Chronic Exertional Compartment Syndrome And Exertional leg pain

1. 1
Chronic Exertional Compartment
Syndrome
Ahmed Youssef
Mubarak Alkabeer Hospital

2. 5
Outline
Designed by Graphic Node
Definition
Anatomy
Pathophysiology
History and Physical Exam
Diagnostic Evaluation
DD
Treatment

3. 5
Definition
Designed by Graphic Node
•Reversible ischemia secondary to a
noncompliant osteofascial compartment
that is unresponsive to the expansion of
muscle volume that occurs with exercise

4. 5
Epidemiology
Designed by Graphic Node
CECS is most common in young adult
recreational runners, elite athletes, and military
recruits
Bimodal distribution (20 vs. 48 years).
Male>Female
Associated with sports (Running)
Diabetic patients with exertional leg pain and
normal vascular studies may have CECS

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Location
Designed by Graphic Node
Can present in various regions of the
body
Lower leg, thigh, foot, and forearm
Lower leg (anterior compartment)
most common region affected.
Bilateral lower leg involvement
commonly occurs.

6. 5
40-60%4,5
32-60%4,512-35%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.
Anatomy

7. 5
Pathophysiology
Designed by Graphic Node
↓↓Compliance of facial structures → ↑ ↑
Compartment pressure
Reduced microcirculatory capacity
Vascular congestion as a result of
decreased venous return
↑↑ muscle volume (Anabolic steroid and
creatine use)

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CLINICAL EVALUATION
Designed by Graphic Node
Typical patient with CECS is
Competitive runner, 20 to 30 years old,
Exercise-induced burning pain ↑↑ after 20 to 30
minutes of running.
The pain usually resolves within 15 to 30 minutes of
cessation of exercise.
Paresthesias of the nerves running through the
involved compartment often are reported.

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Signs of CECS
Designed by Graphic Node
Patients should be examined after completing the
exercise
Tenderness over the musculature of the involved
compartment
Muscle herniation through defects in fascia may be
palpated
Diminished sensation along the affected nerve.
Weakness is often reported

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MPARTMENT PRESSURE TESTI
Pedowitz criteria (One or
more required):
Resting pressure > 15 mm Hg
1-minute postexercise > 30 mm
Hg
5-minute postexercise > 20 mm
Hg

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Other investigations
Designed by Graphic Node
Useful to eliminate other
pathology
Xrays,MRI,Bone scan
MRI in-scanner exercise protocol
—>>(smoothing and
segmentation of bone and blood
vessels useful for screening)

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Differential Diagnosis
Designed by Graphic Node
Medial tibial stress syndrome (shin splints) —vague
diffuse pain reduced with training
Stress fracture—Xrays & Bone scan(localized, intense
uptake)
Periostitis—Bone scan, with diffuse uptake often
covering outer third of the bone.
Superficial peroneal nerve syndrome pain during
active, resisted dorsiflexion and eversion of the ankle,
Tinel sign also may be positive

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Differential Diagnosis
Designed by Graphic Node
Tenosynovitis (Achilles tendon, peroneal tendon, or
tibialis posterior)
Lumbosacral radiculopathy — Lumbar tension signs
Popliteal artery entrapment syndrome —(vascular
studies)
Deep venous thrombosis
Neurogenic & Vascular claudication
Others (Infection, Myopathy, Tumors)

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Treatment
Designed by Graphic Node
Conservative
Interventional
Surgery

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Conservative Treatment
Designed by Graphic Node
Limiting activity to a level that avoids all
but minimal symptoms.
Antiinflammatory medications
Stretching and strengthening of the
involved muscles
Orthotics

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Treatment(Interventional)
Designed by Graphic Node
THE AMERICAN JOURNAL OF SPORTS MEDICINE. NOV 2013;41(11):2558-
2566. MEDICINE. NOV 2013;41(11):2558-2566.

