ORIGINAL RESEARCH
The Utility of Ultrasound in Detecting Anterior
Compartment Thickness Changes in Chronic Exertional
Compartment Syndrome: A Pilot Study
Sathish Rajasekaran, MD,* Cole Beavis, MD,† Abdel-Rahman Aly, MD,* and Dave Leswick, MD‡
Objective: To test the hypothesis that patients with chronic exertional
Key Words: ultrasonography, sports medicine, anterior compartment syndrome
compartment syndrome (CECS) of the anterior leg compartment have
an increased anterior compartment thickness (ACT) compared with
control subjects after exertion using ultrasound.
(Clin J Sport Med 2013;23:305–311)
Design: Prospective comparison study.
Setting: Diagnostic imaging department of a tertiary care hospital.
Patients: Four patients with CECS and 9 control subjects.
Interventions: Patients with CECS and control subjects ran on
a treadmill for up to 10 minutes. Anterior compartment thickness
(both groups) and anterior compartment pressure (CECS patients)
were measured before exertion and at scheduled intervals after
exertion.
Main Outcome Measures: Anterior compartment thickness,
percentage change in ACT from rest, and compartment pressure.
Results: Anterior compartment pressures were diagnostic of CECS
using the modified Pedowitz criteria in patients with CECS. Mean
percentage change in ACT from rest in patients with CECS versus
control subjects at 0.5 minutes was 21.3% versus 6.32% [95%
confidence interval (CI), 6.92-35.6 and 0.094-12.5, respectively; P =
0.011]; at 2.5 minutes, it was 24.6% versus 4.22% (95% CI, 10.738.5 and 21.85-10.3, respectively; P = 0.003); and at 4.5 minutes, it
was 24.9% versus 5.08% (95% CI, 14.3-35.5 and 20.813-11.0,
respectively; P = 0.003). Mean ACT in patients with CECS versus
control subjects significantly increased after exertion (P = 0.003) at
0.5 minutes, 2.5 minutes, and 4.5 minutes.
Conclusions: Ultrasonography reveals a significant increase in
ACT in patients with CECS of the anterior leg compartment. Further
studies are warranted to validate these findings with the goal of
developing anterior leg compartment CECS ultrasound diagnostic
criteria and exploring the role of using ultrasound to diagnose CECS
in other compartments.
Submitted for publication August 15, 2012; accepted December 29, 2012.
From the *Department of Physical Medicine and Rehabilitation, University of
Saskatchewan, Saskatoon, Canada; and †Division of Orthopaedic Surgery,
Department of Surgery, University of Saskatchewan, Saskatoon, Canada;
and ‡Department of Diagnostic Imaging, University of Saskatchewan, Saskatoon, Canada.
The authors report no conflicts of interest.
Corresponding Author: Sathish Rajasekaran, MD, Physical Medicine and
Rehabilitation, 7th Floor, Saskatoon City Hospital, 701 Queen St,
Saskatoon, SK SYK 0M7, Canada (sathish.k.rajasekaran@gmail.com).
