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

1. Gonzalo Samitier MD PhD
Orthopaedic Sports Medicine Fellow
Henry Ford Health System
EXERTIONAL COMPARTMENT SYNDROME
Upper and Lower extremity

2. • What
• Who
• Where
• Why
- Leg
- Thigh
- Foot
- Gluteus
- Erector spinae
- Forearm
LOWER
- Runners
- Basketball
- 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

3. PATHOPHYSIOLOGY

4. Medicine is a science of uncertainty and an
art of probability”
William Osler

5. 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
If you don´t think about it you don´t diagnose
it …
Symptoms

6. DIFFERENTIAL DIAGNOSIS
Bone stress syndrome
Stress fractures
Muscular cramps or ruptures
Fascial defects
Nerve Entrapment Syndromes
Vascular entrapment syndromes
Vascular claudication
Radiculopathy
Spinal Stenosis
Deep Venous Thrombosis
OTHERS
Hypothyroid Myop
Myopathies
Tenosynovitis
Tumor
Infection

7. DIFFERENTIAL DIAGNOSIS
WORKUP
Blood and Urine
Studies
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

8. DIFFERENTIAL DIAGNOSIS

9. COMPARTMENT PRESSURE TESTING
“ NOT EASY BEING PRECISE AND ACCURATE “
DIAGNOSIS

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

11. COMPARTMENT PRESSURE TESTING
• Pedowitz criteria (One or more required):
– Rest pressure > 15 mm Hg
– 1-minute postexercise > 30 mm Hg
– 5-minute postexercise > 20 mm Hg

12. COMPARTMENT PRESSURE TESTING
• Measure pre and postexertional
• Measurements must be made in all
compartments of 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
RECOMMENDATIONS

13. COMPARTMENT PRESSURE TESTING
• 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
• Manufactured
devices
– Stryker (Side port
needle)
– Synthes (cannula and
probe)

14. COMPARTMENT PRESSURE
TESTING

15. COMPARTMENT PRESSURE TESTIING
• 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

16. COMPARTMENT PRESSURE TESTING

17. ANATOMY
LOWER LEG

18. FIFTH COMPARTMENT

19. FOREARM
ANATOMY

20. ANATOMY
THIGH

23. TREATMENT
• Conservative
• Surgical
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

24. SURGICAL TREATMENT

28. SURGICAL TREATMENT

29. SURGICAL TREATMENT

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 and lateral comp: 65-100% success
• Posterior comp: 50-75% success
UPPER
95% satisfied patients

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

38. SURGICAL DESCOMPRESSION FAILURE
• Misdiagnosis
• Inadequate descompression
• Inadequate affected compartment selection
• Scarring

40. Think about it and rely on HPI and PE and
rule out outsiders

41. Compartment pressure testing Gold
Standard with a proper technique

42. Know your anatomy and open just
the affected compartments

43. MADRIDThank you …

44. MADRID

45. MADRID