treatment outcome of CECS in the lower leg.

Material and Methods
A literature search and systematic analysis were performed according to the PRISMA criteria. Studies reporting on outcome following treatment of lower leg CECS were included.

Results
A total of 68 reports fulfilled study criteria (n =; 3783; age range 12‐70 year; 7:4 male‐to‐female ratio). Conservative interventions such as gait retraining (n =; 2) and botulinum injection (n =; 1) decreased ICP (urn:x-wiley:09057188:media:sms13747:sms13747-math-0001 =; 68 mm Hg tourn:x-wiley:09057188:media:sms13747:sms13747-math-0002 =; 32 mm Hg) and resulted in a 47% (±42%) rate of satisfaction and a 50% (±45%) rate of return to physical activity. Fasciotomy significantly decreased ICP (urn:x-wiley:09057188:media:sms13747:sms13747-math-0003 =; 76 mm Hg to urn:x-wiley:09057188:media:sms13747:sms13747-math-0004 =; 24 mm Hg) and was associated with an 85% (±13%) rate of satisfaction and an 80% (±17%) rate of return to activity. Return to activity was significantly more often achieved (P < .01) in surgically treated patients, except in one study favoring gait retraining in army personnel.

Conclusion
Surgical treatment of CECS in the lower leg results in higher rates of satisfaction and return to activity, compared to conservative treatment. However, the number of studies is limited and the level of evidence is low. Randomized controlled trials with multiple treatment arms and standardized outcome parameters are needed.
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NewsBot · Oct 10, 2020

Chronic Exertional Compartment Syndrome of the Leg Management Is Changing: Where Are We and Where Are We Going?
Nwakibu, Uzoma et al
Current Sports Medicine Reports: October 2020 - Volume 19 - Issue 10 - p 438-444

Chronic exertional compartment syndrome (CECS) is one of the wide range of causes of exercise-related leg pain in athletes. It is defined as a transient increase in compartment pressures during activity, which causes pain, because of the inability of the fascial compartments to accommodate and is usually relieved by cessation of exercise. Exercise-induced leg pain in the athletic population is a common complaint, with reports of up to 15% of all runners arriving to initial evaluation with this presentation. Often, this lower-extremity exertional pain is grouped into the common term of “shin splints” by athletes, which is a nondiagnostic term that implies no specific pathology. It may, however, encompass much of the differential for CECS, including medial tibial stress syndrome, muscle strain, and stress fracture. Improving diagnostic techniques, as well as treatments, will continue to help athletes and patients with leg pain in the future.
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NewsBot · Nov 12, 2020

Chronic Exertional Compartment Syndrome in the Leg: Comparing Surgery to Conservative Therapy
Sanne Vogels , Ewan D. Ritchie, Henricus PH Hundscheid, Kim van Someren, Loes Janssen, Rigo Hoencamp, Marc R Scheltinga
Int J Sports Med

The aim of this nonrandomized cohort study was to compare the clinical effectiveness of an elective fasciotomy with conservative treatment for chronic exertional compartment syndrome of the leg. Patients diagnosed with chronic exertional compartment syndrome who opted for surgery (n=188) completed a preoperative questionnaire and a 12-month postoperative questionnaire. Patients who continued conservative treatments (n=23) served as controls. Gender, age, sports activity or affected compartments were comparable, but intensity of pain was higher in the surgical group (at rest: 2.5±0.1 vs. 2.0±0.2, during exercise: 4.2±0.1 vs. 3.8±0.2; both p<0.05). Following treatment, surgical patients demonstrated a larger drop in intensity levels of pain (surgery 1.6±0.1, conservative 0.9±0.2, p=0.01) and tightness (surgery 1.4±0.1, conservative 0.4±0.3, p=0.00) during exercise. Success (good or excellent treatment effect) was attained in 42% of the surgical group compared to only 17% in the conservatively treated group (p=0.02). However, previous activity level was achieved in a mere 26% in the surgical treatment group and 35% in the conservative treatment group (p=0.33). A fasciotomy for chronic exertional compartment syndrome in the leg results in significantly decreased levels of pain and tightness and better satisfaction compared to patients who continued a conservative treatment regimen
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NewsBot · Jan 9, 2021

Botulinum Toxin A for Chronic Exertional Compartment Syndrome Evaluated With Shear Wave Elastography
A Case Report
Berrigan, William A. et al
Clinical Journal of Sport Medicine: January 05, 2021

