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Chronic Exertional Compartment Syndrome

Fraipont, Michael J. MD; Adamson, Gregory J. MD

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Journal of the American Academy of Orthopaedic Surgeons: July 2003 - Volume 11 - Issue 4 - p 268-276
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Abstract

Compartment syndrome is defined as increased pressure within a closed fibro-osseous space, causing reduced blood flow and tissue perfusion in that space, leading to ischemic pain and possible damage to the tissues of the compartment. Compartment syndrome may be either chronic or acute. Chronic compartment syndrome is often recurrent and is associated with repetitive exertion. It is typically seen in athletes whose exercise level elevates the intramuscular pressure to a point that the tissues within the affected compartment become tight and painful, thus preventing further activity. The pain disappears quickly after rest, and there are usually no permanent sequelae in the affected tissue. In 1962, French and Price1 documented elevated compartment pressures as the cause of chronic exertional compartment syndrome (CECS) of the tibia. Previously, in 1956, Mavor2 had successfully treated a CECS by widening the fascia of the anterior compartment of the tibia. The anterior and lateral compartments of the leg are most commonly involved in CECS, but it has been described in all compartments of the leg, shoulder, upper arm, forearm, hand, gluteus, thigh, and foot.

In contradistinction, acute compartment syndromes, whether induced by trauma or repeated exertion, are commonly progressive and require urgent attention to avoid irreversible damage to the tissues of the affected compartment. Patients with acute compartment syndrome present with severe pain that is exacerbated by passive stretch of the muscles and does not resolve spontaneously with rest. Development of paresthesia and pallor can be followed by the loss of pulse in the distal extremity. The typical presentation of an acute compartment syndrome most often occurs after a high-energy trauma with or without fracture or reperfusion of an ischemic limb. In an exercise-induced acute compartment syndrome, symptoms may not develop until 24 to 48 hours after the precipitating event. The syndrome has been reported in the hand, forearm, leg, thigh, gluteus, and foot. In the rare untreated case, an acute compartment syndrome may result in myonecrosis, causing release of myoglobin into the vascular circulation, which can lead to renal failure. Treatment of myonecrosis consists of prompt hydration, restoration of fluid deficits, and concomitant diuresis (maintained at 100 to 200 mL/h).3

Anatomy

The three areas most commonly affected by CECS are the lower leg, thigh, and forearm. The lower leg consists of four compartments: anterior, lateral, superficial posterior, and deep posterior (Fig. 1). Each compartment contains one major nerve, and two compartments (anterior and deep posterior) house major blood vessels, which may be affected by CECS. The anterior compartment contains the anterior tibial artery and the deep peroneal nerve. The lateral compartment contains the superficial peroneal nerve. The superficial posterior compartment contains the sural nerve. The deep posterior compartment contains the posterior tibial nerve and both the posterior tibial and peroneal arteries and veins.

Figure 1
Figure 1:
Cross section of the lower left leg.

The thigh consists of three compartments that can be affected by CECS: anterior, medial, and posterior (Fig. 2). The anterior compartment contains the femoral nerve. The medial compartment contains the obturator nerve and both the femoral and femoral profundus arteries. The posterior compartment contains the sciatic nerve.

Figure 2
Figure 2:
Cross section of the left thigh, 10 to 15 cm inferior to the inguinal ligament. Note the intermuscular fascial septa.

The forearm consists of three compartments: volar (superficial and deep) and dorsal, and the mobile wad (Fig. 3). The volar compartment consists of the six muscles responsible for flexion, pronation, and supination: flexor carpi radialis, flexor pollicis longus, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris, and flexor digitorum profundus. This compartment also contains the median and ulnar nerves along with the radial, ulnar, and anterior interosseous arteries. The dorsal compartment contains the extensor pollicis brevis, extensor digitorum communis, and extensor carpi ulnaris muscles, as well as the posterior interosseous nerve and artery and perforators off the anterior interosseous artery. The mobile wad consists of three muscles: the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis.

Figure 3
Figure 3:
Cross section of the middle of the left forearm distal to the level of the pronator teres insertion.

Pathophysiology

During strenuous exercise, muscle fibers can swell to up to 20 times their resting size, leading to a 20% increase in the muscle volume and weight.4 Increased perfusing blood volume, muscle hypertrophy, and interstitial fluid volume within a nonexpanding compartment increase pressure in accordance with Laplace's law (a capillary membrane subjected to internal and external pressure reaches an equilibrium based on those forces). The blood flow through muscles is chiefly regulated by the resistance of the arteriole, which depends on the tension in the vascular wall. The increase in intramuscular pressure causes a decrease in arteriolar blood flow. Even though the circulation may not be totally arrested, venous return is markedly reduced and some capillaries may become occluded.