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OPERATIVE TREATMENT
Designed by Graphic Node
Single incision (open) technique
One or two incision (subcutaneous) technique
Endoscopic Compartment release (Removal of a
strip of fascia)

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SINGLE-INCISION FASCIOTOMY for Ant.&Lat. CECS
Designed by Graphic Node
A. Incision between tibial crest
and fibular shaft, over
anterolateral intermuscular
septum, when no fascial
hernia exists.
B. In presence of fascial hernia,
incision is directly over
fascial defect.
C. Defect is enlarged across
intermuscular septum (1).
D. and E, Complete longitudinal
release of anterior
compartment (2 and 3) and
lateral compartment (4 and

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DOUBLE MINI-INCISION FASCIOTOMY for anterior CECS
Designed by Graphic Node
A. Two vertical 2-cm skin incisions (15cm apart).
B. Development of subcutaneous flap with blunt dissection.
C. Skin retraction to allow fasciotomy under direct vision.

20. 5
Designed by Graphic Node
A transverse incision at the
anterolateral aspect of the
knee between the fibular
head and Gerdy’s tubercle is
used to access the anterior
and lateral compartments.
The deep fascia encasing the
compartment is exposed.
The balloon dissector is
inserted down to the level of
the ankle under direct
palpation
The balloon is inflated.
Endoscopic
Compartment
release for CECS

21. 5
Endoscopic Compartment
release for CECS
Designed by Graphic Node
Anterior compartment release in a left
leg. The black arrow points to the
intermuscular septum between the
anterior and lateral compartments.
The white arrow denotes the
superficial peroneal nerve exiting the
fascia of the lateral compartment
distally.
Endoscopic visualization of the
posterior fascia of a left leg. The black
arrow denotes the deep posterior
release directly off the tibia. The
white arrow denotes the superficial
posterior compartment release.

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Designed by Graphic Node
POD 1-2
The limb is elevated for 24 to 48 hours and ice is applied
Gentle active and passive ROM, weight bearing as tolerated
Basic activities of daily living
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.
CARE

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Complications of Surgery
Designed by Graphic Node
Infection
Nerve (SPN) most common or vascular injury
Deep vein thrombosis
Wound dehiscence
Complex regional pain syndrome
Scar hypersensitivity
Seroma/hematoma formation

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Tibial Stress Syndrome (Shin Splints)
Overuse injury or
repetitive-load injury of
the shin area that
includes:
medial (posteromedial)
tibial stress syndrome
(most common)
anterior (anterolateral)
tibial stress syndrome

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60% of leg pain syndromes
Vague, diffuse pain along
middle-distal tibia that
decreases with running
Radiographs to exclude stress
fracture
Differentiate from stress
fracture, which shows
"dreaded black line"
Tibial Stress Syndrome (Shin Splints)

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Triphasic bone scan: to
exclude stress fracture
Diffuse, longitudinal
increased uptake along
posteromedial border of
tibia in delayed phase
MRI:periosteal edema,
progressive marrow
involvement
Tibial Stress Syndrome (Shin Splints)

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Treatment
Nonoperative treatment:
First line of treatment and successful in
vast majority
Activity modification with shoe modification
Operative:
Failed non operative treatment
Deep posterior compartment fasciotomy +
release of painful portion of periosteum

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Take Home Messages
Designed by Graphic Node
CECS is most common in young adult
recreational runners, elite athletes, and military
recruits.
Diabetic patients with exertional leg pain and
normal vascular studies may have CECS.
Anterior compartment of lower leg most common
region affected. Bilateral affection is common.

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Take Home Messages
Designed by Graphic Node
Exercise-induced burning pain↑↑after 20 to 30
minutes of running.
The pain usually resolves within 15 to 30 minutes
of cessation of exercise.
D.D.: Tibial stress syndrome—-> pain ↓↓ with
activity.
Fasciotomy (SC,open,endoscopic ) will resolve
the problem.

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