Treatment Of Chronic Exertional Compartment Syndrome Research Articles

Female patients have greater improvement in pain symptoms and physical activity after fasciotomy for treatment of chronic exertional compartment syndrome of the lower leg.

The purpose of this study was to identify sex differences in postoperative outcomes and return-to-sport rates after fasciotomy for treatment of chronic exertional compartment syndrome (CECS) of the lower leg. It was hypothesised that male CECS patients would have a higher rate of return to sport than female CECS patients. A retrospective cohort study was conducted involving patients who underwent primary fasciotomy of one to four leg compartments for treatment of CECS at a single centre from 2010 to 2020. Each affected leg was treated as a separate subject. Postoperative outcomes included CECS pain frequency and severity, return to sport and Tegner activity level. Multivariable regression was used to determine if sex was an independent predictor of outcomes after adjusting for demographic and clinical covariates. p < 0.05 were considered significant. Eighty-one legs (44 M, 37 F) of 47 unique patients (34 of whom had bilateral symptoms) were included with a mean follow-up time of 51.5 ± 31.4 months. Male subjects were older (p < 0.001) and had higher body mass index (p < 0.001) compared to female subjects. Most subjects (84.0%) underwent two- or four-compartment fasciotomies. Female sex was found to be predictive of lower overall postoperative pain severity (p = 0.007), higher odds of return to sport (p = 0.04) and higher postoperative Tegner score (p = 0.005). However, female sex was not predictive of postoperative pain frequency, odds of reoperation or odds of return to sport to at least the presymptomatic level (all p < 0.05). Female sex is independently predictive of reduced overall pain severity, higher odds of return to sport and higher postoperative improvement in Tegner score following fasciotomy for treatment of lower-limb CECS. III.

Intramuscular Pressure and Patient-Reported Outcomes in Patients Surgically Treated for Anterior Chronic Exertional Compartment Syndrome.

Chronic exertional compartment syndrome (CECS) causes exercise-induced leg pain. The diagnosis is confirmed by intramuscular pressure (IMP) measurements. Fasciotomy has been demonstrated to be a successful treatment for CECS; however, few studies have examined postoperative IMP and long-term outcomes. To evaluate long-term outcomes and postoperative IMP in patients surgically treated for anterior CECS, and to identify possible preoperative or postoperative factors associated with overall satisfaction with treatment at follow-up. Case-control study; Level of evidence, 3. A consecutive series of 209 patients who underwent fasciotomy of the anterior compartment for CECS between 2009 and 2019 and had at least 1 year of follow-up were approached for inclusion. A total of 144 patients (69%), with a follow-up time of 1 to 11.5 years, were ultimately included. All patients underwent preoperative and postoperative 1-minute postexercise IMP measurements of the anterior compartment and completed a questionnaire covering pain and activity parameters at both time points. The follow-up questionnaire included an additional question on overall satisfaction with treatment, and surgical details were collected from the patient's medical records. The median IMP was significantly lower at follow-up than at baseline (17 mm Hg [range, 5-91 mm Hg] vs 49 mm Hg [range, 25-130 mm Hg]; P < .001). The overall satisfaction rate was 77%, and 83% reported a decreased pain level. The group of patients who were satisfied with the treatment included more men and had a higher ΔIMP and a lower revision rate (P < .05). Among the 16 patients (11%) who had undergone revision fasciotomies before follow-up, the satisfaction rate was 56%, and 64% reported a decrease in pain level. Fasciotomy significantly reduced 1-minute postexercise IMP in patients with CECS and resulted in satisfaction and decreased pain in more than three-quarters of the patients at long-term follow-up. The male sex and a significant decrease in IMP were both positively associated with treatment satisfaction. Patients who underwent revision surgery before the follow-up had lower satisfaction rates and less pain reduction than the overall group.

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.

Predictors of Improvement After Fasciotomy for Treatment of Chronic Exertional Compartment Syndrome of the Lower Extremity.

