Chronic Exertional Compartment Syndrome Research Articles

Clinical Consensus on Diagnosis and Treatment of Patients with Chronic Exertional Compartment Syndrome of the Leg: A Delphi Analysis

AimDefining universally accepted guidelines for the diagnosis and treatment of chronic exertional compartment syndrome (CECS) is hampered by the absence of high-quality scientific research. The aim of this Delphi study was to establish consensus on practical issues guiding diagnosis and treatment of CECS of the leg in civilian and military patient populations.MethodsAn international expert group was queried using the Delphi technique with a traditional three-round electronic consultation. Results of previous rounds were anonymously disclosed in the questionnaire of rounds 2 and 3, if relevant. Consensus was defined as > 70% positive or negative agreement for a question or statement.ResultsThe panel consisted of 27 civilian and military healthcare providers. Consensus was reached on five essential key characteristics of lower leg CECS. The panel achieved partial agreement regarding standardization of the diagnostic protocol, including muscle tissue pressure measurements. Consensus was reached on conservative and surgical treatment regimens. However, the experts did not attain consensus on their approach of postoperative rehabilitation and preferred treatment approach of recurrent or residual disease. A summary of best clinical practice for the diagnosis and management of CECS was formulated by experts working in civilian and military healthcare facilities.ConclusionThe Delphi panel reached consensus on key criteria for signs and symptoms of CECS and several aspects for conservative and surgical treatment. The panel did not agree on the role of ICP values in the diagnostic process, postoperative rehabilitation guidelines protocol, or the preferred treatment approach for recurrent or residual disease. These aspects serve as a first attempt to initiate simple guidelines for clinical practice.

Systematic Review of Innovative Diagnostic Tests for Chronic Exertional Compartment Syndrome.

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.

Relationship between attachment site of tibialis anterior muscle and shape of tibia: anatomical study of cadavers

BackgroundTibialis anterior (TA) muscle is the largest dorsiflexor of the ankle joint and plays an important role during gait movement. However, descriptions of the TA attachment site are inconsistent even among major anatomy textbooks, and its origin, especially the attachment site for the tibia, has not been reported in detail. This study is the first experimental attempt to investigate the origin of the TA in detail, paying particular attention to the relationship with the shape of the tibia, including sex differences.MethodsForty legs (20 males, 20 females) from twenty Japanese cadavers were examined. Gross anatomical examination of the TA's attachment site to the tibia and the tibia's shape was performed.ResultsThe location of the distal end of the TA's attachment on tibia was significantly more distal in males than in females (p < 0.01). The anterior border of the tibia had a gentle S-like curve, with a medially convex curve in the proximal region and a laterally convex curve in the distal region in frontal plane. The most protruding point of the distal curve of the anterior border located significantly more proximal in females than in males (p = 0.02).ConclusionsThere were sex differences in the distal end of the attachment site on tibia of the TA and the shape of the tibia. Consequently, the variations in the attachment site of TA were considered to provide for differences in function of TA. In males, the TA may enable advantageous power exertion, whereas in females it may work efficiently for dorsiflexion of ankle, respectively. Sex differences in TA's attachment site and the shape of the tibia may be involved in gait movement as well as frequency of lower leg disorders such as chronic exertional compartment syndrome.

Predictors of Positive Outcomes and a Scoring System to Guide Management After Fasciotomy for Chronic Exertional Compartment Syndrome.

