Chronic exertional compartment syndrome (CECS) is defined as a transient increase in compartment pressures during physical activity, which causes pain, because of the inability of the fascial compartments to accommodate and is usually relieved by cessation of exercise (1). In theory, CECS can affect any muscular compartment; however, only 5% of cases affect the forearms, thighs, hands, and feet, while the remaining 95% occur in the leg (2). As such, CECS is one of the wide range of causes of exercise-related leg pain (ERLP), especially in athletes.
ERLP in the athletic population is a common complaint, with reports of up to 15% of all runners arriving to initial evaluation with this presentation (3). Often, this lower-extremity exertional pain is grouped into the common term of “shin splints” by athletes, which is a nondiagnostic term that implies no specific pathology. It may, however, encompass much of the differential for CECS, including medial tibial stress syndrome (MTSS), muscle strain, and stress fracture.
Chronic exertional compartment syndrome also is common among military recruits given the high stresses of basic training as well as the rapid increase in exertional requirements that occur at boot camp. One large retrospective review of all United States military recruits found that, out of a population of 8.3 million military members, an incidence of 0.49 per 1000 servicemen per year were diagnosed with CECS. Increased risk also was seen among lower ranked individuals, females, white race, and within the army branch of the armed forces (4).
Diagnosis of CECS can be difficult, given the wide range of pathologies that may cause lower-extremity pain. Early and accurate diagnosis is hindered by a lack of a clear diagnostic criteria for CECS. There is disagreement on the most appropriate tools to use for diagnosis as well as the most effective treatment strategies once a diagnosis is made. Some clinicians and researchers favor a surgical approach while others promote nonsurgical, conservative options. In this article, we describe the current practices for diagnosing and treating CECS, discuss relevant insights from recently published literature, and propose important considerations for managing CECS in the future. Given the condition's overwhelming prevalence in the lower extremity, what follows will be focused on CECS of the leg.
Clinical Presentation and Differential Diagnoses
Classic features of CECS include reproducible pain, often described as “cramping” or “burning,” that typically occurs at a predictable point after exercise initiation and is relieved by cessation of physical activity. It also includes pathologically elevated pressure in a muscular compartment during physical exercise, which returns to normal at rest. Chronic exertional compartment syndrome also can be associated with paresthesias. Although the exact cause of this syndrome is incompletely understood, pain and paresthesias are generally attributed to the muscle swelling during exercise that the fascial compartments cannot accommodate, thus hindering local tissue perfusion and resulting in ischemic pain (5).
It is generally accepted that there are four compartments of the lower leg (anterior, lateral, deep posterior, and superficial posterior). Included in the anterior compartment is the deep peroneal nerve, extensor digitorum longus, tibialis anterior, and extensor hallucis longus. Within the lateral compartment are the superficial peroneal nerve and peroneal muscles. The deep posterior compartment contains the tibialis posterior, flexor digitorum, flexor hallucis longus, and tibial nerve. Lastly, the superficial posterior compartment contains the gastrocnemius, soleus, and plantaris. Knowledge of the anatomic structures contained within each compartment can help explain clinical symptoms upon presentation. The anterior compartment is most frequently affected (42% to 60%), followed by the lateral (35% to 36%), deep posterior (19% to 32%), and superficial posterior (3% to 21%) compartments (2). Deep posterior (dp)-CECS may be reported less commonly partially due to difficulties associated with diagnosing it (n.b. a treatment delay of more than 3 years was reported in a prospective surgical dp-CECS trial) (6). It should be noted that some clinicians have speculated the tibialis posterior muscle to be contained within its own fascial compartment, effectively giving the lower leg five total compartments. Attached to this theory is the concept that this compartment also is susceptible to isolated elevations in compartment pressures, as described by Davey et al. (7). While the clinical relevance of this potential fifth compartment warrants further investigation, it should be considered in cases with an unclear clinical presentation.