This case presentation offers supportive evidence that shear wave elastography may provide an alternative method of diagnosis of chronic exertional compartment syndrome (CECS). A 39-year-old female runner presented with bilateral anterior shin pain on exertion. She initially underwent compartmental pressure testing confirming the diagnosis of CECS but declined fasciotomy. When her symptoms recurred, she was referred for botulinum toxin therapy. Shear wave muscle elastography was performed in the bilateral anterior and lateral compartments following symptom provocation treadmill testing and compared with 2 control subjects. At 6 weeks and 7 months after onabotulinumtoxinA injections, she was asymptomatic, and elastography measurements revealed a reduction in muscle stiffness from initial treadmill testing.
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NewsBot · Jan 15, 2021

A Comparison of Two Models Predicting the Presence of Chronic Exertional Compartment Syndrome
Emeline Vrignaud, Pierre Menu, Yannick Eude, Yves Maugars, Marc Dauty, Alban Fouasson-Chailloux
Int J Sports Med

Clinical history and physical examination are usually not sufficient to diagnose leg chronic exertional compartment syndrome (CECS). Two predictive clinical models have been proposed. The first model by De Bruijn et al. is displayed as a nomogram that predicts the probability of CECS according to a risk score. The second model by Fouasson-Chailloux et al. combines two signs (post-effort muscle hardness on palpation or hernia). To evaluate those models, we performed a prospective study on patients who were referred for possible CECS. 201 patients underwent intra-compartmental pressure at 1-min post-exercise (CECS if ≥ 30 mmHg) – 115 had CECS. For the De Bruijn et al. model, the risk score was 7.5±2.2 in the CECS group and 4.6±1.7 in the non-CECS group (p<0.001) with an area under the ROC curve of 0.85. The model accuracy was 80% with a sensitivity of 82% and a specificity of 78%. Concerning Fouasson-Chailloux et al. model, the accuracy was 86%; the sensitivity and the specificity were 75 and 98%, respectively. The De Bruijn et al. model was a good collective model but less efficient in individual application. In patients having both muscle hardness and hernia, we could clinically make the diagnosis of CECS.
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NewsBot · Feb 11, 2021

Predictors of Improvement After Fasciotomy for Treatment of Chronic Exertional Compartment Syndrome of the Lower Extremity
John J Mangan et al
Sports Health. 2021 Feb 9

Background: Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating chronic exertional compartment syndrome (CECS). However, not all patients have demonstrated the same level of symptom improvement.

Hypothesis: Specific patient variables will lead to enhanced functional improvement after fasciotomy for CECS of the lower extremity.

Study design: Case series.

Level of evidence: Level 4.

Methods: A review of patients undergoing fasciotomy of the lower extremity for treatment of CECS by a single surgeon from 2009 to 2017 was performed. Pre- and postoperative measures of Foot and Ankle Ability Measure-Sports subscale (FAAM-Sports), FAAM-Sports Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected at a minimum of 12 months postoperatively. The primary outcomes of change in FAAM-Sports, FAAM-Sports SANE, and VAS during sporting activities were calculated by taking the difference of post- and preoperative scores. Generalized multiple linear regression analyses was performed to determine independent predictors of functional and pain improvement.

Results: A total of 61 patients (58% response rate) who underwent 65 procedures were included in this study, with postoperative outcome measures obtained at mean duration of 57.9 months (range, 12-115 months) after surgery. Patients had a mean ± SD improvement in FAAM-Sports of 40.4 ± 22.3 points (P < 0.001), improvement in FAAM-Sports SANE of 57.3 ± 31.6 points (P < 0.001), and reduction of VAS pain of 56.4 ± 31.8 points (P < 0.001). Multiple linear regression analysis revealed deep posterior compartment involvement, younger age, a history of depression, and male sex to be significant independent predictors of enhanced improvement after fasciotomy.

Conclusion: Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater functional improvement.

Clinical relevance: Male patients, younger patients, patients with depression, and patients with deep posterior compartment involvement may serve to benefit more with fasciotomies for treatment of CECS.
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NewsBot · Mar 15, 2021

Microdialysis for chronic exertional compartment syndrome: a pilot study
Heinz Lohrer, Jochen Klein, Tanja Nauck & Tobias Schönberg
BMC Sports Science, Medicine and Rehabilitation volume 13, Article number: 21

Background
Diagnosing chronic exertional compartment syndrome (CECS) is still a challenge. An increase in intramuscular pressure during and following exercise is accepted as the diagnostic standard. However, neither the methods used nor the interpretation of the obtained results are sufficiently standardized.