Background:Chronic exertional compartment syndrome (CECS) of the lower limb usually responds well to fasciotomy in patients with failed nonoperative treatment. Careful history taking and compartment pressure testing are both required to accurately diagnose CECS.Purposes:To evaluate patients with CECS after fasciotomy to establish predictive criteria of positive outcomes and to develop a scoring system to aid clinicians in their management of such patients.Study Design:Case-control study; Level of evidence, 3.Methods:We reviewed data from 28 patients who underwent fasciotomy between 2017 and 2019. All patients had undergone preoperative dynamic intracompartmental pressure (ICP) monitoring. For each patient, subjective preoperative and postoperative pain scores were gained via a questionnaire. The point biserial and Pearson correlation coefficients were used to calculate the association between multiple diagnostic criteria and a reduction in visual analog scale (VAS) pain scores after fasciotomy.Results:A reduction in VAS pain scores was strongly correlated with a peak ICP >40 mm Hg (r = 0.71; P = .0007) and an area under the receiver operating characteristic curve for an intraexercise ICP >22,000 mm Hg·s2 (r = 0.76; P = .0002). A moderate correlation was found between a history of CECS pain (r = 0.61; P = .005), a duration of symptoms of <30 minutes after stopping exercise (r = 0.60; P = .006), and a gradient in the intraexercise ICP >10 mm Hg (r = 0.60; P = .006). When combined into an objective, weighted scoring system (2 points for factors with r > 0.7; 1 point for r = 0.5-0.7), a score of ≥4 points (of 7) had a strong correlation (r = 0.85; P < .00001) with postoperative improvement in the VAS pain score. Linear regression of this score demonstrated a good fit (R 2 = 0.61; P < .0001), indicating a degree of predictive power.Conclusion:We identified diagnostic criteria in the history and examination of patients with CECS that can be used to help predict positive outcomes after fasciotomy. We propose a scoring system to aid clinicians in their management of such patients. We recommend taking these results forward in prospective trials to test the efficacy of predictive scoring.

Chronic exertional compartment syndrome: a review of the literature

Chronic exertional compartment syndrome (CECS) is a serious, yet underdiagnosed condition that can cause severe lower-extremity pain in running athletes. CECS is a transient increase in compartment pressure that can lead to severe pain, paresthesia, and vascular compromise. Understanding the detailed anatomy is paramount to proper diagnosis and treatment. Diagnosis is made with measuring compartment pressures before and after exercise at certain time intervals. When properly diagnosed and treated, CECS can be appropriately managed and patients can return to their previous level of activity. The aim of this review is to familiarize providers with CECS to increase proper diagnosis and treatment with elective fasciotomy. Proper diagnosis and treatment allow patients to return to their previous level of activity without pain.

Nonsurgical Management of Chronic Exertional Compartment Syndrome with Botulinum Toxin-A

Nonsurgical Management of Chronic Exertional Compartment Syndrome with Botulinum Toxin-A

The prevalence and effect of the sites of pain in female soccer players with medial shin pain.

Female soccer players are often diagnosed with medial shin pain, which includes tibial stress fracture, medial tibial stress syndrome, and chronic exertional compartment syndrome. As the possibility of varied sites of pain affecting sports activities has not been fully researched, an urgent discussion and evidence is required. This study investigates the prevalence and effect of sites of pain on the sports activities of female soccer players with medial shin pain. A questionnaire survey was conducted for 196 female soccer players with medial shin pain to assess symptom duration, the effect of practice and performance, and sites of pain. The players were classified into three conditions (tibial stress fracture, medial tibial stress syndrome, or medial shin pain with neurological symptoms) and compared based on sites of pain. We observed that medial tibial stress syndrome had a lower impact on performance compared to that of tibial stress fracture and medial shin pain with neurological symptoms. While participants with tibial stress fracture had to suspend practice sessions more frequently, the difference in symptom duration between the classified groups was not statistically significant. The effect of sites of pain on sports activities was not significantly different in participants with medial tibial stress syndrome. Medial shin pain should be evaluated carefully to differentiate between medial tibial stress syndrome and medial shin pain with neurological symptoms. Restriction of sports activities may help improve the patient's condition early, regardless of the presentation.

Measuring intracompartmental pressures for the chronic exertional compartment syndrome: Challenging commercially available devices and their respective accuracy

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.