Chronic ERLP presents a diagnostic dilemma because multiple diagnoses are possible, and failure to make early accurate diagnosis can lead to treatment failure and resistant, long-lasting problems. Before the diagnosis of CECS can be made, consideration must be given to other exertional-related leg pain pathologies that may present similarly including MTSS, stress fracture, nerve (sural or superficial peroneal) entrapment syndrome, and popliteal artery entrapment syndrome (PAES). It also is important for clinicians to understand that, in particular populations (e.g., military populations), CECS may exist concomitantly with MTSS, fascial hernias, or PAES in a single patient (8,9).
Other potential diagnoses include calf pain (myogenic), tumors, claudication, spinal stenosis, acute compartment syndrome, fascial hernia, and rarely fabella syndrome.
Assessment of Diagnostic Tools
A thorough history should always be incorporated in the diagnosis of pathology. A patient's reported history, particularly the characterization of their pain, may be unreliable for positively diagnosing CECS, but is critical for delineating between overlapping conditions and ruling out other rare and/or life-threatening conditions.
Helpful questions to guide obtaining a useful history include, but are not limited to, asking: do you experience pain with exertion? Upon impact? With motion? Is the pain focal or diffuse, unilateral, or bilateral? At what points during the day or night do you experience pain? Do you experience paresthesias or radicular or exertional pain? Do you experience swelling? Do you experience cramping or spasming?
Patients with CECS will most commonly complain of pain, tightness, weakness, cramping, and sensory loss in the affected extremity (10). Symptomatic individuals are typically pain-free at rest but will often describe a dull ache or burning sensation that comes on shortly after the onset of exercise. The pain slowly progresses over the course of constant exertion and does not resolve until cessation of physical activity, usually within 15 min (8). The reproducibility of pain symptoms is characteristic in CECS, because patients can often identify a relatively consistent time frame and exercise intensity during which they can expect symptoms to occur.
Physical examination, while often unremarkable at rest, is nevertheless essential to guide further diagnostic workup. Similar to the patient history, the physical examination is most helpful in ruling out other potential causes of pain. Medial leg pain that is tender to palpation may point toward MTSS or stress fractures. Again, it also is important to consider overlapping diagnoses, because periosteal swelling, which results from a stress fracture, may be the inciting event that causes a previously asymptomatic CECS to become symptomatic. During the physical examination, it is important to evaluate focal versus diffuse pain, test for Tinel's sign to detect irritated nerves, and check for decreased pulses, swelling, cramping, or spasming.
Given the absence of symptoms at rest, provocative testing is often necessary to adequately assess pathology. To appropriately diagnose CECS, it is of utmost importance to exercise the patient and attempt to reproduce the symptoms that they experience during exercise. The Running Leg Pain Profile (RLPP), initially developed by the Dutch armed forces, can be helpful to evaluate if symptoms are secondary to MTSS, CECS, or a combination of both. The RLPP is a standardized treadmill test during which the speed and incline are gradually increased. Patients perform the test in running shoes and are asked to give a pain score of 1 to 10 for six regions of their legs (Figure) (8).
If symptoms cannot be provoked by running or marching on a treadmill in a medical facility, it may be necessary to visit a sports facility with the athlete and perform diagnostic tests on site (see below). This is particularly relevant in cases of, for example, skating and skiing athletes.
Once clinical suspicion has been raised, the differential has been narrowed, and rare/life-threatening causes of lower-extremity pain have been excluded, further diagnostic workup of exertional compartment syndrome can begin.
Invasive diagnostic tools: Intramuscular compartment pressure measurement
History and physical examination are useful tools to raise suspicion of CECS, but even experienced clinicians find it difficult to exclude related causes of exertional-related leg pain. Intracompartmental pressure measurement after exercise has historically been the gold standard for diagnosis. However, the validity of intracompartmental pressure testing has been challenged. Based on a study with 900 intracompartmental pressure measurements, there was no significant relation between compartment pressures and pain symptoms, meaning some patients with high pain may have low pressures and patients with high pressures may experience minimal pain (11). Thus, looking toward the future, other diagnostic tools may need to be used.
To obtain an intracompartmental pressure measurement, a needle or catheter is inserted into the muscular compartment and pressure is measured. Critics of intracompartmental pressure measurements are concerned that the procedure is overly invasive and painful. However, advice to avoid or minimize intracompartmental pressure measurement is not warranted because a recent study concluded that the needle pain of a 300 ICPM is rated at about a 5/10 (11).
