Chronic Exertional Compartment Syndrome
Sathish Rajasekaran, MD, Clinical Assistant Professor, Division of PM&R, University of Alberta
Disclosures
• None
Choric Exertional Compartment Syndrome (CECS)
Outline
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•
•
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•
•
Introduction
Anatomy
Pathophysiology
History and Physical Exam
Diagnostic Evaluation
Treatment
Objectives
•
Have an approach to adding CECS to your
differential diagnosis based on history and
physical examination
•
Outline an approach to ordering the
appropriate tests for patients where CECS
is on the differential diagnosis
•
Outline conservative and surgical
treatment options for CECS
•
Outline return to play guidelines for CECS
Clinical Case
• 24 year old female – J.M.
• History:
– Classical symptoms?
• Physical Examination
– At rest vs. post-exertion
• Diagnostic Testing
– Compartment pressure testing vs. other
imaging modalities
– Other studies to exclude other diagnoses
• Treatment options
– Conservative (rehabilitation) vs.
interventional options vs. surgery
Epidemiology
• Incidence2,3
– General population (unknown)
– Undiagnosed leg pain (14-27%)
• Age4-8
– Potential bimodal distribution (20 [before 30] vs. 48 years)
• Association with sports4,9
– Involved in sports (87%)
– Running (69%)
– Diabetic patients with exertional leg pain and normal vascular
studies (90%)
Location
• Can present in various regions of
the body10
– Lower leg, thigh, foot, and forearm
• Lower leg most common region
affected (95%)10
• Bilateral lower leg involvement
(82%)4
Anatomy
40-60%4,5
12-35%4,5
32-60%4,5
2-20%4,5
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000.
Pathophysiology
• ↓Compliance → ↑Compartment pressure?
Pathophysiology
• Reduced microcirculatory capacity
• Vascular congestion as a result of decreased
venous return
Pathophysiology
Abstract presented at AMSSM 2013 (Rajasekaran and Aly)
Pathophysiology
History and Physical Examination
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•
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Pain with exertion
Dull → sharp pain
Neurological symptoms
Worsening over time
Pain with passive stretching of muscles in
involved compartment
Diagnostic Evaluation
• Pressure testing
– Pre-exercise (15 mm Hg), 1 min post-exercise (≥30
mm Hg), 5 min post-exercise (≥20 mm Hg)
Diagnostic Evaluation (Imaging)
Diagnostic Evaluation - Imaging
Bresler M, Mar W, Toman J. Diagnostic imaging in the evaluation of leg pain in athletes. Clinics in sports
medicine. Apr 2012;31(2):217-245.
Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the lower extremities:
improved screening using a novel dual birdcage coil and in-scanner exercise protocol. Skeletal radiology. Nov
2007;36(11):1067-1075.
Diagnostic Evaluation - Imaging
ATMG
Fib
TP
Tib
Rajasekaran S, Beavis C, Aly AR, Leswick D. The utility of ultrasound in detecting anterior compartment thickness
changes in chronic exertional compartment syndrome: a pilot study. Clinical journal of sport medicine : official
journal of the Canadian Academy of Sport Medicine. Jul 2013;23(4):305-311.
Treatment
• Conservative
• Interventional
• Surgery
Treatment – Conservative
Treatment – Interventional
Treatment - Interventional
Treatment – Surgery
• Single incision (open) technique
• One or two incision (subcutaneous) technique
with or without endoscopic assistance with
the removal of a strip of fascia
Treatment - Surgery
24
Treatment - Surgery
• Complications (11-16%)28,29
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–
–
–
–
–
–
Infection
Nerve or vascular injury
Deep vein thrombosis
Wound dehiscence
Complex regional pain syndrome
Scar hypersensitivity
Seroma/hematoma formation
Treatment - Surgery
POD 1-2
Gentle active and passive range-of-motion, weight bearing as tolerated, edema
control measures, basic activities of daily living, protect the healing incision at all
times
POD 3-4
Achieve independence with activities of daily living, and begin unassisted
ambulation
Weeks 1-4
Add stair climbing and increase walking distance
Weeks 4-6
Begin non-impact lower extremity aerobic exercise
Weeks 6+
Initiate unrestricted impact lower extremity activities
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000.
Clinical Case
• 24 year old female – J.M.
• Trialed forefoot running
technique
– Symptoms resolved
– Repeat pressures were not
done
– Patient continues to be
asymptomatic (7 months)
Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM &
R. Dec 2012;4(12):985-1000.
Choric Exertional Compartment Syndrome (CECS)
Objectives
Outline
• Introduction
• Anatomy and
Pathophysiology
• History and Physical Exam
• Diagnostic Evaluation
• Treatment
• Return-to-Play Guidelines
•
Have an approach to adding CECS to your
differential diagnosis based on history and
physical examination
•
Outline an approach to ordering the
appropriate tests for patients where CECS
is on the differential diagnosis
•
Outline conservative and surgical
treatment options for CECS
•
Outline return to play guidelines for CECS
References
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2.
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References
11. Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R :
the journal of injury, function, and rehabilitation. Dec 2012;4(12):985-1000.
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of Fascia Do Not Explain Chronic Exertional Compartment Syndrome. Clinical
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syndrome of the leg. Clinical journal of sport medicine : official journal of the Canadian
Academy of Sport Medicine. Jul 2012;22(4):356-370.
Roberts A, Franklyn-Miller A. The validity of the diagnostic criteria used in chronic
exertional compartment syndrome: A systematic review. Scandinavian journal of medicine
& science in sports. Sep 13 2011.
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Jun 2010;14(2):236-244.
Bresler M, Mar W, Toman J. Diagnostic imaging in the evaluation of leg pain in athletes.
Clinics in sports medicine. Apr 2012;31(2):217-245.
Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the
lower extremities: improved screening using a novel dual birdcage coil and in-scanner
exercise protocol. Skeletal radiology. Nov 2007;36(11):1067-1075.
References
21.
22.
23.
24.
25.
Rajasekaran S, Beavis C, Aly AR, Leswick D. The utility of ultrasound in detecting anterior
compartment thickness changes in chronic exertional compartment syndrome: a pilot
study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport
Medicine. Jul 2013;23(4):305-311.
Kirby RL, McDermott AG. Anterior tibial compartment pressures during running with
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Associated With Chronic Exertional Compartment Syndrome. The American journal of
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Acknowledgments
Dr. Jonathan Finnoff