Ultrasound-guided, minimally invasive looped thread fasciotomy for chronic exertional compartment syndrome of the lower leg: A cadaveric feasibility study

Background– Chronic exertional compartment syndrome (CECS) is an exertional pain syndrome that typically affects the lower legs of participants involved in high-intensity running or marching activities. Surgical open fasciotomy is the standard treatment for recalcitrant cases of CECS. Alternative, minimally invasive fasciotomy techniques are emerging which may reduce rates of procedural complications and expedite recovery. The standard fasciotomy procedure for CECS may be improved by looped thread release with additional image guidance. The aim of this study was to describe and evaluate a novel technique of ultrasound-guided, minimally invasive looped thread fasciotomy for release of anterior and lateral compartments of the leg in a cadaveric model. We hypothesized that a fasciotomy of this type would be effective in achieving a target fasciotomy length of 80% of the length of a muscle compartment while avoiding injury to neurovascular structures. Materials and methods– We conducted a controlled laboratory study. Two proceduralists performed anterior and lateral compartment fasciotomies on ten lightly embalmed cadaveric legs. A total of twenty compartment releases were completed, using an ultrasound-guided, percutaneous looped cutting thread technique. The specimens were evaluated for length and completeness of fasciotomy, as well as any inadvertent injury to muscle, tendon, or neurovascular structures. Completeness of fasciotomy was compared between the anterior and lateral compartments. Results– Eighteen of twenty (90%) fasciotomies were continuous. Fasciotomy length was consistently under target (72% complete). Completeness of lateral compartment release was significantly more likely to be under target compared to anterior compartment release (65% vs. 79%, p ​= ​0.014). Sixteen of twenty (80%) fasciotomies incurred no iatrogenic soft tissue injury; no injuries to nerves or vessels were observed. Discussion –Ultrasound-guided, minimally invasive looped thread fasciotomy of the anterior and lateral leg compartments is feasible and can be successfully performed in a cadaveric model with low risk to neurovascular structures. However, further investigation is needed to improve completeness of release prior to recommendation for clinical use.

Chronic Exertional Compartment Syndrome: A Review of Literature

Chronic exertional compartment syndrome (CECS) is a serious, yet underdiagnosed condition that can cause severe lower extremity pain in running athletes. CECS is a transient increase in compartment pressure leading to severe pain, paresthesia, and vascular compromise. Understanding the detailed anatomy is paramount to proper diagnosis and treatment. Diagnosis is made with measuring compartments pressures before and after exercise at certain time intervals. When properly diagnosed and treated, CECS can be appropriately managed and patients can return to their previous level of activity.

Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg-Corrigendum.

Medicine & Science in Sports & Exercise: January 2022 - Volume 54 - Issue 1 - p 193 doi: 10.1249/MSS.0000000000002815

Predicting surgical outcomes for chronic exertional compartment syndrome using a machine learning framework with embedded trust by interrogation strategies

Chronic exertional compartment syndrome (CECS) is a condition occurring most frequently in the lower limbs and often requires corrective surgery to alleviate symptoms. Amongst military personnel, the success rates of this surgery can be as low as 20%, presenting a challenge in determining whether surgery is worthwhile. In this study, the data of 132 fasciotomies for CECS was analysed and using combinatorial feature selection methods, coupled with input from clinicians, identified a set of key clinical features contributing to the occupational outcomes of surgery. Features were utilised to develop a machine learning model for predicting return-to-work outcomes 12-months post-surgery. An AUC of 0.85 ± 0.08 was achieved using a linear-SVM, trained using 6 features (height, mean arterial pressure, pre-surgical score on the exercise-induced leg pain questionnaire, time from initial presentation to surgery, and whether a patient had received a prior surgery for CECS). To facilitate trust and transparency, interrogation strategies were used to identify reasons why certain patients were misclassified, using instance hardness measures. Model interrogation revealed that patient difficulty was associated with an overlap in the clinical characteristics of surgical outcomes, which was best handled by XGBoost and SVM-based models. The methodology was compiled into a machine learning framework, termed AITIA, which can be applied to other clinical problems. AITIA extends the typical machine learning pipeline, integrating the proposed interrogation strategy, allowing to user to reason and decide whether to trust the developed model based on the sensibility of its decision-making.

Comparison of 2 Fasciotomes for Treatment of Patients With Chronic Exertional Compartment Syndrome of the Anterior Leg.