The usefulness of intracompartmental pressure measurement values depends on the reliability of the diagnostic criteria, which will be discussed below. The most appropriate cutoff values for diagnostic criteria have yet to be determined. When using a particular set of diagnostic criteria for diagnosis, the potential flaws of each should be considered.
Invasive diagnostic tools: Continuous intramuscular pressure monitoring
Nilsson et al. 2015 (12), noted that arterial pulsations cause oscillating changes in intramuscular compartment pressures (IMCPs), and that the amplitude of such oscillations are correlated with the absolute level of IMCP, making it a useful parameter in the identification of intracompartmental pathologies. Nilsson studied the use of continuous IMCP monitoring even further and determined that, 1 min after exercise, an absolute pressure recording of >50 mm Hg or amplitude of >5 mm Hg was 96% sensitive and 94% specific for confirming chronic anterior compartment syndrome (13). Therefore, in situations with borderline values and an unclear clinical picture, continuous pressure monitoring may be helpful to determine the mean amplitude of IMCP oscillations. This can provide additional objective data that can be used to support or object a diagnosis of CECS.
Diagnostic criteria of CECS
In 1990, Pedowitz et al. (14) proposed the following diagnostic criteria dependent on IMCP which are still commonly used today: 1) resting preexercise pressure ≥15 mm Hg, 2) 1-min postexercise pressure ≥30 mm Hg, or 3) 5-min postexercise pressure ≥20 mm Hg. There is currently an international debate regarding the reproducibility and the validity of the Pedowtiz diagnostic criteria. A recent review of the diagnostic criteria for CECS concluded that the Pedowitz criteria for CECS are flawed as the CECS and non-CECS groups were preselected by their differences in IMCPs (15). Furthermore, Franklyn-Miller et al. (16) suggest that the Pedowitz criteria are only applicable to the anterior compartment and thus are not useful for diagnosing lateral compartment or dp-CECS.
Recently, Roscoe et al. (17) proposed a dynamic IMCP exercise-based testing protocol using continuous IMCP measurements with significantly improved specificity (95%) but slightly reduced sensitivity (65%) compared with the Pedowitz criteria. Under these criteria, standing resting pressure is abnormal if greater than 35 mm Hg and continuous pressures are abnormal if greater than 105 mm Hg. This can be difficult, however, because of the necessity to continuously monitor the patient. In addition, the provocation test involved loaded marching, which may be relevant for the military population, but not so for nonrunning athletes. It is important to know that continuous dynamic IMCP measurements create a waveform with pressure intensity varying on which phase the athlete is in during a gait or running cycle. Indeed, supine or standing positions effect the pressure measurements. Nevertheless, an important conclusion of the study was that the greatest diagnostic validity was achieved during exercise. This directly undermines a fundamental characteristic of the Pedowitz criteria which relies on compartment pressures measured before and after exercise.
Today, even though the Pedowtiz criteria remain the most common criteria used by most clinicians, several different diagnostic criteria exist, making universal diagnosis of the poorly understood condition even more difficult. Encouragingly, other parts of a clinical assessment may clue a clinician into this diagnosis.
The Future of Diagnosing CECS
Noninvasive diagnostic tools: MRI and near-infrared spectroscopy
Measuring IMCPs is an invasive procedure and, therefore, carries a slight risk of bleeding and infection. Granted, these risks are minimal for the general population; however, in patients where this increased risk is particularly worrisome (i.e., smokers, immunocompromised, or patients with comorbidities such as diabetes or coagulopathies), or in scenarios where IMCP measurements are equivocal, additional diagnostic tools may be utilized. Postexercise MRIs and near-infrared spectroscopy (NIRS) may have use in the diagnosis of CECS and carry the added benefit of being noninvasive.