Copyright © 2013 by Lippincott Williams & Wilkins
Clin J Sport Med Volume 23, Number 4, July 2013
INTRODUCTION
Chronic exertional compartment syndrome (CECS) is
reported to occur in 14% to 27% of patients with undiagnosed
exertional leg pain.1,2 The incidence is equal between men and
women, with a median age of 20 years.2 This condition often
occurs in athletes, with running being the most common precipitating activity.3 The majority of CECS cases have been reported
in the lower leg, with the anterior compartment being most often
affected and bilateral leg involvement in up to 82% of cases.4,5
After a specific amount of exertion, patients with CECS
typically report pain in the affected compartment.2,6 Patients
report a dull aching fullness that worsens with prolonged
activity and resolves with rest.7 The physical examination is
typically normal at rest. Reported findings after exertion
include muscle hernias, pain with passive stretching of the
involved muscles, and abnormal neurological findings in the
distribution of the affected nerve.8
The modified Pedowitz criteria is the most commonly
used method to diagnose CECS in the lower leg using
preexertional and postexertional intracompartmental pressure
testing.5,7,9 However, several weaknesses have been reported
in the design of their study, and the criteria has been found to
have overlapping confidence intervals between healthy subjects and patients with CECS.10 Furthermore, a recent systematic review found conflicting and poor evidence for the
methods used for intracompartmental pressure testing.11
Increased signal intensity changes on magnetic resonance imaging (MRI) in patients with CECS after exertion are
reported in the literature.12–17 However, MRI is not widely
used as a validated technique to diagnose CECS and has only
been reported in 2 studies, with this technique being exclusively used at the Mayo Clinic (Rochester, Minnesota) to
diagnose CECS of the anterior leg compartment.16,17 Functional imaging studies have not proven to aid in the diagnosis
of CECS.18–23 Near-infrared spectroscopy is reported to
approach the accuracy of intracompartmental pressure testing
for the diagnosis of CECS, but further research is needed to
validate this imaging modality for clinical use.24–27 The role
of using ultrasound in the diagnosis of CECS of the anterior
leg compartment was first described by Gershuni et al28 and
subsequently a technique has been validated to measure
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anterior compartment thickness (ACT) by another group.29
This technique was used in 2 studies to measure the change
in ACT after isometric and eccentric exercises in patients with
CECS of the anterior leg compartment and control subjects,
finding no significant differences between the groups.30,31
The objective of our study was to measure ACT with
ultrasound before and after exertion on a treadmill in patients
with CECS of the anterior leg compartment and control subjects
and analyze if ACT and percentage change in ACT from rest
was significantly different after exertion. We hypothesized that
ACT would be significantly increased in patients with CECS
compared with that in control subjects after exertion.
MATERIALS AND METHODS
All subjects gave written informed consent to participate in the study, which was approved by the Institutional
Review Board of the University of Saskatchewan.
TABLE 2. Inclusion Criteria for Patients With CECS
1. Pain (burning, aching, sharp, fullness, dull or pressure)
in the anterior compartment after lower
extremity exertion?
2. Pain worsened with prolonged lower
extremity exertion?
3. Majority of pain relieved within #30 minutes
of rest?
4. Able to run for $5 minutes?
5. No clinical or electrodiagnostic findings of
peroneal neuropathy?
6. No clinical or Doppler ultrasonographic findings of
popliteal artery syndrome?
7. No clinical or positive bone scans confirming the
presence of tibial or fibular fractures?
8. No previous fasciotomy in the leg?
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
A response of “yes” is required for questions 1 to 8 to meet inclusion criteria.
Patients and Control Subjects
Ten control subjects were recruited through the department of diagnostic imaging (medical residents and technicians) and screened (Table 1) for the precision phase of this
study. A letter outlining the study and requesting patients
presenting with symptoms suggestive of CECS be referred
to us was sent to physicians practicing sports medicine within
the health region. Over a 1-year period, 8 patients were
referred and screened with our inclusion criteria (Table 2),
leading to 4 patients (3 men and 1 woman) meeting the clinical criteria to participate in the study (Figure 1). Intracompartmental pressures were not measured in patients suspected
of CECS before the study. Nine control subjects were
TABLE 1. Exclusion Criteria for Precision Phase and Study
Control Subjects
1. Pain (burning, aching, sharp, fullness, dull, or pressure)
after lower extremity exertion in the leg?
2. After lower extremity exertion, pain with palpation of
lower leg muscle(s)?
3. After lower extremity exertion, pain with passive stretch
of lower leg muscle(s)
4. After lower extremity exertion, lower leg muscle
herniation?
5. After lower extremity exertion, dorsiflexion weakness?
6. After lower extremity exertion, eversion weakness?
7. After lower extremity exertion, numbness of the
first web space?
8. After lower extremity exertion, numbness of the dorsum
of the foot?
9. After lower extremity exertion, plantar flexion weakness?
10. After lower extremity exertion, numbness of the
lateral foot?