Background:Chronic exertional compartment syndrome (CECS) of the anterior leg compartment (ant-CECS) is frequently treated with a minimally invasive fasciotomy. Several operative techniques and operative devices exist, but none have been compared in a systematic and randomized manner.Purpose:To compare efficacy, safety, and postoperative pain of a novel operative device (FascioMax fasciotome) with a widely accepted device created by Due and Nordstrand (Due fasciotome) during a minimally invasive fasciotomy for ant-CECS.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:Patients with bilateral isolated ant-CECS between October 2013 and April 2018 underwent a minimally invasive fasciotomy using the FascioMax fasciotome in 1 leg and the Due fasciotome in the contralateral leg in a single operative session. Symptom reduction at 3 to 6 months and >1 year, postoperative pain within the first 2 weeks, peri- and postoperative complications, and ability to regain sports were assessed using diaries, physical examination, and timed questionnaires.Results:Included in the study were 50 patients (66% female; median age, 22 years [range, 18-65 years]). No differences between the devices were found in terms of perioperative complications (both had none), minor postoperative complications including hematoma and superficial wound infection (overall complication rate: FascioMax, 8% vs Due, 6%), or reduction of CECS-associated symptoms at rest and during exercise. At long-term follow-up (>1 year), 82% of the patients were able to regain their desired type of sport, and 67% (33/49) were able to exercise at a level that was comparable with or higher than before their CECS-associated symptoms started.Conclusion:Both the FascioMax and the Due performed similarly in terms of efficacy, safety, and levels of pain within the first 2 weeks postoperatively.Registration:NL4274; Netherlands Trial Register.

Forearm compartment pressures and grip strength in elite motorbike racers with chronic exertional compartment syndrome

BackgroundRemarkably little research has been published on chronic exertional compartment syndrome (CECS) of the forearm. This study investigated forearm flexor compartment pressure pre- and post-exercise in elite motorbike racers clinically diagnosed with CECS and assessed their grip strength before and after arm pump exercise.MethodsElite motorbike riders with a clinical diagnosis of CECS of the right forearm when racing were recruited during the opening rounds of a British Superbike season. Their grip strength and forearm flexor compartment pressures were measured before and after a set exercise programme.ResultsOf the 11 riders recruited to the study, 10 completed the full testing regime. The mean pre-exercise forearm compartment pressures [11.7 mmHg (range 7–17 mmHg)] significantly increased post-exercise [30.5 mmHg (range 15–45 mmHg)], with a mean increase of 18.80 mmHg (P < 0.0001). The mean pre-exercise grip strength [50.61 mmHg (range 37–66.7 mmHg)] decreased post-exercise to [35.62 mmHg (range 17.1–52.5 mmHg)], a mean decrease of 14.99 mmHg (P < 0.0001).ConclusionThere is a statistically significant increase in the forearm flexor compartment pressures in elite motorbike racers with CECS, but with marked variability of these values. Grip strength decreases statistically significantly following onset of symptoms of CECS of the forearm.

MRI findings in chronic exertional compartment syndrome of the forearm: Using signal intensity ratio as a diagnostic tool.

BackgroundChronic exertional compartment syndrome (CECS) of the forearm is a rare but important cause of morbidity amongst athletes involved in strenuous upper limb activities. The diagnosis remains challenging due to the absence of objective, reproducible diagnostic studies.ObjectivesTo assess and quantify signal intensity (SI) changes of involved muscles in patients with CECS of the forearm compared to healthy control subjects competing in similar sporting disciplines. Also, to objectively measure MRI SIs within muscle compartments when using a pre- and post-exercise regime and calculating a signal intensity ratio (SIR) between post- and pre-exercise studies.MethodThe study retrospectively examined MRI scans of patients treated for CECS of the forearm and compared these to the MRI scans of asymptomatic high-level rowers. A specific, reproducible pre- and post-exercise MRI scanning protocol was utilised in both patient and control subjects between 2011 and 2020. Signal intensities were evaluated pre- and post-exercise in involved muscle groups and ratios were calculated.ResultsA total of 86 SIs were measured (43 pre- and 43 post-exercise) in nine study participants (five patients and four controls). After post:pre-exercise comparisons, a statistically significant difference was found between control and patient groups (p = 0.0010). The extensor carpi radialis, flexor digitorum profundus and flexor digitorum superficialis muscles were most commonly involved.ConclusionThis study confirms that significant SI changes are apparent in patients with CECS of the forearm when making use of a standardised pre- and post-exercise MRI protocol. Furthermore, SIR may be used to accurately diagnose CECS of the forearm.