While the exact pathophysiology of CECS remains unclear, it is understood that symptoms of elevated compartment pressures are the result of increased interstitial fluid in muscles (18). MR images of set anatomical regions of interest may be taken before and after exercise, and a change in muscle fluid content can be observed as increased T2-weighted signal in affected muscle groups or compartments of patients with CECS (19). MR imaging also can detect and distinguish periosteal versus endosteal bone marrow edema as well, thus making it a useful tool to exclude other exertional-related leg pain pathologies, such as fascial defects, MTSS, stress fracture, or other structural lesions (20). These initial results suggest that MRI could be an important noninvasive diagnostic tool.
Additionally, NIRS has proven to be equal in sensitivity to IMCP values. Hemoglobin absorbs light differently based on the amount of oxygen it is carrying at a given moment, changing it from a dark to bright red as it becomes more oxygen-saturated (21). At least a portion of pain symptoms in CECS are due to impaired tissue perfusion, thus ischemia occurs during episodes of elevated compartment pressures, leading to increased levels of oxygen extraction from the blood. By measuring venous blood oxygen saturation, NIRS can be used to determine the degree of local tissue ischemia and potentially indicate abnormally elevated compartment pressures (5). Studies have shown that patients with complaints that fit the phenotype of CECS show a larger decrease in tissue oxygen saturation after exercise than healthy controls. Recently, with the expansion of wearable technologies, the availability of NIRS has grown.
Both of these testing modalities offer the added benefit of being noninvasive forms of diagnostic testing. While it is generally not recommended to avoid IMCP testing because of needle pain or the low risk of bleeding or infection, these other testing modalities can be considered for making diagnoses in unique cases. Of note, a shortcoming of NIRS is its inability to reach deep compartments of the extremity, limiting its negative predictive value.
Franklyn-Miller et al. have recently proposed a new school of thought to consider the biomechanical forces behind various causes of exertional leg pain, which leads to early muscle fatigue and cramp-like symptoms, as the pathophysiologic process leading to pain. Military personnel referred with anterior compartment pain consistently demonstrated prolonged ankle dorsiflexion and reduced heel lift during swing phase with excessive dorsiflexion at heel strike, reduced ankle plantarflexion at toe-off, and persistent ankle dorsiflexion and toe extension at midstance. Within minutes of initiating running, the patient develops an audible “slapping” of the foot at heel strike. These observations are consistent with repeated and prolonged inner range tibialis anterior contraction. Franklyn-Miller et al. proposed that, in patients with exertional leg pain related to the myofascial compartments, particularly the anterior compartment, we may simply be observing a phenomenon seen commonly in other patient groups, that of muscle overload. Because the etiology in these patients is biomechanical, we have described their condition as a “biomechanical overload syndrome” (BOS). This is in contrast to the rise of intracompartmental pressures directly leading to pain and reduced muscle function, an association for which there currently is no substantial evidence to support (16). Zimmermann et al. (11) proposed to use the term BOS for those patients with high anterior compartment pain, but low (“normal”) IMCPs. By viewing these conditions through the lens of a new diagnosis, a new target arises to address biomechanical deficiencies, which in theory should reduce the load on tissues and structures thought to be responsible for the pain experienced in these exertional lower-limb conditions.
Treatment options for CECS include surgical approaches, as well as a range of nonsurgical, “conservative” options. The efficacy of both surgical and nonsurgical treatment options is controversial and has been under significant debate. Historically, many clinicians have considered fasciotomy as first-line treatment, particularly for individuals hoping to quickly return to a high level of performance (9). However, this assumption is now being questioned because the long-term effects of fasciotomy are unknown, and research begins to demonstrate success with conservative treatments in some groups. The benefits and risks of both avenues of treatment will be discussed further below.
Current Treatment Options
Suboptimal conservative treatment options
Conservative management of CECS includes methods, such as rest, deep tissue massage, warming, stretching, and mobility exercises. Given the difficulty of standardizing these interventions, it is inherently difficult to obtain objective data on the quality of conservative treatment options. Nevertheless, critiques of conservative options suggest that they have largely been unsuccessful in allowing active patients to return to pain-free physical activity (10). A small study by Blackman et al. (22) found that in patients with CECS, all who were managed conservatively reported some clinical improvement, but continued to experience exercise-induced pain and pathologically elevated compartment pressures. Therefore, for many, success of conservative treatment options depends on permanent activity or duty restrictions, which is often an unappealing option to a high percentage of athletes and military personnel who are affected by the condition.
