Anterior Exertional Compartment Syndrome Research Articles

Perineural Injection Therapy forChronic Exertional Compartment Syndrome Refractory to Initial Compartment Release: A Case Report.

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.

ASTYM® versus massage in the treatment of chronic exertional anterior compartment syndrome of the lower leg: a randomized controlled trial

ASTYM® versus massage in the treatment of chronic exertional anterior compartment syndrome of the lower leg: a randomized controlled trial

Return to Sports After Chronic Anterior Exertional Compartment Syndrome of the Leg: Conservative Treatment Versus Surgery

This study supports surgery as the treatment of choice for anterior chronic anterior exertional compartment syndrome of the leg with differential benefit for fasciotomy in terms of pain and return to pre-diagnosis athletic activity. Chronic anterior exertional compartment syndrome (CECS) of the lower leg usually results from repetitive physical activity, especially in young people and amongst athletes and causes a reduction in athletic frequency and intensity. It is classically diagnosed on history and examination with recording of raised compartmental pressures following exercise. The aim of the study is to evaluate if surgical treatment for CECS of the lower leg will lead to full athletic activity recovery compare to conservative treatment. Patients with anterior CECS of the leg were followed, assessing both groups for pain, functional status and the Tegner sports activity score with comparisons at diagnosis and following treatment. Forty three patients were treated for CECS (31; 72.1% with surgery and 12; 27.9% conservatively) with a mean follow-up of 28.15 (4.16-54.09) months. Reported pain improved at follow-up by 1.59 (0-6) points and by 4.27 ± (0-10) points in the conservatively and the surgically treated patient groups, respectively (P=0.014) with a mean change in the Tegner score of 0.09 (-5-5) and 3.22 (-4-7), respectively (P=0.009). Three patients in the conservatively treated group (25% of 12) and 24 patients in the operated group (77.4% of 31) reported full resumption of their pre-diagnosis activity level (P=0.001). This study supports surgery as the treatment of choice for anterior CECS of the leg with differential benefit for fasciotomy in terms of pain and return to pre-diagnosis athletic activity.

CHRONIC COMPARTMENT SYNDROME OF LOWER LEG. AN UNUSUAL CASE IN NON ATHLETIC PATIENT

Chronic exertional anterior compartment syndrome is debilitating disease of lower limb. The clinical picture is characterised by limited symptomology at rest, pain during sporting activities, tumefaction and contractures of limb as well impotency by pain of the entire forefoot and hypoesthesia. Usually the most affected patients are athletes. We analyse a case of chronic post traumatic compartment syndrome of the anterior tibial muscle in an unsportsmanlike patient.

Surgical management of exertional anterior compartment syndrome of the leg.

To describe the characteristic presentation of exertional leg pain in athletes and to discuss the diagnostic options and surgical management of exertional anterior compartment syndrome of the leg in this group of patients. Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology. Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. Sixteen patients in a first group of 20 patients with a provisional diagnosis of exertional anterior compartment syndrome of the leg underwent a closed fasciotomy with complete resolution of symptoms. A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia. Exertional leg pain is a common presenting complaint of athletes to sports physicians and physiotherapists. Careful analysis can lead to an accurate diagnosis and commencement of effective treatment. Exertional anterior compartment syndrome can be successfully treated utilizing a closed fasciotomy with a rapid return to sport.