Methods
In the present pilot study, the metabolic state of CECS patients was investigated using microdialysis. We hypothesized that there was no difference in intramuscular concentrations of glucose, lactate, glutamate, and glycerol before and after exercise (H10) or between patients suffering from CECS and healthy control subjects (H20). This study was designed as an explorative case-control study (level of evidence III). Twelve patients suffering from CECS of the lower leg and six matched asymptomatic control subjects underwent microdialysis in the anterior (n = 7) or deep posterior compartment (n = 11) of the leg. Following ultrasound-guided insertion of the microdialysis catheters, 10-minute fractions of the dialysates were collected first during rest and then following fatigue- or pain-induced discontinuation of exercise. Dialysates were analysed for lactate, glucose, glutamate, and glycerol concentrations 6 × 10 min before and 6 × 10 min after exercise.

Results
Exercise-induced increases in lactate, glutamate, and glycerol concentrations were detected in both CECS patients and control subjects (all p < 0.001). No differences between CECS patients and control subjects were found by comparing the intramuscular glucose, lactate, glutamate, and glycerol concentrations at rest and following exercise (all p > 0.05).

Conclusions
We found exercise-induced increases in the lactate, glutamate, and glycerol levels in skeletal muscle. However, the metabolic changes did not differentiate CECS patients from healthy subjects
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NewsBot · Jul 20, 2021

Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg
VOGELS, SANNE et al
Medicine & Science in Sports & Exercise: August 2021 - Volume 53 - Issue 8 - p 1549-1554

Purpose
This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial.

Methods
Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result.

Results
Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14–37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2–65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity.

Conclusion
An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.
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NewsBot · Oct 5, 2021

The effect of gender on intramuscular pressure in patients with chronic exertional compartment syndrome of the lower leg
Sophia Lindorsson,Kajsa Rennerfelt,Helena Brisby,Qiuxia Zhang,
27 September 2021

This study aimed to compare intramuscular pressure (IMP) in all four compartments of the lower leg between men and women in patients with suspected chronic exertional compartment syndrome (CECS), and to assess possible effects of gender in relation to covariation factors. A consecutive series of patients with exertional leg pain (n = 962, median age 27 years, 56.2% women) underwent IMP measurements between 2009 and 2019. The CECS diagnosis was confirmed (n = 491, 48% women) or ruled out (n = 471, 65% women) based on the patient's history, clinical examination, and IMP measurements. IMP values of the compartments were compared between genders. A multiple linear regression analysis was performed for IMP in the anterior and lateral compartments, where the number of patients was large enough to investigate the possible impact of other factors such as height, age, and duration of pain. Among those with a confirmed CECS diagnosis, one-minute post-exercise IMP was significantly lower in women than in men for all four muscle compartments: anterior (median [range] mmHg 44 [24–120] vs. 50 [24–130]), lateral (35 [20–89] vs. 40 [26–106]), deep posterior (31 [25–36] vs. 34 [24–53]), and superficial posterior (32 [27–39] vs. 37 [22–54]). In the multiple regression analysis, gender differences remained significant in the anterior compartment but not the lateral compartment, where only height remained a significant predictor of IMP. Gender should be considered when using cut-off values for IMP in diagnosing CECS, especially for the anterior compartment.
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NewsBot · Feb 24, 2022

Two-Compartment or Four-Compartment Fasciotomy for Lower Leg Chronic Exertional Compartment Syndrome: A Systematic Review
Chris Weiss, BSc et al
February 23, 2022