Botox® injections are one example of a treatment option that is controversial. While they seem to show promising results in its ability to decrease intramuscular pressure and eliminate exertional pain symptoms, they unfortunately also resulted in muscle weakness in a significant number (69%) of patients (23). While that may lead some clinicians to avoid this treatment option for their high-functioning patients, further research may prove Botox® injections to be particularly beneficial for patients whose lives are less dependent on their maximal muscle function.
Surgical treatment options
With these results in mind, physicians have found themselves turning to surgery as a first-line treatment method for patients hoping to return to a high level of physical activity. Fasciotomy has been shown to be an effective treatment of CECS, and new operative techniques are being developed to improve outcomes.
Fasciotomies have remained the mainstay of surgical treatment since it was first reported by Mavor in 1953 (24). The goal of surgery is release and decompression of any and all fascial compartments susceptible to abnormally high-pressure elevations. The technique, which initially consisted of a single large, open incision, later evolved to subcutaneous releases through smaller incisions. The procedure involves one or two small incisions that are essentially used as portals, through which other instruments can be used to divide the fascia proximally and distally (25). While less invasive than open fasciotomies, subcutaneous fascial releases still have their limitations and risks for complications. The semiblind nature of a subcutaneous approach allows for a significant chance of incomplete fascial release or nerve injuries (26). Additionally, as with any surgery, there remains a risk for stiffness, excessive scar tissue, and postsurgical cellulitis. More recently, endoscopic techniques have been developed and described. They allow for better visualization under direct magnification and also decrease the extent of surgical scarring (27). Despite the progression of surgical techniques used for treatment of compartment syndrome, the success of these various techniques depends on the type of CECS. For example, there is no consensus on the optimal surgical technique to resolve dp-CECS (28).
Classically, we have advised our patients that returning to sports would be possible in 8 wk to 12 wk following surgery. Schepsis et al. (29) describes a grading system which objectifies patient's impressions of the success of their surgeries and level of postoperative activities. Outcomes are graded from poor to fair, good, and excellent. Some studies report 80% to 90% good or excellent surgical outcomes, though this value is slightly lower for female athletes (30) and the military (8).
Surgery was — and for many physicians, still is — thought to be reliable and the gold standard treatment option. However, recent long-term outcomes have demonstrated surprisingly low success rates. Thein et al. (31) recently found that, just under 23% of patients who underwent surgical management of CECS were unable to return to their previous activity level. While this number is certainly better than the 75% of patients who failed conservative management, the large volume of patients receiving unsatisfactory results warrants further exploration.
It is possible that surgery poses long-term risks, complications, or limitations that were not previously considered. It also is possible that other factors that were not considered are turning out to affect outcomes more than previously suspected. For instance, suboptimal results are at least partially compartment-specific, with better outcomes reported in anterior as opposed to posterior CECS cases (29,32). Packer et al. (33) also noted that patients who underwent surgical release of anterior and lateral compartments had higher failure rates than isolated anterior releases (31% vs 0%, respectively). Additionally, high school and college patients had greater surgical satisfaction rates than postcollege patients (89% and 94% vs 66%, respectively). Apparently, there are many factors, known or unknown that affect results of surgery, which warrants more thoughtful consideration for who would benefit from such interventions.
The Future of Treating CECS
Promising conservative treatment options
There have been recent developments in nonsurgical approaches to CECS, and recent studies suggest that some conservative strategies may significantly improve patient outcomes while reducing the number of surgical procedures required to return patients with CECS to pain-free activity.
Within the military population, a study was performed to test the effectiveness of combining several conservative interventions to reduce symptoms of ant-CECS. The interventions included stretching, strengthening, massaging, dry-needling, and gait retraining. The study, which was the largest case series on the topic at the time (n = 75), found that 65% of patients were able to return to active duty. Furthermore, at the time of follow-up — which was the longest follow-up period to date (>2 years) — 57% of the patients remained on active duty. It must be noted that they were not necessarily pain free, but rather past the success criteria of return to active duty. These findings demonstrate the potential success of effective implementation of conservative treatment options and suggest that in many cases surgical intervention can be avoided with a conservative treatment plan (9). The study also strongly supports the concept of attempting a conservative approach prior to committing to definitive surgical release.
