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Nonoperative Management of Chronic Exertional Compartment Syndrome

A Systematic Review

Rajasekaran, Sathish MD; Hall, Mederic M. MD

Current Sports Medicine Reports: May/June 2016 - Volume 15 - Issue 3 - p 191–198
doi: 10.1249/JSR.0000000000000261
Training, Prevention, and Rehabilitation: Section Articles
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Although nonoperative treatment options for chronic exertional compartment syndrome (CECS) are often used in clinical practice, supporting evidence is limited. The objective of this study was to systematically review the literature for nonsurgical treatment options for CECS of the lower leg. The literature search identified seven articles describing in total four different treatment options: massage, gait changes, chemodenervation, and ultrasound-guided (USG) fascial fenestration. Pertinent studies were in the form of case series and one case report, which limited the robustness of the data. Nevertheless, all four treatment options have little to no reported adverse effect profiles and can be considered in clinical practice. In addition, gait changes and USG fascial fenestration were found to have continued effect at 1 and 1.5 years, respectively.

Department of Orthopaedics and Rehabilitation, University of Iowa Sports Medicine, Iowa City, IA

Address for correspondence: Sathish Rajasekaran, MD, UI Sports Medicine, 2701 Prairie Meadow Drive, Iowa City, IA 52242; E-mail: Sathish.k.rajasekaran@gmail.com.

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Introduction

In athletes presenting with exertional leg pain (ELP), the incidence of chronic exertional compartment syndrome (CECS) has been reported to be up to 27%, and the mean age of presentation was between 26 and 28 years (18,23). Although thought of as a condition commonly affecting young athletes, Edmundsson and Toolanen (7) found that 90% of patients with diabetes presenting with nonvascular ELP had CECS, and the mean age of presentation was 48 years. Cases of CECS have been reported in the forearm, thigh, and foot, but the majority of the cases, approximately 95%, have been reported in the lower leg (2). Any of the four compartments (anterior, lateral, superficial posterior, or deep posterior) in the lower leg can be involved, with the anterior compartment most commonly affected. Several theories have been proposed to explain the pathophysiology of CECS, but the true cause of CECS and the process by which it develops has yet to be delineated (19). What is known is that with exertion, intracompartmental volume increases in association with increased intracompartmental pressure, and this process causes pain in the involved compartment.

Athletes with CECS often report worsening pain in any or all of the involved compartments after a specific amount (time, distance, or intensity) of exertion. In the lower legs, bilateral presentation has been reported in up to 82% of cases (4). Pain is often described as a fullness or cramplike sensation with or without associated paraesthesias and weakness in the peripheral nerve distribution of the affected compartment(s). Symptoms are described to worsen with exertion and cease immediately or shortly after cessation of activity. Over time, the patient may note a longer duration of time postexertion until symptoms completely subsided.

The examination is normal at rest in patients with CECS. Postexertion, the above noted sensory complaints may develop, with associated physical findings (numbness and weakness in the affected peripheral nerve distribution). In addition to this, passive stretching of the muscles in the involved compartment may be painful.

Although magnetic resonance imaging and functional imaging have been described in the diagnosis of CECS, needle manometry is the current standard of practice (19). This is so despite two recent systematic reviews noting a lack of standardization in exercise protocol and technique used to perform compartment pressure testing, and overlapping confidence intervals in the diagnostic criteria (modified Pedowitz criteria) (1,17,20).

Surgery is thought of as the definitive treatment for CECS. Surgical techniques include fasciotomies and fasciectomies, and both can be performed open or endoscopically (19). Although fasciectomies have a lower reported success rate, no direct comparisons against fasciotomy exist in the literature (19). Furthermore, success rates between open and endoscopic techniques have not been directly compared, but the latter has been found to lead to a quicker recovery (19). Despite the belief that surgery is the definitive treatment for CECS, the success rate is not 100% and can be associated with complications causing significant comorbidities (4,24). Success rates for anterior compartment CECS range from 81% to 100% at 5.2 years after surgery, with the former lower rate associated with concomitant lateral compartment release (16). The success rate for deep posterior compartment CECS is lower (30% to 65% at varying follow-up periods, 3 to 89 months), and the reason for this is unknown but may be due to the complex nature of the surgery and anatomical variability (i.e., fifth compartment) (25).