Patients with lower leg chronic exertional compartment syndrome are impaired due to exercise-related pain. Fasciotomy is the surgical gold standard. However, it is unknown whether number of simultaneously opened compartments affects outcome. The purpose of this systematic review was to compare patient-reported outcomes of a two-compartment fasciotomy with a four-compartment fasciotomy. Controlled clinical trials (randomized/non-randomized), cohort studies and case series reporting on outcome following either two-compartment or four-compartment fasciotomy for lower leg chronic exertional compartment syndrome were searched until May 31, 2021 in PubMed, EMBASE and Cochrane. Results were qualitatively synthesized. Risk of bias and levels of evidence were determined. Seven studies reporting on altogether 194 athletes and military personnel (mean age 24 years) were included. Quality assessment revealed a high risk of bias in all studies. Both two-compartment and four-compartment fasciotomy were associated with a 50-100% “return to activity” rate (in studies reporting group results separately: two-compartment 90-100%; four-compartment 50-100%) and a 41-100% “return to previous activity” rate (in studies reporting group results separately: two-compartment 82-100%; four-compartment 50-100%) without significant differences. Mean Marx activity score of one study found a small significant standardized mean difference (0.196 (0.524,0.916)) favoring four-compartment fasciotomy. Rate of satisfaction (two-compartment 74-89%; four-compartment 75-100%) and residual symptoms (two-compartment 0-36%; four-compartment 0-50%) indicated no group differences. In conclusion, a two-compartment fasciotomy or a four-compartment fasciotomy for lower leg chronic exertional compartment syndrome appears to be equally successful. However, included studies were hampered by methodological shortcomings (low sample size, selection bias, heterogeneity and no uniform outcome measures).
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NewsBot · Mar 28, 2022

Two-Compartment or 4-Compartment Fasciotomy for Lower Leg Chronic Exertional Compartment Syndrome: A Systematic Review
Chris Weiss et al
J Foot Ankle Surg. 2022 Feb 24

Patients with lower leg chronic exertional compartment syndrome are impaired due to exercise-related pain. Fasciotomy is the surgical gold standard. However, it is unknown whether number of simultaneously opened compartments affects outcome. The purpose of this systematic review was to compare patient-reported outcomes of a 2-compartment fasciotomy with a 4-compartment fasciotomy. Controlled clinical trials (randomized/nonrandomized), cohort studies and case series reporting on outcome following either 2-compartment or 4-compartment fasciotomy for lower leg chronic exertional compartment syndrome were searched until May 31, 2021 in PubMed, EMBASE, and Cochrane. Results were qualitatively synthesized. Risk of bias and levels of evidence were determined. Seven studies reporting on altogether 194 athletes and military personnel (mean age 24 y) were included. Quality assessment revealed a high risk of bias in all studies. Both 2-compartment and 4-compartment fasciotomy were associated with a 50% to 100% "return to activity" rate (in studies reporting group results separately: 2-compartment 90%-100%; 4-compartment 50%-100%) and a 41% to 100% "return to previous activity" rate (in studies reporting group results separately: 2-compartment 82-100%; 4-compartment 50%-100%) without significant differences. Mean Marx activity score of 1 study found a small significant standardized mean difference (0.196 [0.524,0.916]) favoring 4-compartment fasciotomy. Rate of satisfaction (2-compartment 74%-89%; 4-compartment 75%-100%) and residual symptoms (2-compartment 0%-36%; 4-compartment 0%-50%) indicated no group differences. In conclusion, a 2-compartment fasciotomy or a 4-compartment fasciotomy for lower leg chronic exertional compartment syndrome appears to be equally successful. However, included studies were hampered by methodological shortcomings (low sample size, selection bias, heterogeneity and no uniform outcome measures).
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NewsBot · Jul 4, 2022

Measuring intracompartmental pressures for the chronic exertional compartment syndrome: Challenging commercially available devices and their respective accuracy
S.Vogels et al
Journal of Biomechanics Volume 135, April 2022, 111026

The aim of this study was to compare commercially available manometers and needles used for intracompartmental pressure measurements for accuracy. An experimental compartment simulation model was developed in order to compare four different terminal devices (Compass manometer, Stryker device, Meritrans transducer, and arterial line) and 22 types of needles. First, all possible device/needle combinations were introduced in rubber ports at the bottom of a water column. The water column was gradually drained three times for each device/needle combination and pressures were recorded by two researchers. This procedure was repeated after placement of a sample of homogenous porcine gluteal muscle tissue. When measuring the fluid column only, all Intraclass Correlation Coefficients were found to be ≥0.980, indicating good resemblance to the reference pressure. After addition of the muscle tissue to the experimental set up, accuracy of the Stryker device and arterial line remained the same. The accuracy of the Compass manometer and Meritrans transducer became less. Excellent reliability was found for 7 out of 22 needles when combined with the Stryker device and for 2 out of 22 needles when combined with the arterial line. The four terminal devices tested were all accurate when measuring pressure in a water column, whereas only the Stryker device and arterial line accurately represented the water column pressure in a porcine gluteal muscle model. Future research will have to verify whether these results can be repeated in human cadaver models and in vivo.
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NewsBot · Jul 14, 2022

Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg
VOGELS, SANNE et al
Medicine & Science in Sports & Exercise: August 2021 - Volume 53 - Issue 8 - p 1549-1554

Purpose
This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial.

