Case Report
Debra Rink
Bilateral Exercise Induced Compartment Syndrome of the Lower Leg
Abstract:
Background: This report deals with the treatment of one case of exercise induced
compartment syndrome (EICS) in a 52 year old military male who is also a runner.
His chief complaints are of lower leg pain and parasthesia while running. Symptoms
reported while running include lower leg pain in all areas of the lower leg,
parasthesia, swelling, and tension in all areas of the lower leg. The symptoms
subsided after cessation of exercise. The patient has been on a stretching program
to try to prevent the symptoms from occurring while running, but has had no
success. Differential diagnosis: The history of pain and parasthesia in the lower
leg can suggest diagnosis such as: nerve entrapment, shin splints, stress fractures,
medial tibial stress syndrome, venous or arterial diseases or entrapment, muscle
strain, tendonitis, and compartment syndrome. They can all cause similar
symptoms. Treatment: A thorough history was taken along with manual muscle
testing of the lower leg muscles. No weakness was noted. The diagnosis was
defined as EICS of all 4 compartments of the lower leg bilaterally.
Intracompartmental pressure testing was ordered and the patient was instructed on
a conservative option and a surgical option for treatment. The conservative option
including physical therapy of the muscles of the lower legs and a change in activity
levels was chosen rather than immediate surgical treatment with a fasciotomy of all
4 compartments bilaterally. Physical therapy for 3-6 months and no running or
jumping are included in the conservative plan. Intracompartmental pressure will be
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obtained at the beginning of the treatment period and at the end of the treatment
period. If the exertional intramuscular pressures at the end of the conservative
physical therapy period are >15 mmHg at rest, >30 mmHg 1-2 minutes post
exercise, and >20 mmHg 5 minutes post exercise, then surgical treatment will be
recommended to prevent the occurrence of acute EICS which has devastating
consequences. Uniqueness: The mechanism of injury appears to be running in a
military male which is a common factor to this diagnosis, however, exercise induced
compartment syndrome is most commonly diagnosed in the anterior and/or lateral
compartments of the lower leg. This case has a diagnosis of all 4 compartments in
both of the lower legs including the anterior, lateral, superficial posterior and deep
posterior compartments. Conclusions: In this case, an adult military male felt
symptoms of lower leg pain and lower leg parasthesia while training for fitness
tests. A diagnosis of EICS was established, conservative therapy was chosen instead
of surgery. The return to normal activity is not yet known, as not enough time has
passed for the conservative treatment to be completed. Many case reports
published on EICS are on military personnel or runners and this case included both,
however, this case included all compartments of the lower legs bilaterally rather
than the more common anterior or lateral compartments only. This case should
validate the importance of an extensive history and evaluation of lower leg
symptoms, as there are several severe differential diagnosis to consider, some of
which can cause severe consequences to the individual. Word Count: 516 words.
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Introduction
Exercise induced compartment syndrome is a well recognized but
uncommon clinical diagnosis that occurs post intense exercise.1 Progression into an
acute EICS is a devastating injury with devastating consequences of possible limb
loss, acidosis, myoglobinuria, hyperkalemia, sepsis, shock, and renal failure which
might lead to death.1,2 EICS is defined by its symptoms which are, pain, swelling,
and impaired muscle function induced by exercise.3–6 It is usually found in young
active individuals, especially those participants of running sports and those in
military training and is said to be due to overuse.3,4,7 The occurrence of ischemia
and neurological deficits may be caused from circulation problems in a muscle
group that are caused by an abnormal increase in compartment pressure of a
muscle group.3,5–7 This can arise from surrounding fascia not adjusting to muscle
hypertrophy induced by exercise, which can increase the volume of the muscle by
20% in its compartment.3 Many other differential diagnosis exhibit similar
symptoms to EICS and are more common, which makes finding the correct clinical
diagnosis difficult and can cause misdiagnosis.8–10 A suspected diagnosis is based on
a clinical history and an intramuscular pressure test, which is the gold standard of
testing for EICS.5,10–12 Other potential tools to diagnose EICS are MRI, near-infrared
spectroscopy and thallium scanning.5 Upon a tested diagnosis of EICS, a surgical
fasciotomy releasing the compartment is the best next step in treatment.9,10,13
Case Report
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The patient is a 52 year old adult male, who works for the US military. His
chief complaint is having pain and parasthesia in his lower legs while running. The
patient states that he started noticing these symptoms several months ago and they
have progressively gotten worse. He now has to cut his runs short at less than one
mile into a 3 or 4 mile training run. His symptoms at the onset included both lower
legs and both feet “being sore” and “tight” while running. Progression of the injury
brought symptoms to pain, tingling and numbness at about 3 miles and swelling by
the end of his running. Both feet would be completely numb by the end of his 3-4
mile runs. Over the next few months, the symptoms would start sooner and be
more intense until he had to quit running only 200-400 meters into his training run
with the same or more severe symptoms. While examining the patient, his muscles
perform dorsiflexion and plantarflexion normally. The muscles appear and feel soft
and healthy upon palpation. He states no symptoms while in the clinic, however,
does state that the symptoms do occur with every run and is confident that the
symptoms will appear upon an exercise test.