Conservative management has long been anecdotally referred to as an option for patients presenting with CECS, and these options include anti-inflammatory drugs, stretching, prolonged rest, decreasing or avoiding the problematic activity, orthoses, and massage (8,10,14,21,22). More recently, running technique modification and chemodenervation have been described as nonsurgical treatment options for CECS (6,11). Given the numerous options previously described in the literature based on anecdotal evidence, and newly described measures, it would be of benefit to systematically review the literature for nonsurgical treatment options for CECS, and to our knowledge, this has yet to be published. The aim of this study was to systematically review the literature for nonsurgical treatment options for CECS of the lower leg.

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Materials and Methods

Search Strategy

The search strategy and the systematic review protocol were performed in compliance with the PRISMA statement (15). The electronic databases of PubMed, SPORTDiscus, and Cochrane were searched up to July 31, 2015. The MeSH terms used were as follows: chronic exertional compartment syndrome OR anterior tibial compartment syndrome.

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Study Selection and Summary

One author (S.R.) assessed the title, abstract, and text from the combined electronic search database for eligibility (any original research or case reports pertaining to nonsurgical management of CECS of the lower leg). Each included study was subsequently reviewed, and the level of evidence of each article was ranked according to the scale published by the Journal of Bone and Joint Surgery (26). The studies were evaluated qualitatively for pertinent details and summarized in text and tabular format. General categories of nonsurgical treatment options were created based on the identified studies, and study details were reviewed under these categories in chronological order.

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Results

Search Results

Ten articles were assessed for eligibility, and subsequently, seven studies were included in the systematic review (Fig. 1).

Figure 1

Figure 1

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Summary of Studies

One randomized crossover study, one prospective case crossover study, four case series, and one case report were identified (3,5,6,9,11–13). Details of the seven studies are summarized in the Table (3,5,6,9,11–13). General categories for treatment options for CECS were formulated based on the identified studies and included (from least to most invasive) massage, gait changes, chemodenervation, and ultrasound-guided (USG) fascial fenestration (3,5,6,9,11–13).

Table

Table

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Massage

Blackman et al. (3) investigated the effect of a 5-wk course of massage treatment on patients presenting with anterior compartment CECS of the lower leg. Inclusion criteria included the following: age of 18 to 40 years, clinical symptoms suggestive of anterior compartment CECS and positive compartment pressure tests (3). Exclusion criteria included previous compartment release or massage therapy (3). Seven athletes were included in this case series (3). Compartment pressures were performed before study commencement using a repeated ankle dorsiflexion protocol (repeated until exhaustion or pain prevented further participation) and a slit catheter. All patients met the study diagnostic criteria, which were defined as a 3-min postexercise compartment pressure of greater than or equal to 35 mm Hg (3). This exercise regimen was completed on a Cybex 340 isokinetic dynamometer where the amount of work performed in joules (J) was calculated (3). Treatment over 5 wk consisted of two sessions in the first week and one per week thereafter. Each session included various massage techniques, including transverse gliding (friction massage), mobilizing digital ischemic pressure (blockage of blood in an area of the body deliberately made), and myofascial release and posterior compartment massage (3). The article did not detail what type of health care provider performed these techniques (3). A home stretching program (two times per day) also was prescribed, which included kneeling with plantarflexion, forward lunge with ankle in dorsiflexion and knee fully extended, and forward lunge with ankle in dorsiflexion and knee flexed (3). No pain-aggravating activity (running) was allowed over the 5-wk treatment period (3). Pain was assessed before and after the 5-wk treatment course using an ordinal scale (none, mild, moderate, and severe) at rest, at start of activity, during activity, and after activity (3). Posttreatment (5 wk), there was a significant difference (P = 0.026) in the postexercise pain rating. Before treatment, four subjects noted moderate pain and three noted severe pain. After treatment, three subjects had no pain, three had mild pain, and one had moderate pain (3). There was no significant difference in the 3-min postexercise compartment pressure (P = 0.156) (3). The total work performed increased from 318.71 to 930 J posttreatment and was significant (P = 0.016) (3). The authors concluded that massage led to significant increase in mean work-to-pain onset and decrease in postexercise pain in CECS patients (3). They went on to conclude that this was a result of massage causing an increase in compartmental volume via fascial stretching after massage or an increase in pain threshold via functional alterations to neural receptors in the fascia or intrinsic changes to the muscle (3).

