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Chronic Exertional Compartment Syndrome
Chronic exertional compartment syndrome (CECS) is characterized by reversible ischemia in a noncompliant muscle compartment that causes pain with exercise but resolves with rest. It most commonly affects the anterior compartment of the lower leg in young, competitive runners and military recruits. The pain is exercise-induced and worsens over 20-30 minutes of running before resolving within 15-30 minutes of stopping. Diagnosis involves clinical evaluation for tenderness over the affected muscles and compartment pressure testing at rest and after exercise. Treatment begins with activity modification, but refractory cases may require fasciotomy to release the tight fascia.
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Chronic Exertional Compartment Syndrome
- 1. 1 Chronic Exertional Compartment Syndrome AhmedYoussef Mubarak Alkabeer Hospital
- 2. 5 Outline Designed by GraphicNode Definition Anatomy Pathophysiology History and Physical Exam Diagnostic Evaluation DD Treatment
- 3. 5 Definition Designed by GraphicNode •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 GraphicNode 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
- 5. 5 Location Designed by GraphicNode 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, KvinlaugK, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000. Anatomy
- 7. 5 Pathophysiology Designed by GraphicNode ↓↓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)
- 8. 5 CLINICAL EVALUATION Designed byGraphic 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.
- 9. 5 Signs of CECS Designedby 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
- 10. 5 MPARTMENT PRESSURE TESTI Pedowitzcriteria (One or more required): Resting pressure > 15 mm Hg 1-minute postexercise > 30 mm Hg 5-minute postexercise > 20 mm Hg
- 11. 5 Other investigations Designed byGraphic 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)
- 12. 5 Differential Diagnosis Designed byGraphic 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
- 13. 5 Differential Diagnosis Designed byGraphic 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)
- 14. 5 Treatment Designed by GraphicNode Conservative Interventional Surgery
- 15. 5 Conservative Treatment Designed byGraphic Node Limiting activity to a level that avoids all but minimal symptoms. Antiinflammatory medications Stretching and strengthening of the involved muscles Orthotics
- 16. 5 Treatment(Interventional) Designed by GraphicNode THE AMERICAN JOURNAL OF SPORTS MEDICINE. NOV 2013;41(11):2558- 2566. MEDICINE. NOV 2013;41(11):2558-2566.
- 17. 5 OPERATIVE TREATMENT Designed byGraphic Node Single incision (open) technique One or two incision (subcutaneous) technique Endoscopic Compartment release (Removal of a strip of fascia)
- 18. 5 SINGLE-INCISION FASCIOTOMY forAnt.&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
- 19. 5 DOUBLE MINI-INCISION FASCIOTOMYfor 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 GraphicNode 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 forCECS 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.
- 22. 5 Designed by GraphicNode 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
- 23. 5 Complications of Surgery Designedby Graphic Node Infection Nerve (SPN) most common or vascular injury Deep vein thrombosis Wound dehiscence Complex regional pain syndrome Scar hypersensitivity Seroma/hematoma formation
- 24. 5 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
- 25. 5 60% of legpain 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)
- 26. 5 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)
- 27. 5 Treatment Nonoperative treatment: First lineof 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
- 28. 5 Take Home Messages Designedby 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.
- 29. 5 Take Home Messages Designedby 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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