11. After lower extremity exertion, numbness of the
distal calf?
12. After lower extremity exertion, numbness of the
sole of the foot?
13. Previous diagnosis of CECS?
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
A response of “yes” to any of the questions (1-13) excludes the individual from
participating in the precision phase or as a control subject in the study.
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FIGURE 1. Schematic overview of patient inclusion and exclusion criteria. ELP, exertional leg pain; PAES, popliteal artery
entrapment syndrome.
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Clin J Sport Med Volume 23, Number 4, July 2013
recruited through the department of diagnostic imaging (medical residents and technicians) for the study and screened for
exertional leg pain symptoms (Table 1).
Equipment
Ultrasound images were obtained using a Philips iU22
(Philips Ultrasound Systems, Bothell, Washington) with a 12-5
MHz linear array transducer by the diagnostic medical
sonographer (N.K.). Standard ultrasound gel was used for all
scans. The general musculoskeletal settings of the ultrasound
machine were used for image optimization, and the ultrasound
machine received routine maintenance based on the manufacturer’s recommendations. The Stryker Intracompartmental
Pressure Monitor System with a side-ported 18-gauge needle
(Stryker Surgical, Kalamazoo, Michigan) was used for pressure
testing.
Ultrasound Technique
The ACT was measured at 20% of the distance from the
head of the fibula to the lateral tip of the lateral malleolus,
where the ACT was found to correlate with the crosssectional area of the anterior compartment.29 This landmark
was located while the subjects lied supine. Using ultrasound
coupling gel, the probe was placed on the landmark at an
approximated 90-degree angle to the anterior tibial muscle
group to minimize anisotropy and parallel to the interosseous
membrane.29 Real-time images of the anterior tibial muscle
group were captured (Figure 2).29 The thickness of the anterior tibial muscle group was measured by placing one caliper
on the border of the interosseous membrane facing the anterior compartment and the second caliper on the interior border
of the fascia adjacent to the subcutaneous fat measuring the
shortest distance between the borders (Figure 2). All ACT
measurements were made by the same diagnostic medical
sonographer (N.K.).
Ultrasound Findings in CECS
Precision Phase
The diagnostic medical sonographer’s (N.K.) technique
was validated with a precision phase before scanning study
patients using 10 control subjects who were screened for exertional leg pain symptoms (Table 1). Resting ACT was measured after lying supine for 10 minutes and again after 3 sets
of 10 calf raises. The same exercise protocol and ultrasound
recordings were repeated after 10 minutes of rest in each
control subject.
Study Phase
Patients (n = 4) were asked to refrain from exercising on
the day before testing. The point of needle insertion for pressure testing in the dominant leg (all patients had bilateral symptoms) was localized by marking a point 10 cm distal to the
tibial tubercle and 1.5 cm lateral to the anterior tibial crest.32
The ankle was placed in a neutral position and the knee placed
in 10 degrees of flexion (confirmed with goniometer)
to minimize the effect of joint position on intracompartmental
pressure.32 Patients then laid supine for 20 minutes to ensure
the intracompartmental pressure normalized. The insertion site
was prepped with antiseptic and anesthetized with 1 mL of 1%
lidocaine. The needle was inserted at the previously localized
point to a depth of 2.5 cm at a 45-degree angle to the skin
surface.32 The pressure was allowed to stabilize and then
recorded. Anterior compartment thickness was then measured
and recorded.
Patients were asked to exercise on a treadmill beginning at
3 mph and a 0% grade of incline. After 2 minutes, the running
speed was increased gradually up to 7 mph (1 mph/1 minute)
and a 20% grade of incline (5% grade/1 minute). Patients were
instructed to run for at least 5 minutes and to increase the speed
and incline (within the exercise protocol) as tolerated to
maximize their symptoms. The duration of exertion was
recorded, and the timer was restarted once the patient stopped
running. Patients were instructed to lie supine with the previous
configuration of the dominant leg once they stopped running.