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. Specific patient variables will lead to enhanced functional improvement after fasciotomy for CECS of the lower extremity. Case series. Level 4. 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. 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. Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater functional improvement. 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.

Ultrasound-Guided Fasciotomies of the Deep and Superficial Posterior Leg Compartments for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation.

Chronic exertional compartment syndrome (CECS) is a type of leg pain related to elevated intracompartmental pressure with activity in one or more of the four compartments of the leg. Open fasciotomy is the definitive treatment for CECS but has a reported complication rate of up to 15.7% and return to full activity reported up to 16 weeks. Ultrasound-guided (USG) fasciotomy of the anterior and lateral compartments has been translated into clinical practice. To determine the safety and feasibility of a USG fasciotomy of the deep posterior compartment (DPC) and superficial compartment (SPC) of the leg in a fresh-frozen cadaveric model. Prospective, cadaveric laboratory investigation. Procedural skills laboratory at an academic institution. Ten fresh-frozen cadaveric knee-ankle-foot specimens from five female and five male donors aged 58 to 93 years (mean 77.4 years) with body mass indexes of 18.1 to 33.5kg/m2 (mean 25.1 kg/m2 ). One experienced operator performed 10 USG DPC and SPC fasciotomies. A clinical anatomist performed dissections of each. Achievement of target length and continuity of release was recorded. Target lengths of 10 cm for the superficial posterior compartment (SPC) and 15 cm for the deep posterior compartment (DPC) were established based on previous studies. Tendinous and neurovascular structures were assessed for damage. No tendon or neurovascular injuries were observed. In the SPC, target length was achieved in 90% and continuous release was observed in 80%. In the DPC, target length was achieved in 60% and continuity observed in 30%. These findings suggest that SPC USG fasciotomies using the technique described in this study are feasible, may be safe, and warrant further translational research; however, DPC USG fasciotomies are more challenging and require more technical refinement prior to clinical translation.

Predictors of Improvement in Patient Outcomes after Fasciotomy for Chronic Exertional Compartment Syndrome of the Lower Leg

Category:Sports; OtherIntroduction/Purpose:Chronic exertional compartment syndrome (CECS) of the lower leg is the result of increased pressure in intramuscular compartments that occurs during repetitive physical activity. Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating CECS. However, not all patients have the same level of symptom improvement or ability to return to sport. The purpose of this study was to determine if any independent patient variables were predictive of outcomes following fasciotomy for CECS of the lower leg.Methods:A retrospective review of patients undergoing fasciotomy of the lower leg for treatment of CECS by a single fellowship-trained orthopaedic surgeon from 2009 to 2017 was performed. All patients had a diagnosis confirmed by pre- and post-exercise compartment pressure testing using the Pedowitz criteria. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process or underwent revision fasciotomy were excluded. Preoperative measures of Foot and Ankle Ability Measure-Sport subscale (FAAM-Sport), FAAM-Sport single assessment numeric evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected. Patients with at least 12 months of follow-up were included. The primary outcomes of change (delta, Δ) in FAAM-Sport, FAAM-Sport SANE, and VAS during sporting activities were calculated. To determine significant predictors of outcomes, a generalized multivariate linear regression model developed based on univariate analysis and clinical experience was used. Statistical significance was set at p<0.05.Results:In total, 61 patients underwent 65 procedures, with outcome measures obtained on average 57.9 (range, 12-115) months postoperatively. Median age was 22, median BMI was 24.4, and 59.0% of the cohort was female. Of the 65 fasciotomies, 39 (60.0%) were simultaneous bilateral, 6 procedures (9.2%) performed on 3 patients were staged bilateral, and 18 (27.7%) wereunilateral. There were 16 four-compartment fasciotomies performed (24.6%), while 49 (75.4%) involved 2 compartments. Twenty- two procedures involved deep posterior compartment pressures meeting the Pedowitz criteria. Patients had mean (+- standard deviation) improvement in FAAM-Sport of 40.4 +- 22.3 points (p<0.001), improvement in FAAM-Sport SANE of 57.3 +- 31.6 (p<0.001), and reduction of VAS pain of 56.4 +- 31.8 (p<0.001). Multivariate linear regression results are listed in Table 1.Conclusion::Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater improvement. Independent predictors of improvement of FAAM-Sport SANE following surgery included younger age, history of depression, and male sex. A history of depression was an independent predictor of greater VAS pain reduction following fasciotomy. Patients with deep posterior compartment pressure testing meeting the Pedowitz criteria was an independent predictor of increased improvement in FAAM-Sport. To our knowledge, this is the first study to investigate and identify independent patient variables predictive of greater functional improvement following fasciotomy for CECS.

Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg.

ObjectiveSurgery 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 MethodsA literature search and systematic analysis were performed according to the PRISMA criteria. Studies reporting on outcome following treatment of lower leg CECS were included.ResultsA 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 (x- =; 68 mm Hg tox- =; 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 (x- =; 76 mm Hg to x- =; 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.ConclusionSurgical 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.

Historic cohort: outcome of chronic exertional compartment syndrome-suspected patients

IntroductionExercise-related leg pain (ERLP) may be caused by chronic exertional compartment syndrome (CECS), occurring mainly in athletes and military recruits. In military populations, the effectiveness of surgical treatment in CECS...

Long-Term Outcome of Mini-Open Surgical Decompression for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Riders.

To evaluate results of mini-open fasciotomy (MOF) in high-level motorcycling or motocross riders with chronic exertional compartment syndrome (CECS) at long-term follow-up (minimum 5 years). Case series. IV. University Hospital/Private Practice. Fifty-four professional motorcycling riders treated with MOF for a CECS of the forearm from January 2006 to June 2011. Inclusion criteria comprised: high-level motorcycling or motocross riders, clinical symptoms of CECS for at least 6 months, diagnosis confirmed using preoperative compartment hydrostatic pressure measurement and/or magnetic resonance imaging of the forearm, minimum follow-up of 5 years. A MOF to obtain decompression of all compartments was performed in all patients. Visual analog scale; a subjective scale to measure strength; QuickDash functional scores. Time to resume full riding capacities as short-term evaluation. A total of 54 patients who underwent 77 MOF procedures overall (23 bilateral) were included. The mean age was 23.6 ± 5.2 years. Mean Visual Analog Scale decreased from a preoperative value of 68.2 to a 3-month postoperative value of 26 (P < 0.001). Mean QuickDash scale was 84 at preoperative registration, falling to 20, 3 months after surgery (P < 0.001) and down to 12 at 1-year follow-up (P = 0.017). The average time to return to full riding capacities was 3.5 ± 1 week. Mini-open fasciotomy resulted safe and effective for the treatment of chronic exertional compartment syndrome in high-level motorcycling or motocross riders. The good outcome at follow-up resulted stable at 5 years and the incidence of complications remained low. Our data demonstrate that the resolution of symptoms is reliable and durable. Pain recovery was immediate after surgery, instead functional scores showed a more gradual recovery throughout the 12 months after surgery. Mini-open fasciotomy is a reliable treatment for CECS of the forearm in professional motorcycling riders. This treatment should also be considered in young riders due to the absence of tardive relapse reported in this study.

Chronic exertional compartment syndrome: current management strategies.

Chronic exertional compartment syndrome (CECS) is an underdiagnosed condition that causes lower and upper extremity pain in certain at-risk populations. Lower-extremity CECS is most often observed in running athletes and marching military members. Upper-extremity CECS is most commonly seen in rowers and professional motorcyclists. Although early outcome research on CECS has been based mostly on adult male patients, there has been an increase in the number of studies in pediatric and adolescent patient populations, particularly in females. Evaluation of CECS must include a thorough history and physical exam to rule out other causes of exertional leg pain, but differential diagnosis must remain high on the list. Needle manometry can be used to confirm diagnosis of CECS by measuring intracompartmental pressure. Operative treatment of CECS with fasciotomy has been shown to be effective in resolution of CECS, and new surgical techniques are being developed. In the pediatric population, endoscopy-assisted compartment release has provided high success rates with low complication rates. Nonoperative management of CECS is more commonly described in the literature, and consists of cessation of activities, altering foot-strike pattern, physical therapy, taping, and injections of botulinum toxin A. Nonetheless, larger samples and a more diverse population are needed to better understand the outcomes of nonoperative management. There have been fewer studies on upper-extremity CECS, given its rarity. Success has been found in the treatment of upper-extremity CECS with open fasciotomy, but more studies are needed to understand the efficacy of minimally invasive techniques in the upper extremity. Further research also needs to be done to understand why a large portion (approximately 20%) of the patient population does not experience full resolution of symptoms after fasciotomy.