Leg-runner

HISTORY: A 42-year-old male runner presented with a complaint of his left foot "turning in" and a "funny feeling" in his lateral foot. Symptoms occurred only with running. He had recently been treated for interdigital neuroma and metatarsalgia with corticosteroid injection and orthotics. Foot pain had resolved. He denied any other significant pain in the left lower extremity. His orthotic was modified without improvement in his current complaints. He subsequently began to complain of lateral lower leg paresthesias and low back pain. He denied previous injuries and was otherwise a healthy nonsmoker. PHYSICAL EXAMINATION: This gentleman had a thin, muscular build. Complete neurologic exam was normal including detailed lower extremity strength evaluation. Bilateral lower extremities were without palpable deformities or tenderness. Full range of motion of concerned joints was noted. Spine exam was unremarkable with a negative straight leg raise bilaterally. Distal pulses were normal. Tinel's sign was absent at the sural and peroneal nerve distributions. Video treadmill running showed excessive left foot supination and foot slap after a few minutes. Post-exercise examination still did not reveal any significant tenderness of his leg or foot. Slight foot eversion weakness was appreciable. Distal pulses were still excellent. DIFFERENTIAL DIAGNOSIS: L5 radiculopathy Chronic exertional compartment syndrome Peripheral neuropathy or nerve entrapment Peripheral vascular disease TESTS AND RESULTS: Sensory/motor nerve conduction studies_normal MRI lumbar spine-essentially normal Tibia/fibula x-ray_normal Compartment pressure testing: resting left anterior 16 and 14, resting left lateral 18 and 20, post-exertion left anterior 50 and 52, post-exertion left lateral 63 and 65, post-exertion right lateral 15. FINAL WORKING DIAGNOSIS: Chronic exertional anterior and lateral compartment syndrome TREATMENT AND OUTCOMES: Anterior and lateral compartment fasciotomies were performed. At 4-week follow-up, he was slowly improving. He had some pain and swelling thought secondary to increasing his activity level too soon. He was encouraged to use compression stockings and to return to his previous activity level in a slow, step-wise fashion. The next follow-up appointment is expected in 2 weeks.

A technique for arthroscopic fasciotomy for the chronic exertional tibialis anterior compartment syndrome

Chronic exertional anterior compartment syndrome (CECS) is a condition that causes pain over the front of the shin bone that usually occurs in physically active people, especially runners. It may require sometimes an immediate fasciotomy. A longitudinal incision just over the fibula has used as surgical treatment bad cosmetic appearance. Although nowadays mini surgical incisions are preferred. The aim of this study to evaluate a simple fasciotomy technique with a minimal incision by using arthroscope. Nine legs of six patients that diagnosed as CECS has underwent fasciotomy operation with a 1 cm incision. Complaints had disappeared after operation. The mean follow-up time is 2 years. The results were good all of the patients and they never experienced exertional pain episodes. The arthroscopic assisted mini incisional fasciotomy technique has advantage such as early rehabilitation and good cosmetic appearance.

Revision Surgery for Exertional Anterior Compartment Syndrome of the Lower Leg

Background Recurrent symptoms or failure after fasciotomy for exertional anterior compartment syndrome is not uncommon. Hypothesis Symptoms from high compartment pressures can be secondary to involvement of the entire compartment or to localized constrictions from postsurgical fibrosis, as well as to entrapment of the superficial peroneal nerve. Study Design Case series; Level of evidence, 4. Methods Eighteen patients who underwent revision surgery for exertional anterior compartment syndrome were available for follow-up. All were athletes who had either a failure or a recurrence of symptoms at a mean of 23.5 months (range, 8-54 months) after the index fasciotomy. Pressure measurements using a slit catheter at rest, at 1 minute postexercise, and at 5 minutes postexercise were performed in 2 places within the compartment: in the area of the previous incision and in the proximal muscle belly of the tibialis anterior. Surgical technique consisted of a 2-incision approach with partial fasciectomy, exploration and decompression of the superficial peroneal nerve, and excision of all fibrotic tissue. An objective examination and a comprehensive subjective questionnaire previously described were performed at a mean follow-up of 42 months (range, 22-67 months). Results Sixty percent of patients had abnormal pressures only in a localized area, whereas 40% had high pressures throughout the compartment. Eight of 18 (44%) patients had symptoms, signs, and surgical findings of entrapment of the superficial peroneal nerve. At follow-up, 72% of patients had a satisfactory outcome (5 excellent, 8 good), and 28% had an unsatisfactory outcome for intense running sports (4 fair, 1 poor), although 3 patients with the fair results reported improvement with low-level activity. All 8 patients with documented peroneal nerve entrapment had a satisfactory outcome. Conclusion Symptoms from high pressures can be secondary to involvement of the entire compartment or localized to a certain area from postsurgical fibrosis. Pressure measurements should be performed in at least 2 separate areas.