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Gait Changes

Kirby and McDermott (13) were the first to investigate the effect of initial contact (heel vs forefoot) on anterior tibial compartment pressure in a prospective case crossover study. Their study included 17 legs of 14 young adults (10 men and 4 women), where all but one patient had clinical features suggestive of anterior leg compartment CECS (13). Compartment pressures were continuously measured using a solid-state transducer intracompartmental catheter (STIC). Two footswitches (heel and metatarsal break) were used to record transition from the rearfoot to the forefoot running pattern and analyzed in comparison with continuous pressure recordings (13). Subjects ran on a treadmill at a speed of 2.24 m·s−1, where for the first 2 min they ran without cuing, then 2 min with a rearfoot pattern, then 2 min without cuing, then 2 min with a forefoot pattern, and then 2 min without cuing (13). Their study found no significant difference in mean compartment pressure between forefoot and rearfoot running, but they did note that 12 of the 17 individual comparisons had a significant change in compartment pressure based on running style (13). However, they found significant variability in this change based on running style, where an increase, decrease, or no change in compartment pressure could be seen with all three styles (13).

Jerosch et al. (12) investigated the effect of a negative sole (heel rocker) on anterior tibial compartment pressure. Thirty-five healthy controls (30 men and 5 women) participated in the randomized crossover study (12). Participants were randomized to first run 20 min with a 0 ascent using either a conventional shoe or the heel rocker, and then switch shoes 2 wk later and run with the same protocol (12). Anterior compartment pressure was continuously monitored using a STIC catheter (12). The gait cycle was recorded by a high shutter-speed video camera and analyzed by single-frame analysis (12). Maximal pressure was significantly less (P < 0.001) with the heel rocker (36.5 ± 11.8 mm Hg) compared with the conventional sole (59.7 ± 9.1 mm Hg) (12). Mean pressure was significantly less (P < 0.001) with the heel rocker (29.8 ± 11 mm Hg) compared with the conventional sole (47.1 ± 9 mm Hg) (12). At heel strike, mean dorsiflexion was reduced by 8° with the rocker sole compared with the heel rocker (12). After initial contact, 6° of mean plantarflexion was seen with the rocker sole and 16° with the conventional sole (12). The mean duration of plantarflexion was 0.1 s with the rocker sole and 0.17 s with the conventional sole (12). The authors concluded that a heel rocker (negative sole) decreases anterior compartment pressure by decreasing the eccentric load of the tibialis anterior, and this may be a treatment option to promote gait changes in patients with CECS (12).

Diebal et al. (5) investigated the effect of implementing a systematic treatment model focused on forefoot running in two CECS patients. Two patients (one man and one woman) aged 21 years were involved in the case series, and the man had previously had a right anterior and lateral leg compartment fasciotomy (5). Their pretreatment pressures were both diagnostic of CECS according to the modified Pedowitz criteria, and they had to stop running secondary to pain at 0.8 km (female) and 1.56 km (male) (5,17). Treatments were provided 3 times a week for 6 wk (5). Treatment involved increasing cadence to 180 steps per minute, using hamstrings to initiate swing phase rather than gastrocnemius muscles (5). Therapy also included practicing weight shifting, falling forward, foot tapping, high hopping, and running with a specialized belt (EZ Run Belt, Posetech.com) (5). Both patients also practiced forefoot running barefoot and were cued to land on their forefoot by “running quietly” (5). Video feedback also was provided from running sessions, and the last 3 wk of therapy focused on improving running speed and endurance while maintaining proper form (5). Compartment pressures were determined 6 wk after treatment initiation (5). In addition, an instrumented treadmill was used to assess variables illustrating running technique (step length, step rate, vertical ground reaction force [GRF], and impulse) before treatment and 6 wk after treatment (5). Postintervention, both patients were able to run for 5 km without any pain symptoms (5). Statistical analysis was not performed, but there was a trend toward increased pressure at rest posttreatment and decreased pressure postexertion despite running for a longer distance (5). Kinematic measurements revealed a trend toward decreased step length, vertical GRF, and impulse and an increase in step rate (5). The authors concluded that altering their running mechanics to a forefoot striking pattern allowed them to obtain symptom relief, and of note, this was achieved in one patient who previously had a failed anterior and lateral compartment fasciotomy (5).