Surgical Tips for Performing Open Fasciotomies for Chronic Exertional Compartment Syndrome of the Leg.

Chronic exertional compartment syndrome (CECS) of the leg is a debilitating condition that has previously been characterized in athletes and military personnel. The results of surgical management in these patient populations have previously been published with inconsistencies in surgical methods and patient outcomes noted. While endoscopic and minimally invasive techniques have been described, a detailed description of a "standard" open, 2-incision lateral and single-incision medial technique for the treatment of CECS has not been previously published. The purpose of this technique article is to highlight several tips and considerations related to this procedure in the hopes of standardizing treatment and potentially improving patient outcomes. Level of Evidence: Level V, expert opinion.

Concurrent Exertional Compartment Syndrome and Functional Popliteal Artery Entrapment Syndrome: A Case Report

Exertional leg pain is a common and disabling condition in athletes with challenging diagnosis and management. We report the case of a 29-year-old rugby player with a history and clinical examination consistent with chronic exertional compartment syndrome (CECS). Compartment pressure measurement was supportive of the diagnosis. However, magnetic resonance angiography (MRA) with provocative maneuvers showed functional popliteal artery entrapment syndrome (PAES). For the treatment of CECS, bilateral fasciotomy of the anterolateral compartments permitted return to full sport participation in 8 weeks. A follow-up MR angiogram at 12 months showed resolution of the popliteal entrapment leading us to hypothesize a possible relationship between CECS and functional PAES.

Biomechanical differences between cases with suspected chronic exertional compartment syndrome and asymptomatic controls during running

Chronic exertional compartment syndrome (CECS) has been hypothesised, following clinical observations, to be the result of abnormal biomechanics predominantly at the ankle. Treatment of CECS through running re-education to correct these abnormalities has been reported to improve symptoms. However no primary research has been carried out to investigate the movement patterns of those with CECS. This study aimed to compare the running kinematics and muscle activity of cases with CECS and asymptomatic controls.20 men with bilateral symptoms of CECS of the anterior compartment and 20 asymptomatic controls participated. Barefoot and shod running 3D kinematics and muscle activity of the left and right legs; and anthropometry were compared.Cases displayed less anterior trunk lean and less anterior pelvic tilt throughout the whole gait cycle and a more upright shank inclination angle during late swing (peak mean difference 3.5°, 4.1° and 7.3° respectively). Cases demonstrated greater step length and stance time, although this was not consistent across analyses. There were no consistent differences in Tibialis anterior or Gastrocnemius medialis muscle activity. Cases were heavier (mean difference 7.9kg, p=0.02) than controls with no differences in height (p>0.05)These differences only partially match the clinical observations previously described. However, no consistent differences were found at the ankle joint suggesting that current running re-education interventions which focus on adjusting ankle kinematics are not modifying pathological aspects of gait. The longer step length is a continuing theme in this population and as such may be a key component in the development of CECS.

BIOMECHANICAL DIFFERENCES BETWEEN CASES WITH CECS AND ASYMPTOMATIC CONTROLS DURING RUNNING

Chronic exertional compartment syndrome (CECS) presents as exertional pain in the lower limb as a result of elevation of intramuscular compartment pressure. Treatment of CECS through a change in running...