FOOT DROP IN A MARATHONER

HISTORY - A 68 year-old male marathoner began experiencing a “floppy left foot” which “slaps the ground” after running a distance of one-half mile while training for the New York Marathon. He notes that the symptoms are present for fifteen to twenty minutes after ceasing running, and will dissipate with rest. The patient related a skiing accident three months prior in which he suffered a left hamstring injury resulting in significant swelling and ecchymosis posteriorly from the thigh to the calf. He recalls having extreme difficulty with walking, but gradually improved enough to resume training. He also had noted numbness laterally in the left lower leg for two months. He presently denies leg pain. PHYSICAL EXAM - Examination in the office revealed a pleasant male, 68 years old, conversive and friendly. Inspecton of the posterior left leg revealed no acute ecchymosis or other signs of trauma. There was a palpable fullness in the musculotendinous junction of the hamstrings, and a defect in the muscle belly 22 cm proximal to the superior popliteal crease, in which a 6 cm by 6 cm mass can also be palpated. The patient had obvious weakness graded 3+/5 to resisted knee flexion compared to his right leg, 5/5. The strength of the left tibialis anterior muscle, left extensor hallucis longus muscle, and left gastrocnemius/soleus complex were graded 4/5 versus his right leg, 5/5. The patient struggled to attain 10 toe raises on the left leg, but reached 10 on the right leg without difficulty. Sensory exam revealed subjective numbness to light touch on the lateral aspect of the left calf and the dorsolateral aspect of the left foot. DTR's were 2+ at the bilateral patellar tendons, undetectable at the bilateral hamstring tendons, and asymmetric at the achilles tendons with the left graded 1+ and the right graded 2+. DIFFERENTIAL DIAGNOSIS Hamstring tear L5-S1 disc herniation Multiple sclerosis Exertional anterior compartment syndrome Common peroneal nerve entrapment syndrome TESTS AND RESULTS MRI Lumbar spine and left thigh - extensive complete hamstring tear involving the long head of the biceps femoris, the semimembranosus, and the semitendinosus muscles. Atrophy of the involved muscles. Hematoma formation with hemosiderin adjacent to, and tethering, the sciatic nerve. - no evidence of lumbar disc herniation. EMG left leg - absent conduction of the left sural nerve and the left superficial peroneal nerve. - decreased amplitude in motor testing of the left tibial nerve. FINAL DIAGNOSIS Left sciatic nerve neuropraxia secondary to hematoma and scar tissue formation from a prior hamstring tear TREATMENT Left sciatic nerve neurolysis Physical therapy Gradual return to activity following post-op recovery

Fasciotomy for exertional anterior compartment syndrome: is lateral compartment release necessary?

The standard surgery for exertional anterior compartment syndrome is fasciotomy of the anterior and lateral compartments of the leg. We prospectively studied the necessity of lateral compartment release, which can add morbidity and extend recovery. We performed 30 anterior compartment releases in 20 patients (10 bilateral operations) with exertional anterior compartment syndrome but not lateral compartment involvement. We alternately performed only an anterior compartment release or both anterior and lateral compartment releases on 10 patients. The 10 patients who underwent bilateral surgery each had, during the same surgery, an anterior and lateral compartment release on one leg and only an anterior compartment release on the other. All were athletes involved in running sports. Overall, satisfactory outcomes were seen in 90% of the limbs--93% (14 of 15) that had anterior compartment release and 87% (13 of 15) that had release of both compartments (no statistically significant difference). For the patients who had unilateral surgery, the average time for full return to sports was 8.1 weeks after anterior release only and 11.4 weeks after release of both compartments, a statistically significant difference. The average time for full return to sports after bilateral surgery was 12.1 weeks. Among these patients, seven said that the leg with only anterior release seemed to recover faster. We concluded that when doing a fasciotomy for exertional anterior compartment syndrome alone, a lateral compartment release is not necessary.