When the blood flow is insufficient to meet the requirements of the muscle, the patient experiences pain with continued activity. The symptoms of CECS, which result from this ischemia, are caused by inadequate tissue oxygenation from the decreased venous return and insufficient perfusion of muscle tissue. Because muscles have blood flow only during the relaxation phase of exercise, increased intracompartmental pressures during the relaxation phase are thought to have the greatest effect on muscle ischemia. The most critical intracompartmental pressures are those present when the muscle is not in a contractile state. During this phase, the balance between intramuscular compartment pressure and the microvascular pressure determines the adequacy of perfusion and, hence, the oxygenation of the muscle. These values are best reflected by measuring postexercise pressure. The patient will continue to experience pain in the affected extremity after exercise until the total intramuscular pressure decreases to a level at which the blood flow can again meet the muscle's requirements.

Of patients with CECS involving the legs, 39% to 46% have fascial defects over the anterolateral lower leg compared with asymptomatic individuals, who have <5% incidence.4,5 These fascial hernias or defects are usually 1 to 2 cm2 in size and occur near the intermuscular septum between the anterior and lateral compartments, often at the exit of the superficial peroneal nerve. The fascial hernia is approximately at the junction of the middle and distal thirds of the leg. The superficial peroneal nerve can be compressed by either the edge of the fascial defect itself or the muscle bulging through the defect. At rest, no palpable abnormality may be apparent, but with exercise, local tenderness and swelling may occur. Occasionally Tinel's sign may be found at the site of the hernia.

It is not clear why patients with CECS have increased total intramuscular pressure at rest and higher than normal intramuscular pressure with exercise compared with normal individuals. It is unlikely that a limited osseofascial expansion can be the sole explanation of this increase because, after fasciotomy, the total intramuscular pressure at rest usually remains higher than that in normal individuals. In addition, while fascial hernias are a contributing anatomic finding, fascial hernias are not present in all patients with CECS. Arteriole regulation also may be a factor; however, it is likely that a combination of anatomic limitations contributes to the presence and severity of CECS.6

Evaluation

History

During physical exertion, a patient with CECS often notices pain that initially begins as a dull ache. If it is ignored and the patient continues to train, the pain increases to the point that the activity must be stopped. The onset and degree of the pain often become both predictable and reproducible because the pain begins at about the same time during the exercise activity. The pain typically is well localized to the entire affected compartment.

Patients experience a feeling of fullness or a cramplike sensation in the affected compartment when they attempt to exercise. They also may complain of transient numbness, tingling, or weakness in the motor and sensory distributions of nerves within the involved compartments. In some cases, patients may have had a recent increase in training time or intensity that now takes them over their threshold level for generating symptoms. Rest usually relieves the pain, but it takes some time for complete relief to occur, especially as the CECS becomes more severe. Patients typically will not have persistent pain the following day unless they exercise again. Generally, they have no history of trauma, and if they return to their sport after discontinuing it for some time, the symptoms typically recur. Most patients present with bilateral symptoms.7

Patients with CECS of the forearm complain of a feeling of firmness or cramping associated with weakness in the hands and wrists during vigorous athletic or repetitive grasping activities. In addition, they may experience numbness and tingling. These symptoms can manifest in the thenar, interosseous, or hypothenar regions as well as in the forearm. Symptoms resolve quickly when the activity is discontinued but recur with resumption of the activity.

Physical Examination

Results of the physical examination of the lower extremity at rest are usually normal. However, Rowdon et al8 showed that athletes with CECS demonstrated a contradictory electromyographic finding: decreased postexercise potentiation of the peroneal motor amplitude and mild impairment in vibratory sensation. Direct inspection and circumference measurements are typically normal; however, muscle atrophy may be found if the condition is unilateral. Results of physical examination of the extremity after it has been provoked by exercise may reveal tenderness and increased tension in the involved compartment. In addition, there may be an associated decreased sensation or tingling in the distal region.

In the upper extremity, results of physical examination usually reveal neither signs of nerve entrapment (eg, a Tinel sign at the wrist or elbow) nor abnormal two-point discrimination. Results of the neurodiagnostic evaluation, including nerve-conduction studies and electromyographs of the ulnar and median nerves, also should be normal, although Kutz et al9 reported slowed median nerve conduction in one case. While muscle tenderness may be noted, symmetrically functioning muscles in the hands and forearms are usually found.

Differential Diagnosis

A number of different conditions may overlap with the diagnosis of CECS (Table 1). When the patient history, physical examination results, and pressure measurements are not diagnostic for CECS, consideration should be given to further imaging, neurophysiologic testing, and/or laboratory studies.