Diebal et al. (6) published a subsequent case series involving 10 subjects. Inclusion criteria for this study included clinical characteristics of CECS of the anterior and/or lateral compartment and being a military member (6). Exclusion criteria included previous fasciotomy, other medical comorbidities, creatinine supplementation, and nonsteroidal anti-inflammatory use (6). Preintervention measures included kinematic (step length, step rate, and support time) and kinetic (peak vertical GRF, impulse, and weight acceptance rate) measurements, compartment pressure (side-port needle), lower leg outcome survey, and the single assessment numeric evaluation (6). After resting anterior compartment pressures were determined, patients ran until they reported a pain level of 7 out of 10 (visual analog scale) or ran for 5 km (Borg rate of perceived exertion recorded), and postexertional compartment pressures were determined within 1 min of running cessation (6). Kinematic and kinetic measurements were taken with the same running protocol using an instrumented treadmill (Kistler Gaitway, Winterthur, Switzerland) within 2 d after the pressure measurements (6). The same intervention described in Diebal et al.’s first article on the topic was used in this study (5,6). At 6 wk postintervention initiation, anterior compartment pressures and kinetic and kinematic measurements were taken using the same methodology described before the intervention (6). At 6 wk postintervention, running distance significantly increased (P < 0.001) from 1.4 ± 0.6 to 4.8 ± 0.5 km, postexertional pain significantly decreased (P < 0.001) from 71.3 ± 7.9 to 2.7 ± 5.1 mm, and postexertional compartment pressure significantly decreased (P < 0.01) from 78.4 ± 32.0 to 38.4 ± 11.5 mm Hg (6). All kinematic and kinetic variables decreased postintervention except for step rate, which increased (6). At 1-year postintervention, performance on the annual army physical fitness test 2-mile run significantly improved (P < 0.01) (6). Authors concluded that a 6-wk gait retraining program had effects that lasted for at least 1 year postintervention and resulted in none of the patients having to undergo surgery (6).

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Chemodenervation

Isner-Horobeti et al. (11) retrospectively reviewed the effectiveness of botulinum toxin A (BoNT-A) on patients presenting with anterior or anterolateral compartment CECS. Pain was assessed as present or not present after running on a treadmill until development of symptoms and anterior and lateral compartment pressure measurements were taken with a slit catheter at 1 min (P1) and 5 min (P2) postexertion (11). Muscle strength was graded using the medical research council grading system pre- and postintervention (11). They identified 16 patients (10 bilateral and 6 unilateral) who underwent treatment (11). Treatment consisted of electrical stimulation-guided BoNT-A injections (11). A total of 500 U of BoNT-A (Dysport, Ipsen, Boulogne-Billancourt, France) was used, and three muscles in the anterior compartment (tibialis anterior, extensor digitorum longus, and extensor hallucis longus) were injected in patients with anterior compartment CECS, and in anterolateral compartment CECS, the two muscles in the lateral compartment were also injected (11). Posttreatment, pain subsided in less than 1 month in 10 patients, within 1 to 3 months in two patients, and within 3 to 5 months in three patients. The mean follow-up for compartment pressure testing was 4.4 ± 1.6 months after treatment, and in 14 patients, P1 decreased by 63% ± 17% (P < 0.00001) and P5 decreased by 59% ± 24% (P < 0.0001) (11). In one of the patients not included in the analysis, postintervention pressures increased, but they became asymptomatic (11). In the other patient, no change in pressure was seen, but the symptoms continued and the patient underwent successful fasciotomy (11). ELP was absent in 15 patients at follow-up (11). No weakness was found preintervention, and postintervention weakness was 4 or 4.5 (anterior or lateral leg compartment muscles) in 11 patients (11). The authors concluded that BoNT-A reduced intramuscular pressure in the compartments involved and eliminated the associated ELP (11).

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USG Fascial Fenestration

Finnoff and Rajasekaran (9) published a case report detailing the successful treatment of bilateral anterolateral compartment CECS with USG percutaneous needle fascial fenestration, with no adverse effects. The patient was an 18-year-old female college lacrosse player with a 2-year history of bilateral anterolateral ELP (9). Compartment pressure testing was diagnostic of CECS according to the modified Pedowitz criteria (9,17). The procedure was detailed in the case report and involved the use of a 2-inch needle for anesthesia administration, an 18-gauge 3.5-inch needle for fascial fenestration, and an ultrasound machine for needle guidance (9). At 18-month follow-up, the patient was symptom free and had no restriction with participation in lacrosse at the collegiate level (9).

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Discussion

Although nonoperative treatment options are frequently described in clinical review articles as an treatment option for CECS of the lower leg, the evidence for them as a whole has been unclear. This is the first article to systematically review the topic, and seven articles were found describing in total four different treatment options: massage, gait changes, chemodenervation, and USG fascial fenestration (3,5,6,9,11–13).

The one case series that investigated the effect of massage in CECS of the anterior compartment concluded it was effective in decreasing symptoms and increasing the amount of exertion (3). However, the article had a significant weakness outside of the inherent weaknesses of a case series (3). Patients were not allowed to participate in any exacerbating activity over the 5-wk treatment course, and this in itself (rest from exacerbating activity) may have led to decreases postexertional pain and increased amount of work completed (3). In addition, the exercise regimen (repeated dorsiflexion) may not be clinically applicable, because it may not reproduce symptoms in the same manner as their exacerbating activity (running) (3). Having said that, there are no apparent adverse effects from this treatment option, and it may be suggested as an adjunct treatment if relative rest is the nonoperative treatment option the patient wishes to pursue.

