Rationale, from diagnosis to definitive treatment for an uncommon and limitating sports injury, the Chronic Exertional Compartment Syndrome

1. Upper and Lower extremity
Gonzalo Samitier MD
Shoulder and Elbow Fellow UF

2.  What
 Who
 Where
 Why
- Leg
- Thigh
- Foot
- Gluteus
- Erector spinae
- Forearm
LOWER
- Runners
- Basket
- Soccer
- Skiers
UPPER
- Motocyclist
- Mountaineering
- Weightlifting
- Rowers
- Martial arts
- Wheelchair athletes
ATHLETES
WORKERS
MILITARY
- Muscle Hyperthrophy
- Fascial thickening
- Fascial inflexibility
- Fascial hernias
- Arteriole regulation
- Inherent susceptibility
EXERTIONAL COMPARTMENT
SYNDROME

3. PATHOPHYSIOLOGY

4. ANATOMY
LOWER LEG

5. ANATOMY
FIFTH COMPARTMENT

6. ANATOMY
FOREARM

7. ANATOMY
THIGH

8. DIAGNOSIS
 May I have a certainly diagnosis?
“Probably Not but You can have a very
precise guess”
 Clinical history and Physical exam
 Rule out other problems
 Compartment pressures
 New tools: MRI, CT SPECT

9. PRESENTATION
 Patient
 Symptoms
 Signs
- Pain
- Tightness
- Increased tension
- Fascial herniations
- Muscle athropy or normal
circunference
- Cramping
- Burning
- Aching
- Numbness sensory nerve
territory
- Tingling
- Radiating symptoms distally
- Weakness motor nerve territory
- Reduced athletic perfomance
Bilaterally 80-95% pac
COMPARTMENTS INVOLVED
- Anterior 40-60%
- Deep Posterior 32-60%
- Lateral 12-35%
- Superficial Posterior 2-20%

10. DIFFERENTIAL DIAGNOSIS
 Medial tibial stress syndrome (MTSS)
 Tibial and fibular stress fractures
 Muscular cramps or ruptures
 Fascial defects
 Nerve Entrapment Syndromes
 Vascular entrapment syndromes
 Vascular claudication
 Lumbosacral Radiculopathy
 Spinal Stenosis
 Deep Venous Thrombosis
 Others:
 Hypothyroid Myopathy
 Myopathies
 Tenosynovitis
 Tumor
 Infection

11. DIFFERENTIAL DIAGNOSIS

12. DIFFERENTIAL DIAGNOSIS
WORKUP
 Blood and Urine
Studies
 Lower extremity
Imaging studies
 Electromyography
Serum creatine kinase (CK) and myoglobin level
(identifies myopathy or rhabdomyolysis)
Urinalysis (UA) and urine myoglobin
(rhabdomyolysis)
D-dimer level (deep venous thrombosis)
Complete blood cell count with differential
(infection, osteomyelitis)
Complete metabolic panel (metabolic
derangements, acidosis, hypercalcemia,
hyperkalemia)
Thyroid-stimulating hormone (thyroid myopathy)
Erythrocyte sedimentation rate (ESR) (infection,
rheumatologic conditions)
Rx, Bone Scan, CT, MRI

13. COMPARTMENT PRESSURE
TESTING
• GOLD STANDAR
• NOT EASY BEING PRECISE AND CONSISTENT

14. Roberts, A. Franklyn-Miller. The validity of the diagnostic
criteria used in chronic exertional compartment syndrome:
Systematic review. Scand J Med Sci Sports 2011
 Recommend only the confidence limits
from the studies in this review
 It is not possible in this review to
comment on the best diag- nostic
thresholds for a particular protocol that
maximizes both specificity and
sensitivity.
COMPARTMENT PRESSURE
TESTING

15. COMPARTMENT PRESSURE
TESTING

17. COMPARTMENT PRESSURE
TESTING

18.  Simple Needle
 18 gauge
 Least accurate
 Usually gives falsely
higher reading
 Slit Catheter and Side
ported needle
 No significant difference
 More accurate
Side port
Moed et al JBJS 1993
COMPARTMENT PRESSURE
TESTIING

19. COMPARTMENT PRESSURE
TESTIING
 Infusion
 manometer
 saline
 3-way stopcock
(Whitesides, CORR
1975)
 Catheter
 wick
 slit wick
 Arterial line
 16 - 18 ga. Needle
(5-19 mm Hg higher)
 transducer
 monitor
 Stryker device
 Side port needle

20. COMPARTMENT PRESSURE TESTIING

21.  Measure pre and postexertional
 Measurements must be made in all
compartments of both legs
 Bilaterally
 Marginal readings must be followed with repeat
physical exam and repeat compartment
pressure measurement
 Personal Protocol with readings in controls
 Use ultrasounds in deep posterior compartment
COMPARTMENT PRESSURE
TESTIING
RECOMMENDATIONS

22.  Pedowitz criteria (One or more required):
 Rest pressure > 15 mm Hg
 1-minute postexercise > 30 mm Hg
 5-minute postexercise > 20 mm Hg
COMPARTMENT PRESSURE
TESTIING

23. DIAGNOSIS
 Clinical history and Physical exam
 Rule out other problems
 Compartment pressures
 New tools: MRI, CT SPECT

24.  Conservative
 Surgical
TREATMENT
Fasciotomy +/- Fasciectomy
- Single incision
- Doble incision
- Miniopen (Endoscopic assisted)
• Physical Therapy
• Proper Training techniques
• Muscle imbalance
• Aquatic Therapy
• Pt. Education
• Flexibility training
• Manual- deep tissue work
• NSAIDs and Diuretics
ANTERIOR AND LATERAL
COMPARTMENTS
POSTERIOR COMPARTMENTS
IDEALLY OPEN ONLY AFFECTED COMPARTMENTS

25. SURGICAL TREATMENT

30. SURGICAL TREATMENT

31. SURGICAL TREATMENT

34. TREATMENT
 Upper Extremity

35. POSTOP
• EARLY MOVILIZATION
• INCLUDE POOL OR CYCLING AFTER WOUND HEALING
• ISOKINETIC MUSCLE STRENGTHENING EXERCISES AT 3-4 WEEKS
• FULL ACTIVITY INTRODUCED AT 6-12 WEEKS

36. RESULTS
LOWER
 Anterior comp: 65-100% success
 Posterior comp: 50-75% success
UPPER
95% satisfied patients

37. RESULTS

38. COMPLICATIONS
 Hemorrage
 Wound infection
 Nerve entrapment
 Swelling
 Lymphocele
 Peripheral nerve injury
 Deep vein thrombosis
 Recurrence

39. SURGICAL DESCOMPRESSION
FAILURE
 Misdiagnosis
 Inadequate descompression
 Inadequate affected compartment
selection
 Scarring

40. MISCELANEA

41. THANK YOU