Methods
Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result.

Results
Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14–37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2–65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity.

Conclusion
An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.
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NewsBot · Jul 15, 2022

Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg
VOGELS, SANNE et al
Medicine & Science in Sports & Exercise: August 2021 - Volume 53 - Issue 8 - p 1549-1554

Purpose
This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial.

Methods
Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result.

Results
Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14–37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2–65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity.

Conclusion
An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.
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NewsBot · Jul 20, 2022

Systematic review of innovative diagnostic tests for chronic exertional compartment syndrome
Ewan D. Ritchie , Sanne Vogels , Thijs T.C.F. van Dongen , Boudewijn Borger van der Burg , Marc R Scheltinga , Wessel O. Zimmermann , Rigo Hoencamp
SOurce

The diagnosis chronic exertional compartment syndrome is traditionally linked to elevated intracompartmental pressures, although uncertainty regarding this diagnostic instrument is increasing. The aim of current review was to evaluate literature for alternative diagnostic tests. A search in line with PRISMA criteria was conducted. Studies evaluating diagnostic tests for chronic exertional compartment syndrome other than intracompartmental pressure measurements were included. Bias and quality of studies were evaluated using the Oxford Levels of Evidence and the QUADAS-2 instrument. A total of 28 studies met study criteria (MRI n=8, SPECT n=6, NIRS n=4, MRI and NIRS together n=1, miscellaneous modalities n=9). Promising results were reported for MRI (n = 4), NIRS (n = 4) and SPECT (n = 3). These imaging techniques rely on detecting changes of signal intensity in manually selected regions of interest in the muscle compartments of the leg. Yet, diagnostic tools and protocols were diverse. Moreover, five studies explored alternative modalities serving as an adjunct, rather than replacing pressure measurements. Future research is warranted as clinical and methodological heterogeneity were present and high quality validation studies were absent. Further optimization of specific key criteria based on a patient’s history, physical examination and symptom provocation may potentially render intracompartmental pressure measurement redundant.
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NewsBot · Feb 27, 2023

Psychiatric Disorders Are Predictive of Worse Pain Severity and Functional Outcomes After Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg
Bi, Andrew S. MD et al
Clinical Journal of Sport Medicine ():10.1097/JSM.0000000000001122, February 10, 2023. | DOI: 10.1097/JSM.0000000000001122

Objective:
To determine whether concomitant psychiatric diagnoses and medication use were associated with postfasciotomy outcomes in patients with chronic exertional compartment syndrome (CECS).

Design:
Retrospective comparative cohort study.

Setting:
Single academic medical center from 2010 to 2020.

Patients:
All patients above 18 years old who underwent fasciotomy for CECS.

Assessment of Risk Factors/Independent Variables:
Psychiatric history was recorded from electronic health records including disease diagnosis and medications.

Main Outcome Measures:
The 3 main outcome measures were postoperative pain using the Visual Analog Scale, functional outcomes using the Tegner Activity Scale, and return to sport.

Results:
Eighty one subjects (legs), 54% male, with an average age of 30 years and follow-up of 52 months were included. 24 subjects (30%) had at least one psychiatric diagnosis at the time of surgery. Regression analysis found psychiatric history to be an independent predictor of worse postoperative pain severity and postoperative Tegner scores (P < 0.05). Furthermore, subjects with psychiatric disorders not on medication had worse pain severity (P < 0.001) and Tegner scores (P < 0.01) versus controls, whereas subjects with a psychiatric disorder on medication had better pain severity (P < 0.05) versus controls.

Conclusions:
History of psychiatric disorder was predictive of worse postoperative pain and activity outcomes after fasciotomy for CECS. Use of psychiatric medication was associated with improvement in pain severity in some domains.
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NewsBot · Jun 16, 2023

The Pressure Is Rising: Evaluation and Treatment of Chronic Exertional Compartment Syndrome
Malik, G. Ross MD; Vyas, Krina A. MD
Current Sports Medicine Reports 22(6) 204-209, June 2023. | DOI: 10.1249/JSR.0000000000001074