Compartment pressures were obtained at 1 minute, 3 minutes,
and 5 minutes after exercise. Anterior compartment thickness
was measured at 30 seconds, 2.5 minutes, and 4.5 minutes after
exercise. Anterior compartment pressure was used to confirm
the diagnosis of CECS using the modified Pedowitz criteria.5
Control Phase
The same ultrasound measurements were taken without
corresponding compartment pressures in control subjects (n = 9).
All control subjects ran for 10 minutes and reached 7 mph and
a 20% grade of incline (1 mph/1 minute and 5% grade/1 minute)
after warming up at 3 mph and a 0% grade of incline for
2 minutes.
Statistical Analysis
FIGURE 2. Ultrasound marker placement for ACT measurement
using ultrasound in patients at rest. Line represents interosseous
membrane, dotted line represents fascial border with subcutaneous fat, crosshairs denote calipers, and double-headed
arrow denotes ACT. ATMG, anterior tibial muscle group; Fib,
fibula; TP, tibialis posterior; Tib, tibia.
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Intraclass correlation coefficient equations were used to
examine the repeatability of the preexercise and postexercise
ACT data in the precision phase.33 Confidence intervals (95%)
for means were calculated using the 1-sample t test. The Wilcoxon signed rank test was used to compare postexertion pressure
and ACT within each group from resting values. The Wilcoxon
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Rajasekaran et al
rank sum test was used to compare ACT and percentage change
in ACT from rest between patients with CECS and control subjects. All data analysis was completed using SAS 9.3 for Windows software (SAS Institute, Inc, Cary, North Carolina).
2.12-2.45; P = 0.086) (Figure 3). Statistical significance was
not found in mean ACT in patients with CECS versus control
subjects at rest (P = 0.05) but was significant (P = 0.003) at
0.5 minutes, 2.5 minutes, and at 4.5 minutes after exertion.
Percentage Change in ACT
RESULTS
Precision Phase
Preexertional and postexertional ACT repeatability was
high, and intraclass correlation coefficients (1,1) for both
measurements was 0.96 [95% confidence interval (CI), 0.860.99 and 0.85-0.99, respectively].
Patient and Control Demographics
Mean age of patients with CECS (3 men and 1 woman)
and control subjects (5 men and 4 women) was 35.3 years and
32.6 years, respectively (95% CI, 28.0-42.5 and 27.8-37.3,
respectively). Mean running time in patients with CECS was
6.0 minutes (95% CI, 3.8-8.3), and control subjects ran for
10 minutes.
Compartment Pressure
Compartment pressure in patients with CECS was 21.5
mm Hg at rest (95% CI, 17.3-25.7), 38.3 mm Hg at 1 minute
(95% CI, 30.3-46.2; P = 0.068), 34.5 mm Hg at 3 minutes
(95% CI, 27.4-41.6; P = 0.068), and 38.8 mm Hg at 5 minutes
(95% CI, 18.9-58.6; P = 0.068). Pressures in all 4 patients were
diagnostic of CECS using the modified Pedowitz criteria.5
Anterior Compartment Thickness
Mean ACT in patients with CECS was 2.63 cm at rest
(95% CI, 2.11-3.15), 3.17 cm at 0.5 minutes (95% CI, 2.733.61; P = 0.068), 3.26 at 2.5 minutes (95% CI, 2.92-3.59; P =
0.068), and 3.26 at 4.5 minutes (95% CI, 2.82-3.69; P = 0.068)
(Figure 3). Anterior compartment thickness in control subjects
was 2.18 cm at rest (95% CI, 2.06-2.30), 2.32 at 0.5 minutes
(95% CI, 2.13-2.50; P = 0.086), 2.27 cm at 2.5 minutes (95%
CI, 2.10-2.43; P = 0.173), and 2.29 cm at 4.5 minutes (95% CI,
FIGURE 3. Mean ACT in patients with CECS and control
subjects. Statistical significance was found in between-group
comparisons (P = 0.05 at rest, P = 0.003 at 0.5 minutes,
2.5 minutes, and 4.5 minutes). Statistical significance was not
found in within-group comparisons (P . 0.05). Vertical lines
represent 95% CIs.