Short-Term Results of a Rehabilitation Program for Service Members With Lower Leg Pain and the Evaluation of Patient Characteristics.

Lower leg pain (LLP), including medial tibial stress syndrome (MTSS) and chronic exertional compartment syndrome (CECS), remains a major problem for the military. Evaluation of patient characteristics and short-term results of the rehabilitation program for service members used in the Military Rehabilitation Centre Aardenburg. This retrospective study includes 161 service members of the Netherlands Armed Forces. Service members were grouped into the following diagnostic categories: MTSS (n = 47), conservative treatment of CECS (n = 34), and rehabilitation after operative intervention of the CECS (CECSo; n = 80). The results showed a significant improvement in all groups regarding the Patient-Specific Functional Scale (PSFS). Only the CECSo group showed significant improvement on the Numeric Pain Rating Score (NPRS). None of the patient characteristics like gender, age, military service, duration of symptoms, and treatment setting were identified to correlate with outcome results. Short-term results of the rehabilitation program for service members with LLP are successful as obtained with the PSFS. Evaluation by the NPRS seems insufficient and researchers should consider using other outcome measurements. The CECSo group seems to benefit the most from the rehabilitation program. No patient characteristics could be identified to correlate with outcome results.

Assessing Outcomes in Individuals Undergoing Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg

The purposes of this study were to evaluate patient-reported outcomes after fasciotomy of the leg for chronic exertional compartment syndrome (CECS) and to determine the rate at which revision surgery was required and the prognostic value of intracompartmental pressure (ICP) testing. This was a retrospective consecutive case series of patients with CECS who underwent preoperative ICP testing and surgical fasciotomy for treatment of CECS of the leg between September 2001 and January2012. Of 69 eligible patients, 46 were evaluated at a mean follow-up time of 54.9 months (range, 3.9 to 127.3 months). Forty-two patients met the Pedowitz criteria for CECS diagnosis. Mean score on the Lower Extremity Functional Scale (LEFS) was 70.4 (standard deviation [SD] ± 11.2) at follow-up and 72.3 (SD ± 11.2) at the patient-perceived time of best outcome. Best outcome was reported at a mean time of 14.3 months (range, 0.5 to 84 months). Five of 46 (11%) patients required a revision fasciotomy. Thirty-six of 46 (78%) patients reported being either satisfied (n= 14) or very satisfied (n= 22) at follow-up. The Pedowitz criteria were highly sensitive (97%) but not specific (10%) and had a positive predictive value (PPV) of 79%. Functional outcomes after fasciotomy for CECS were favorable. ICP testing was shown to be sensitive but not specific. Revision surgery was required for 5 of the 46 patients (11%). Patient satisfaction rates, return to sport, return to preoperative activity levels, and LEFS scores were all high. This case series confirms that fasciotomy is a safe and effective surgical treatment for CECS. Level IV, therapeutic case series.

Common compartment syndromes in athletes. Treatment and rehabilitation.

Compartment syndromes in athletes are rare, but they can also be limb-threatening events. Chronic exertional compartment syndrome (CECS) is a less emergent form where symptoms recur with repetitive loading or exertional activities. CECS is the most common form of compartment syndrome seen in athletes. Acute compartment syndromes may also occur in athletes secondary to direct trauma or may develop from pre-existing CECS. The leg is by far the most common site of compartment syndrome in athletes. The thigh, forearm, and foot are the next most common sites, although any fascially limited compartment can be affected. Awareness of the clinical presentation and pathophysiology of compartment syndromes can help the examiner make a prompt and accurate diagnosis. The treatment of acute compartment syndrome is emergent while the treatment of CECS is not. Conservative treatment and rehabilitation can be successful in treating CECS. Acute compartment syndromes must be treated immediately with surgical decompression. With CECS, if conservative treatment fails, surgical decompression is also indicated. Some authors have suggested that the results of surgical fasciotomy and rate of return to sport for athletes with CECS has not been uniform. If the diagnosis is accurate and carefully documented, a high degree of success with athletes returning to sport can be expected.