Chronic exertional compartment syndrome is a condition that typically affects athletic/active individuals. Chronic exertional compartment syndrome predominantly affects the lower leg; however, there are cases involving the hand, forearm, foot, and thigh. The signs and symptoms of chronic exertional compartment syndrome are severe pain, tightness, cramping, muscle weakness, and paresthesias during participation in exercise. Dynamic intramuscular compartmental pressure (preexertion and postexertion) is the standard diagnostic test. Although other imaging modalities, such as radiography, ultrasound, and magnetic resonance imaging are typically incorporated to rule out other pathologies. In addition, these modalities are being utilized to limit invasiveness of the diagnostic experience. Initial care commonly involves conservative treatment, such as physical therapy, modifications of patient's exercise technique, foot orthoses, and various procedures over a period of 3 to 6 months. Recalcitrant cases may be referred for surgical intervention (fasciotomy), which has inconclusive head-to-head data with conservative management with regard to return to prior sport and specific activity level.
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NewsBot · Sep 4, 2023

Perineural Injection Therapy for Chronic Exertional Compartment Syndrome Refractory to Initial Compartment Release: A Case Report
Tam Bui et al
Mil Med. 2023 Aug 29

This is a case of a 26-year-old active duty male with a 1-year history of distal anterolateral leg pain and numbness which would persist following activity cessation. He was referred to physical therapy and eventually orthopedic surgery for bilateral anterior exertional compartment syndrome and underwent bilateral anterolateral fasciotomies. One year after surgery, he continued to have pain along the posterior aspect of his lower legs with residual numbness over his left dorsomedial foot. He was referred to sports medicine for further evaluation and Botox injections without significant symptomatic changes. He subsequently underwent diagnostic ultrasound of his lower legs which showed multiple entrapment points of the left superficial peroneal nerve along the fasciotomy scar. An additional electrodiagnostic study showed left superficial peroneal sensory mononeuropathy. Eighteen months following surgery, he received his first perineural injection therapy (PIT) treatment. A mixture of lidocaine and D5W was prepared to achieve 1 mg/cc which was then injected along his tibial, saphenous, and sural nerves. Following four PIT sessions, the patient's overall lower extremity pain, weakness, and functionality had improved. This case demonstrates potential benefit with PIT in patients with refractory symptoms following surgery for chronic exertional compartment syndrome. These symptoms may be due to chronic irritation of cutaneous nerves and they may benefit from treatment with PIT. Our case may represent a possible paradigm shift in the conservative treatment of chronic exertional compartment syndrome, especially when refractory to surgical compartment release.
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NewsBot · Sep 6, 2023

Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome
Atsunori Onoe, Takashi Muroya, Yoshihiro Nakamura, Fumiko Nakamura, Takuma Yagura, Mari Nakajima, Masanobu Kishimoto, Kazuhito Sakuramoto, Kentaro Kajino, Hitoshi Ikegawa & Yasuyuki Kuwagata
BMC Musculoskeletal Disorders volume 24, Article number: 704 (2023)

Background
The shoelace technique for compartment syndrome allows application of sustained tightening tension to an entire wound and intermittent tightening of the shoelace without requiring its replacement or anesthesia. We retrospectively evaluated the usefulness of the shoelace technique in the management of extremity fasciotomy wounds before and after its introduction in our institution.

Methods
We targeted 25 patients who were diagnosed as having compartment syndrome and underwent extremity fasciotomy at our hospital from April 2012 to December 2021. The N group, comprising 12 patients treated without the shoelace technique, and the S group, comprising 13 patients treated with the shoelace technique, were compared retrospectively for each outcome.

Results
There were no significant differences between the two groups in patient background. Compared with the N group patients, all of the S group patients avoided skin grafting (S group: n = 0, 0%; N group: n = 6, 50.0%; p < 0.01). However, there was no significant difference in the number of days to final wound closure (S group: 39.5 [IQR 24.3–58.0] days; N group: 24.0 [IQR 18.5–31.0] days, p = 0.06).

Conclusions
We considered the shoelace technique to be a useful wound closure method for fasciotomy wounds caused by compartment syndrome because it can significantly reduce the need for skin grafting and tends to shorten the wound closure period.
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NewsBot · Oct 19, 2023

Chronic Exertional Compartment Syndrome of the Lower Extremity: Diagnosis and Surgical Treatment
Nathan W Callender et al
JBJS Essent Surg Tech. 2022 Nov 16;12(4):e21.00059

Background: Chronic exertional compartment syndrome of the lower extremity is a condition that characteristically presents as recurrent anterior, posterior, and/or lateral lower-extremity pain on repetitive activity and physical exertion1. This condition is commonly seen in athletes, runners, and military personnel2. Open fasciotomy has been demonstrated to be a highly effective surgical treatment for patients with this condition who do not experience symptomatic relief after a thorough trial of nonoperative treatment3.