Some of the most promising conservative treatment options arise from the sports medicine approach which focuses on reducing provoking activities, reducing local pain and limitations in surrounding joints, improving risk factors (i.e., gait mechanics, type of exercise, and training intensity), progressively increasing weight-bearing exercise, and evaluating the goals of the patient.
Recently, a number of important studies have provided evidence that reducing risk factors is an effective and important strategy. Gait retraining is one example of a therapeutic intervention used to reduce risk factors of ERLP that shows great promise. The goal of gait training may differ slightly based on the particular cause of ERLP; for instance, in patients with MTSS, the primary goal is to reduce the ground reaction forces experienced with each step. In CECS, however, the primary goal is to reduce muscular activation in the symptomatic compartments (34). It has demonstrated the ability to alleviate pain symptoms in patients with CECS and has the added benefit of being relatively cheap and simple to implement. In fact, ground reactive forces experienced by the heel can decrease simply by providing three gait training cues: change to a ball-of-foot strike, increase cadence to 180 steps per minute, and stand up taller (34).
Gait retraining may combine several mechanisms to reduce pain symptoms experienced during periods of increased exertion. For instance, switching from a hindfoot strike to forefoot strike gait pattern has the effect of decreasing ground reaction forces as well as decreasing eccentric activity of the tibialis anterior (35). Diebal et al. (36) found that 6 wk of instruction geared toward forefoot strike running was able to significantly reduce intracompartmental pressures after running and negate the need for surgical intervention in patients diagnosed with CECS. It must be noted that gait retraining of running and marching is only relevant to patients that have symptoms during running sports. Changing gait mechanics may be less relevant for skaters, skiers, trampolinists, and so on.
Ultimately, treatment of CECS must always involve an in-depth discussion regarding goals of treatment as well as setting expectations for recovery. Surgery, while effective for many, may not be the best first-line option for all patients as often as previously suspected. Conservative management may best be instituted for specific populations as a collaborative process, involving sports medicine, physiatry, physical therapy, and so on, to ensure optimal patient outcomes and satisfaction. If or when such conservative approaches fail, then surgical intervention remains a viable option.
Exertional leg pain is a common complaint among athletes and military recruits. The common chief complaint carries several potential diagnoses that may be difficult to distinguish. CECS should be suspected in any patient who presents with complaints of burning exertional leg pain and tightness. Despite the condition originally being described more than 60 years ago, the pathophysiology remains only partially understood and specific diagnostic criteria have yet to be established and universally accepted. Therefore, clinicians should keep a high index of suspicion for CECS while still making sure to rule out other potential causes of ERLP during a diagnostic workup. The condition remains a challenge to diagnose, but recent years have seen developments in diagnostic tools, including standardized provocation test with detailed symptom description, NIRS, and MR imaging, which may provide more pieces of information to make a definitive diagnosis. Accurate diagnosis will allow targeted treatment and improve outcomes. Once the condition is properly identified, treatment options should be discussed with consideration given to the patient's presymptomatic, current, and target activity levels. While fasciotomy remains the gold standard treatment option for many physicians, recent literature suggests that the results may not be as successful as previously thought. Conversely, conservative management options, particularly gait retraining, is showing encouraging results as a nonsurgical treatment option that may return patients to pain-free physical activity. At the present moment, it seems likely that some patients may be able to delay or completely avoid the need for surgery by using conservative management options. A collaborative approach between conservative and surgical approaches appears to be the wise next step. Future research on the subject, specifically randomized control trials with three treatment arms (conservative only, surgery only, and a combination of surgery plus gait retraining), would provide valuable information to aid in the advancement of treatment options. As more research is conducted, the long-term results of surgery versus newer conservative methods will become increasingly clear.
The authors declare no conflict of interest and do not have any financial disclosures.
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