Conservative physical therapy of the muscles of the lower legs has been
chosen instead of a fasciotomy surgical treatment of all 4 compartments bilaterally.
The physical therapy includes stretching and light strengthening of the lower legs
and a reduction in activity to try to accomplish atrophy of the lower leg muscles.
Literature suggests that the time before the onset of pain can be lengthened with
massage and stretching, however, this has been shown to be unsuccessful in
accomplishing a return to previous activity.5 An exertional intramuscular pressure
test has been ordered for all 4 compartments in both lower legs. This case will be
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unique if all 4 compartments of both lower legs are diagnosed with high
compartmental pressures during exercise. The compartments affected most
commonly are the anterior and lateral compartments. If the exertional
intramuscular pressures are >15 mmHg at rest, >30 mmHg 1-2 minutes post
exercise, and >20 mmHg 5 minutes post exercise, then surgical treatment will be
recommended to prevent the occurrence of acute EICS which has devastating
consequences. A fasciotomy will be recommended, but will only be done on the
compartments that show high pressure from the exertional pressure test. Physical
therapy will follow surgery for 6-12 months until a return to normal activity is
achieved if surgery is necessary. Physical therapy will focus on ROM and light
strengthening exercises along with proprioception and some agility matching his
military fitness tests. In order to consider this case a successful return to full
activity, all strength tests must be 4/5 or better, all ROM must be normal, and no
return of symptoms must be accomplished within 12 months after surgery.
Discussion
A diagnosis of EICS typically requires a patient’s history to include exercise
induced symptoms, a reproduction of the patient’s usual symptoms during an
exercise test, and an increased intramuscular pressure during the exercise test of
>15 mmHg at rest, >30 mmHg 1-2 minutes post exercise, and >20 mmHg 5 minutes
post exercise.10–12 The pathophysiology of EICS is difficult to understand which
makes for a difficult diagnosis. There are numerous benign injuries that have the
same symptoms as EICS adding to the difficulty in diagnosing, however, the correct
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diagnosis is of utmost importance.1 Differential diagnosis are, medial tibial stress
syndrome, stress fracture, nerve entrapment, popliteal artery entrapment
syndrome, vascular disorders muscle strain, tendonitis, and shin splints.1,3,4,10,11
Unfortunately, the further along the syndrome is and the more pronounced the
symptoms, the easier it is to diagnose, but this causes many complications.3 If the
diagnosis is delayed, the outcome can be poor for the patient and have catastrophic
consequences. It can lead to limb loss and acidosis, myoglobinuria, hyperkalemia,
sepsis, shock, and renal failure that may lead to death.1
The lower leg contains 4 compartments; anterior, lateral, superficial
posterior, and deep posterior. Causes of EICS in any individual compartment are
believed to be anything that creates hypertrophy of the muscles such as eccentric
weight training and steroid use. Posttraumatic soft tissue inflammation, myofascial
scarring, and venous hypertension, are theorized causes of EICS also.3 One theory
explains how the pressure in the compartment increases with eccentric exercise,
and myofiber damage occurs and releases proteins. This increases the osmotic
pressure of the compartment. When exertion is added with exercise, the exertion
creates swelling of the fibers and increased blood volume in the compartment,
therefore, raising the pressure in the compartment also.1,4 Muscles have been found
to have as much as a 20% increase in volume during exercise.14 The increased
pressure causes venous congestion which leads to decreased blood perfusion and
possible ischemia. The blood flow becomes insufficient to meet metabolic
requirements and the tissue will lose its function and capability.1,3
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EICS is not commonly exhibited in the superficial posterior compartment or
the deep posterior compartment. Activity modification and rehabilitation of the
lower leg muscles in the compartments involved are sometimes used as a
conservative treatment, but have shown to be less effective than a surgical
fasciotomy on returning to normal activities.14,15 However, there are conflicting
reports of surgical success with some reports being 20-27% of the patients having
unsuccessful surgical management of EICS and unable to return to full activity,15 and
other reports state 75-100% resolution of symptoms.3,10,15
In conclusion, EICS is difficult to diagnose early which creates more problems
with treatment and recovery for the patient. The age of the patient in this case may
affect the treatment used. If the patient can remain conservative in his activities, he
may be able to delay surgery long term. Conservative treatments may be sufficient
enough to maintain a healthy and satisfactory quality of life.
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