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Mean percentage change in ACT from rest in patients
with CECS was 21.3% at 0.5 minutes (95% CI, 6.92-35.6),
24.6% at 2.5 minutes (95% CI, 10.7-38.5), and 24.9% at
4.5 minutes (95% CI, 14.3-35.5) (Figure 4). Mean percentage
change in ACT from rest in control subjects was 6.32% at
0.5 minutes (95% CI, 0.094-12.5), 4.22% at 2.5 minutes
(95% CI, 21.85-10.3), and 5.08% at 4.5 minutes (95% CI,
20.813-11.0) (Figure 4). Statistical significance was found in
mean percentage change in ACT from rest in patients with
CECS versus control subjects at 0.5 minutes (P = 0.011),
2.5 minutes, and 4.5 minutes (P = 0.003) after exertion.
DISCUSSION
Our study is the first to describe statistically significant
findings (ACT, percentage change in ACT from rest) between
patients with CECS of the anterior leg compartment and
control subjects after exertion using ultrasound.
Two studies have used ultrasound to measure ACT in
patients with CECS of the anterior leg compartment, performing eccentric or isometric exercises and found no statistical
difference between patients with CECS and control subjects
after exertion.30,31 In the isometric exercise study, patients
with CECS reported a median pain score of 6 with a range
between 1 and 9 after 20 minutes of exercise compared with
a median pain score of 1.5 (range, 0-6) in control subjects.31
In the eccentric exercise study, there was no statistical difference in pain scores between patients with CECS and control
subjects during exercise or recovery.30 The varied severity of
symptoms in patients with CECS after exercise in the isometric exercise study and lack of significant differences in
symptoms between patients with CECS and control subjects
in the eccentric exercise study may have contributed to the lack
of significant findings on ultrasound in both studies.30,31
FIGURE 4. Mean percentage change in ACT from rest in
patients with CECS and control subjects. Statistical significance
was found in between-group comparisons (P = 0.011 at
0.5 minutes and P = 0.003 at 2.5 and 4.5 minutes). Vertical
lines represent 95% CIs.
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Clin J Sport Med Volume 23, Number 4, July 2013
Additionally, in the isometric exercise study, percentage
change in ACT was measured at rest, 20 minutes, 22.5 minutes,
25 minutes, 27.5 minutes, and 30 minutes after exercise.31
These delayed postexercise measurements may have also contributed to the lack of significant findings on ultrasound in the
isometric exercise study.31 In our study, we refrained from
having a set duration and intensity of exercise but allowed
patients with CECS to titrate this using a standardized protocol
to ensure that they were symptomatic after exercise.
Our validated technique revealed a significant difference
in ACT and percentage change in ACT from rest in patients
with CECS compared with control subjects at all time points
after exertion. Statistical significance was not found when
comparing ACT after exertion with resting values within
patients with CECS. The 95% CIs for mean ACT compared
with mean percentage change in ACT from rest in patients with
CECS versus control subjects were more distinct for mean ACT
after exertion. Furthermore, the statistical significance was
greater for ACT at 0.5 minutes than percentage change in
ACT from rest in patients with CECS versus control subjects
(P = 0.003 vs P = 0.011, respectively) but identical at 2.5 and
4.5 minutes (P = 0.003). However, we hypothesize that percentage change in ACT may prove to be more beneficial
Ultrasound Findings in CECS
because it corrects for differences in leg size in the general
population. Larger studies need to be undertaken to more confidently assess the benefit of one over the other with the goal of
constructing a criteria for anterior leg compartment CECS diagnosis using ultrasound.