Description: Diagnostic compartment pressure management is achieved through direct insertion of a compartment-pressure-measuring device into the anterior, lateral, and posterior compartments of the lower extremity4. Surgical treatment of the anterior and lateral compartments with use of open fasciotomy employs longitudinal proximal and distal incisions that are made on the lateral surface of the leg approximately 3 finger-breadths distal and proximal to the fibular flare, respectively, and 3 finger-breadths lateral to the tibial crest. Surgical treatment of the posterior compartments with use of open fasciotomy employs a single, mid-shaft incision made approximately 2.5 cm medial to the tibial ridge. Dissection is carried down to the deep fascia at both sites, beginning at the distal operative site. Care is taken to avoid transection of the superficial peroneal nerve at the distal anterolateral incision and saphenous vein and nerve at the medial incision. Once down to the deep fascia, a scalpel is utilized to incise the fascia. Metzenbaum scissors are then employed under the incision, spreading the scissors while sliding them over the muscles proximally and distally to release the muscular attachments from the fascia as well as to release the fascia itself3. This process is repeated in the anterior, lateral, and superficial posterior compartments through the proximal and distal incisions. In the deep posterior compartment, the fascia is released from the tibial ridge with a large Cobb elevator. Closure is achieved with deep dermal and superficial sutures.

Alternatives: Nonoperative alternatives have been reported to include nonpharmacological modalities such as walking modification and shoe inserts, pharmacological therapy with nonsteroidal anti-inflammatory drugs, and physical therapy targeted at conditioning the lower extremity5. Nonoperative intervention has been demonstrated to increase endurance in select patients; however, most patients must either stop the activity associated with the compartment syndrome altogether or proceed to surgery for complete resolution of symptoms5. There are a few surgical alternatives that differ in their utilization of minimally invasive approaches versus a direct open approach6; however, all existing surgical treatments of this condition involve physical release of the fascial compartment.

Rationale: Diagnostic compartment-pressure measurement is useful in confirming or ruling out the presence of this condition in patients with unclear symptoms4. Furthermore, diagnostic compartment-pressure management ensures accuracy in diagnosis and validates invasive treatment when patients desire surgical intervention. Surgical management of exertional compartment syndrome of the lower extremity is indicated in patients when nonoperative treatment has failed despite clinically notable symptoms and objectively elevated lower-extremity compartment pressures. Open fasciotomy has been postulated to prevent compression of local vasculature and effectively prevent ischemia; however, the definitive mechanism is unclear1.

Expected outcomes: Surgical treatment of chronic exertional compartment syndrome with use of open fasciotomy is highly successful in the civilian population. One study showed excellent return to activity/sport in 15 of 16 patients (25 of 26 limbs; 96%), with patients often reporting no symptoms postoperatively3. Military personnel have been reported to experience satisfactory results, with another study showing positive subjective feedback in 35 (76%) of 46 patients on long-term follow-up; however, only 19 patients (41%) were able to return to full active duty postoperatively7.

Important tips: Balloting the fascial compartment with ∼1 cc of saline solution can be helpful in determining successful placement of the pressure-measuring device at the time of needle entry.Identifying the course of the superficial peroneal nerve via physical examination can help avoid iatrogenic injury to this important superficial structure during the dissection leading to the distal fasciotomy.Deep posterior compartment release with use of open fasciotomy may not provide symptomatic relief; patients who demonstrate elevation of pressures in this specific compartment should be counseled accordingly.
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NewsBot · Nov 9, 2023

Chronic Exertional Compartment Syndrome in
Athletes: An Overview of the Current Literature
Mohammed M. Tarabishi et al
Cureus 15(10): e47797. DOI 10.7759/cureus.47797

Chronic exertional compartment syndrome is an incapacitating condition that primarily affects athletes and
individuals with high activity levels.
The exact etiology of the condition is unknown to date, but multiple factors play a role in its occurrence. The
clinical presentation includes pain, tightness, muscle weakness, paresthesia, and cramps.
Common tools utilized during the diagnostic approach include intramuscular compartment pressure
measurement, advanced imaging to exclude other disorder entities, near-infrared spectrometry, and shear
wave elastography, with the clinical diagnosis being the gold standard.
Management includes both conservative and surgical options. Conservative treatment includes gait retraining and botulinum toxin injections. Further, the operative treatment has variable approaches and may
be combined with conservative modalities.
This article reviews the literature on chronic exertional compartment syndrome and elucidates future
recommendations.
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NewsBot · Dec 24, 2023