The effect of gender on intramuscular pressure in patients with chronic exertional compartment syndrome of the lower leg.

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 27years, 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.

Chronic Exertional Compartment Syndrome.

Chronic Exertional Compartment Syndrome.

Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management.

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.

Calf Pain Relay - Long Distance Runner

HISTORY: A 33-year-old male, avid long-distance runner, presented with one year of right posterior calf pain exacerbated by running. The patient was initially noted to have necrotic lipomas over the medial head of gastrocnemius and underwent surgical excision with improved symptoms. Three months later, he developed pain secondary to Medial Tibial Stress Syndrome. He was advised to rest for 12 weeks and start physical therapy once improved. Upon follow-up, the patient was noted to have another palpable mass associated with tenderness to palpation preventing him from running extended distances. The pain had only improved approximately 10% despite physical therapy. The patient denied numbness, tingling, weakness or radiation into his right lower extremity. PHYSICAL EXAMINATION: On examination, the patient had full strength and intact sensation in bilateral lower extremities without atrophy or erythema. A firm mass was palpated along the insertion of soleus muscle onto proximal tibia. No bony tenderness was noted upon palpation of tibia or fibula. DIFFERENTIAL DIAGNOSIS: 1. Soleus Enthesopathy 2. Medial Tibial Stress Syndrome 3. Lipoma 4. Chronic Exertional Compartment Syndrome 5. Popliteal Artery Entrapment Syndrome TEST AND RESULTS: - Inflammatory markers: Normal - Rheumatologic studies: Negative - Compartment pressure testing: Negative - Ultrasound of right lower extremity: Focal enthesopathy at the soleus muscle attachment - MRI of right lower extremity: Interval improvement with near resolution of the mid tibial stress reaction. Enthesopathic change at the insertion of the soleus muscle on the proximal tibia and distal soleus myotendinous junction muscle strain. - CT of right tibia and fibula: Broad, cortically based ossification along the posterior tibial cortex at the level of the proximal calf. FINAL WORKING DIAGNOSIS: Soleus Enthesopathy TREATMENT AND OUTCOMES: The patient was advised to continue physical therapy for several more weeks. The patient then received ultrasound-guided trigger point injections at the attachment of the soleus on the tibia without improvement. Given no improvement with the injection, he was referred to Orthopedic Surgery who suggested elective surgical excision of the ossification. The patient will follow up after completion of the surgery.

Botulinum Toxin A for Chronic Exertional Compartment Syndrome: A Retrospective Study of 16 Upper- and Lower-Limb Cases.

To assess initial and mid-term efficacy of botulinum toxin A (BoNT-A) injections in patients with chronic exertional compartment syndrome (CECS) in the lower and upper limbs. Retrospective monocentric study. A University Hospital Department of Physical Medicine and Rehabilitation. Sixteen patients with CECS of the lower and upper limbs treated with BoNT-A injections (first-line treatment) were included. We collected data from a follow-up consultation (initial pain reduction [complete, partial, or ineffective] and specific activities triggering CECS) and a subsequent phone questionnaire (mid-term efficacy, pain recurrence, and adverse effects). Sixteen patients were included (median age: 25.5 years), and 68.75% reported initial efficacy (4 partial and 7 complete); 8/16 patients were able to resume the activity that triggered CECS. All the patients with initial partial efficacy had pain recurrence (median time of 2.25 months). Among patients with initial complete efficacy, 57.14% had recurrence (median time of 5 months). Minor adverse effects were observed, but with no functional impact. In 16 individuals with CECS treated with BoNT-A injections, we observed moderate efficacy without major adverse effects, but an initial improvement was often followed by recurrence, especially among those with partial initial efficacy.