A convexity in the anterior compartment fascia was
seen in the ultrasound images of patients with CECS after
exertion (Figure 5). We did not attempt to quantify this convexity, as the entire width of the fascia of the anterior compartment was not imaged. The combination of bowing of the
fascia and a statistically significant increase in the ACT in
patients with CECS compared with control subjects argues
against the decreased compliance theory as the underlying
pathophysiology of CECS.34,35 Furthermore, a recent study
found no significant difference in the compliance of fascial
tissue samples of patients with CECS of the anterior leg compartment compared with control subjects, which contradicts
previous findings.34–36 Quantifying the changes in anterior
compartment volume versus pressure of patients with CECS
and control subjects would help clarify the role compliance
plays in CECS. A more practical approach may be to use
ACT to estimate volume because it has been found to correlate with the anterior compartment cross-sectional area.29
FIGURE 5. Anterior compartment thickness visualized with ultrasound. A, CECS patient at rest. B, CECS patient at 30 seconds
after exertion. C, Control at rest. D, Control at 30 seconds after exertion.
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FIGURE 6. Mean ACT plotted against
corresponding (30-second delay)
mean anterior compartment pressure
in patients with CECS. Time 1 = 0.5minute ACT/1-minute compartment
pressure; Time 2 = 2.5-minute ACT/
3-minute compartment pressure; Time
3 = 4.5-minute ACT/5-minute compartment pressure.
Correlating the relationship between ACT and pressure may
prove to be a means of estimating compliance in patients with
CECS of the anterior leg compartment (Figure 6). Comparing
the estimated compliance curves between patients with CECS
of the anterior leg compartment and control subjects may lead
to a better understanding of the pathophysiology of CECS.
Several study limitations are noteworthy. First, our
sample size of patients with CECS (n = 4) and control subjects (n = 9) was very small and would need to be expanded to
properly assess the role of using ultrasound to diagnose CECS
of the anterior leg compartment. As this is a relatively uncommon condition, a multicenter trial or conducting this project at
a larger referral center would help recruit more patients in
future studies. Second, we did not standardize the discomfort
perceived by patients with CECS or control subjects after
exertion using a validated scale (Visual Analog Scale). However, we instructed patients with CECS to run until they could
not tolerate the discomfort, and all the 9 control subjects
reported no symptoms after exertion. Third, our control subjects were not age matched to patients with CECS. Fourth, the
length and intensity of exercise was not identical between the
groups or within patients with CECS. In an attempt to compensate for the difference between patients with CECS and
control subjects, all control subjects ran for a longer duration
(10 minutes) than patients with CECS and reached the full
incline and speed defined in our exercise protocol. Even
though duration, incline, and speed of the treadmill sessions
were different among patients with CECS, all patients ran to
the point where they could no longer tolerate the discomfort in
their legs. Fifth, compartment pressure was not recorded at the
same time ACT was measured. However, to do this, a different
method (ie, slit catheter) would need to be used, and a further
precision phase completed to ensure that pressure recordings
were not affected by sonopalpation. Sixth, interrater reliability
was not assessed in our precision phase. Seventh, repetitive
dorsiflexion would have activated the anterior compartment
muscles to a greater degree in the precision phase rather than
calf raises. Eight, we did not blind the diagnostic medical
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sonographer, which undoubtedly decreased the quality of the
study. However, this was attempted but complicated by the
clearly apparent discomfort that patients with CECS had with
transferring onto the bed, ankle positioning, and sonopalpation.
Despite the limitations mentioned above, our study
shows a promising role for using ultrasound, a noninvasive,
readily available, and cost-effective method of imaging patients
with suspected CECS of the anterior leg compartment. Further
studies are warranted to validate the findings of this study in an
attempt to develop an anterior leg compartment CECS
ultrasound diagnostic criteria using ACT or percentage change
in ACT from rest. If this is accomplished, further studies
investigating the role of using ultrasound to diagnose CECS in
other compartments is warranted. Furthermore, our novel
description of estimating compliance may lead to a better
understanding of the pathophysiology of CECS.
ACKNOWLEDGMENTS
The authors thank Nadine Kanigan for scanning study
patients and recruiting controls.
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