Mini Open Fasciotomy for Chronic Exertional Compartment Syndrome: A Prospective Case Series
Daniel Baumfeld et al
Foot Ankle Spec. 2023 Dec 12

Chronic exertional compartment syndrome (CECS) is a challenging pathology that causes pain and physical limitations. Fasciotomy is the gold standard and different techniques have been described. Techniques that allow a fast return to sports and low recurrence rates are of great interest for the athletic population. This is a prospective case series presenting a mini open surgical technique and its results regarding the level of return to sports and quality of life in 13 patients. A specific CECS questionnaire was applied and analyzed concerning the distance patients were able to run before and after treatment, Tegner score, Medical Outcomes Short-Form Health Survey (SF-36), and epidemiological measures. The minimum follow-up was 12 months. The mean distance the patients were able to run per week following the surgical treatment improved from 14.1 to 38.1 km (P = .042) and the mean Tegner score improved from 3.92 to 7.08 (P = .01). Notably, 12 out of 13 patients were satisfied or very satisfied with the outcome. In this sample, the mini open technique improved patients' sports performance and quality of life and minimized pain. Chronic exertional compartment syndrome can be safely approached using a mini open technique with a good rate of satisfaction and return to sport
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NewsBot · Apr 18, 2024 at 5:56 AM

Running Biomechanics and Clinical Features Among Adolescent Athletes With Lower Leg Chronic Exertional Compartment Syndrome
Chanchi, Mayela Leal et al
Clinical Journal of Sport Medicine ():10.1097/JSM.0000000000001221, April 16, 2024.

Objective:
To compare clinical measures between patients with chronic exertional compartment syndrome (CECS) and healthy controls and evaluate running biomechanics, physical measurements, and exertional intracompartmental (ICP) changes in adolescent athletes with lower leg CECS.

Design:
Cross-sectional case–control study.

Setting:
Large tertiary care hospital and affiliated injury prevention center.

Participants:
Forty-nine adolescents with CECS (39 F, 10 M; age: 16.9 ± 0.8 years; body mass index (BMI): 23.1 ± 2.9 kg/m2; symptom duration: 8 ± 12 months) were compared with 49 healthy controls (39 F, 10 M; age: 6.9 ± 0.8 years; BMI: 20.4 ± 3.7 kg/m2).

Interventions:
All participants underwent gait analyses on a force plate treadmill and clinical lower extremity strength and range of motion testing. Patients with chronic exertional compartment syndrome underwent Stryker monitor ICP testing.

Main Outcome Measures:
Symptoms, menstrual history, and ICP pressures of the patients with CECS using descriptive statistics. Mann–Whitney U and χ2 analyses were used to compare CECS with healthy patients for demographics, clinical measures, and gait biomechanics continuous and categorical outcomes, respectively. For patients with CECS, multiple linear regressions analyses were used to assess associations between gait biomechanics, lower extremity strength and range of motion, and with ICP measures.

Results:
The CECS group demonstrated higher mass-normalized peak ground reaction force measures (xBW) compared with controls (0.21 ± 0.05 xBW (P < 0.001) and were more likely to have impact peak at initial contact (P = 0.04). Menstrual dysfunction was independently associated with higher postexertion ICP (ß = 14.6; P = 0.02).

Conclusions:
The CECS group demonstrated increased total force magnitude and vertical impact transient peaks. In women with CECS, menstrual dysfunction was independently associated with increased postexertion ICP. These biomechanical and physiological attributes may play a role in the development of CECS.
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Chronic Exertional Compartment Syndrome

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Chronic Exertional Compartment Syndrome

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Chronic Exertional Compartment Syndrome Caused by Functional Venous Outflow Obstruction

chronic exertional compartment syndrome in right forearm in podiatrists

Chronic exertional compartment syndrome

Chronic Exertional Compartment Syndrome

A Combined case of CECS (Chronic Exertional Compartment Syndrome) 4 compartments, FPAES (Functional

Effects of forefoot running on chronic exertional compartment syndrome

Chronic Exertional Compartment Syndrome in Foot

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