Gait modifications (forefoot running) were first described by Kirby and McDermott (13) in 1983. Their results suggested that compartment pressures decreased with forefoot running (individual comparisons), but mean pressures in all patients with forefoot and hindfoot initial contact were not significantly different (3). Of note, clinical symptoms were not assessed during their exercise regimen, and patients were not asked to run with each gait pattern until symptom provocation, but for a set amount of time (2 min) (3). Furthermore, forefoot running compartment pressures were not assessed until 6 min of running had been completed, and thus, pressures may have been elevated before beginning to run with a forefoot pattern (3). Nevertheless, this was the first article to describe gait modifications to treat patients with anterolateral compartment CECS and suggested it as a nonoperative treatment option (3). Subsequently, Jerosch et al.’s article described the effect of sole modifications (heel rocker) to decrease compartment pressure in control subjects in 1995 (12). The clinical applicability of these results was limited, given that CECS patients were not used in this case series (12). It seems that gait changes via shoe modifications or cuing did not receive further attention in the literature until Diebal et al.’s (5) first publication of two cases in 2011, almost 18 years after Kirby and McDermott’s publication. Diebal subsequently published a case series of 10 patients who participated in a 6-wk course of therapy, three times a week, focusing on changing their running technique to promote a forefoot running pattern, decreased stride length, and increased cadence (6). Their article suggested that forefoot running could provide long-lasting symptom relief in patients with anterior or anterolateral CECS (6). Although the authors noted increased performance in the annual military run, what effect an altered gait pattern would have in sports that involve cutting or jumping may need to be considered when counseling patients (6). Nevertheless, for the recreational athlete whose primary activity is running, this treatment offers a viable option for anterior or anterolateral CECS and could be implemented by any health care professional who has reviewed the study’s therapy protocol.

Isner-Horobeti et al.’s (11) case series provides a novel option for patients presenting with CECS. However, the lack of long-term follow-up does not clarify if BoNT-A provides a permanent or transient improvement in symptoms for patients with CECS, but it did note that most patients had complete resolution of symptoms within 5 months of treatment (11). Furthermore, its use in patients with anterior or anterolateral CECS should be considered after they have tried gait modifications. It may be considered as a first-line alternative to surgery in patients with superficial or deep posterior compartment CECS, although the clinician and patient should be aware that the study only investigated anterior and anterolateral compartment CECS. Furthermore, the report of decreased strength should be a cause for concern in offering this treatment to competitive athletes. Although the study detailed muscle localization with electrical stimulation, ultrasound could be considered because it may provide higher accuracy. If ultrasound is used, the procedure should only be performed by a sonologist with significant interventional experience.

Finnoff and Rajasekaran (9) described a novel alternative to surgery. However, one must be critical of the effectiveness of this technique until further studies, at least in the form of a case series, have been published. That being said, in a patient with anterior, anterolateral, or superficial posterior compartment CECS, this is a potentially low-risk alternative to surgery. It can be considered before surgery in patients failing gait modification therapy for anterior or anterolateral CECS, and those who also fail or decline chemodenervation. Caution should be used when performing this procedure, because potential complications such as peripheral nerve injury or Morel-Lavallée lesion can result in significant comorbidities (9). Thus, the procedure should only be performed by a sonologist with significant interventional experience.

This systematic review is noteworthy of several weaknesses. First, the identified studies and recommendations of this article are based primarily on case series data. Second, a formal bias assessment was not performed, but a high-quality tool is not available for case series studies. Third, one case report was included in this study but was done so given the novel nature of the treatment option and the low risk of recommending this in clinical practice. Despite these weaknesses, the identified treatment options offer a low-risk alternative to surgery for patients presenting with ELP and subsequently being diagnosed with CECS.

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Conclusion

This is the first systematic review to investigate nonoperative treatment options for CECS of the lower leg. Four treatment options were identified, and each of the seven identified articles were reviewed in this article along with critiques of each article (3,5,6,9,11–13). In addition, a treatment algorithm was suggested in the discussion and is summarized in Figure 2. Currently, limited evidence in the form of case series or case reports is only available for these treatment options. More robust, higher level studies are needed to better ascertain their clinical utility.

Figure 2

Figure 2

The authors declare no conflict of interest and do not have any financial disclosures.

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