Treatment of chronic exertional anterior compartment syndrome with massage: a pilot study.

To determine the effect of massage on anterior chronic exertional compartment syndrome (CECS) with respect to symptoms, intracompartmental pressures, and work output of the anterior compartment in dorsiflexion. One group-repeated measures design. A private sports medicine clinic in Melbourne, Australia. Seven athletes (six men and one woman), aged between 21 and 29 years, were selected on the basis of clinical suspicion for anterior CECS. Historical questionnaire and examination were followed by intracompartmental pressure testing of the anterior compartment. Study exclusion criteria were history of a bleeding diathesis and previous treatment consisting of compartment fasciotomy or massage. All athletes completed the study. A 5-week course of massage consisting of two sessions in the first week and one session per week thereafter, for a total of six treatments. Between each session, a twice-daily standard stretching program involving both anterior and posterior compartments was performed. Postexercise anterior compartment pressures (mm Hg) before and after treatment, work output (J) in dorsiflexion to pain onset before and after treatment, self-reported symptoms before and after treatment. There was no significant difference in the 3-minute postexercise compartment pressures after the treatment. There was a significant (p = 0.016) increase, however, in work performed in dorsiflexion to pain onset following the massage course. Intermittent massage combined with specific stretching should be considered in the treatment of anterior CECS.

Metabolic Assessment of Anterior Exertional Compartment Syndrome Using Phosphorus-31 Magnetic Resonance Spectroscopy

Metabolic Assessment of Anterior Exertional Compartment Syndrome Using Phosphorus-31 Magnetic Resonance Spectroscopy

Acute exertional anterior compartment syndrome in an adolescent female

Acute compartment syndromes usually occur as a complication of major trauma. While the chronic exertional anterior tibial compartment syndrome is well described in the sports medicine literature, reports of acute tibial compartment syndromes due to physical exertion, or repetitive microtrauma, are rare. The case of an adolescent female who developed an acute anterior compartment syndrome from running in a soccer game is described in this report. Failure to recognize the onset of an acute exertional compartment syndrome may lead to treatment delay and serious complications. Whereas the chronic exertional anterior compartment syndrome is characterized by pain that diminishes with the cessation of exercise, the onset of the acute exertional anterior compartment syndrome is heralded by pain that continues, or increases, after exercise has stopped. Compartment pressure measurement confirms the clinical diagnosis and helps guide treatment. True compartment syndromes require urgent fasciotomy.

Management of Chronic Exertional Anterior Compartment Syndrome of the Lower Extremity

Eighteen patients (28 compartments) with chronic exertional compartment syndrome and 14 normal asymptomatic volunteers (18 compartments) were studied. Evaluation included clinical assessment followed by quantitative determination of intracompartmental pressures as monitored by wick or slit catheters before and after exercise. Intramuscular pressures measuring greater than or equal to 10 mmHg at rest and/or greater than or equal to 25 mmHg five minutes after exercise were defined as abnormally elevated. The patients with chronic compartment syndrome described reproducible exertional anterolateral leg pain, and 39% of these patients had a fascial hernia. Such a defect was present in less than five percent of the normal volunteers. Nonsurgical treatment was selected by five patients and all five reported persistent inability to participate in athletics because of their exertional pain. Of the remaining 13 patients, 12 were treated by decompressive fasciotomy and 11 of the 12 (92%) had pain relief and increased exercise tolerance. A single patient had had fascial closure instead of fasciotomy, and this procedure produced an acute compartment syndrome. Effective treatment of the chronic compartment syndrome consists of reduction of exertional activities or surgical decompression by fasciotomy.