Table 1
Table 1:
Differential Diagnosis for Chronic Exertional Compartment Syndrome

Testing

Equipment and Criteria

Patients with CECS demonstrate increased intracompartmental pressures in the affected extremity at rest and during and after exercise. Measuring intracompartmental pressures during exercise is difficult and impractical; resting and postexercise measurements have been shown to be the best method of confirming the diagnosis of CECS.4,5,10-12 The type of exercise used during measurement taking can vary, but it must be sufficiently provocative to induce symptoms. The following different compartment measurement methods show equal effectiveness, assuming correct use: slit catheter,13 microtip pressure method,14 wick catheter,15 microcapillary infusion,5 and needle manometer.16

Many authors use the criteria of Pedowitz et al10 to evaluate patients. These criteria are appropriate for evaluation of both the upper and lower extremities: a resting pressure measurement ≥15 mm Hg, and/or a measurement taken 1 minute after exercise ≥30 mm Hg, and/or a measurement taken 5 minutes after exercise ≥20 mm Hg. The criteria of Whitesides and Heckman17 for acute compartment syndrome have been applied to CECS. Compartment ischemia is considered to occur when a compartment pressure increases to 20 mm Hg below the diastolic pressure.

Measurement Limitations

Factors that can affect the accuracy of pressure measurements include proper use of the equipment, correct anatomic placement of the catheter tip, depth of needle insertion, position of the extremity during pressure measurement, and the contractile force of the muscle. This process can be especially difficult to control and interpret in the clinical setting. Therefore, care must be taken to place the limb in a relaxed and consistent position for accurate, reproducible measurements.

Although the measurement of intracompartmental pressures of the anterior compartment of the leg is relatively simple, the same cannot be said for the deep posterior compartment or for the so-called fifth compartment, the tibialis posterior muscle. When measuring deep posterior compartment and tibialis posterior muscle pressures, the exact location of the tip of the catheter may vary. Schepsis et al18 described a method of placing the catheter medially, parallel to the posterior surface of the tibia at the junction of the middle and distal thirds of the leg, into the flexor digitorum longus muscle. Wiley et al19 proposed using ultrasound as a guide for catheter placement into the deep posterior compartment. Mollica and Duyshart20 advocated placing intracompartmental pressure measurement apparatus in the medial foot compartment. Upper extremity catheter placement is determined by the affected compartment.21,22

Other Testing Modalities

Alternative methods of testing for elevated compartment pressures are being considered, especially because of the difficulty in measuring the deep compartment pressures. Mohler et al23 found that patients with CECS of the anterior compartment had greater deoxygenation of the muscle during exercise and delayed reoxygenation of the muscle after exercise compared with patients who did not have CECS, as measured by infrared spectroscopy. A more promising and practical measurement of elevated pressure is by magnetic resonance imaging, which can be used in diagnosing CECS.24 The affected compartment shows an increase in T2-weighted signal intensity during exercise. Although the assistance of an experienced radiologist in reviewing these subtle findings can be helpful, the intracompartmental signal intensity can be normalized with the signal intensity from surrounding tissue not affected by CECS.24 Bone scan technology using thallium Tl 201 single-photon emission computed tomography (SPECT) has been shown to localize an ischemic compartment.25

Management

CECS occurs when athletes perform an activity above their threshold level. Therefore, nonsurgical treatment of CECS can be successful only when the patient gives up the activity or the activity level that causes the symptoms. However, it is not unreasonable to offer a treatment plan that includes stopping the activities that provoke the symptoms while introducing a different program of appropriate conditioning. Nevertheless, because most patients with CECS who seek medical attention are unwilling to modify their exercise programs, subcutaneous fasciotomy of the involved compartment should be considered. It is the mainstay of treatment and is successful in relieving pain and allowing a return to full activities.12,26

Endoscopically assisted, twoincision fasciotomy is an alternative technique purported to be as safe and effective as single-incision fasciotomy.27 The advantages of endoscopic release in the lower extremity are access to the entire length of the compartment and visualization of the superficial peroneal nerve and its branches.27

Surgical Techniques

Anterior and Lateral Leg Compartment Fasciotomy

Surgical release of the anterior and lateral compartments is done through a 10-cm longitudinal incision over the anterolateral aspect of the leg in its midportion between the tibial crest and the fibula (Fig. 4, A). After identification of the anterior intermuscular septum between the anterior and lateral compartments (Fig. 4, B and C), the fascia is divided proximally and distally in both compartments under direct visualization (Fig. 4, D). Care must be taken to identify the superficial peroneal nerve before release. Fasciotomy should include inspection for and release of any fascial hernias.

Figure 4
Figure 4:
The single-incision or perifibular approach allows access to all four compartments through a lateral incision. A, The skin incision is made in line with and directly over the fibula. B, Release of the lateral compartment (2) can be done directly after identification of the intermuscular septum. Care must be taken to preserve the superficial peroneal nerve, and the fasciotomy is done 1 cm posterior to the intermuscular septum. C, If the anterior compartment (1) needs to be released, the skin is retracted anteriorly and the fasciotomy is done 1 cm anterior to the intermuscular septum. D, For the fasciotomy of the superficial posterior compartment (3), the skin is retracted posteriorly for exposure. E, For fasciotomy of the deep posterior compartment (4), the lateral and superficial posterior compartments are retracted and the compartment is reached by following the interosseous membrane from the posterior aspect of the fibula. (Adapted with permission from Rorabeck CH: A practical approach to compartment syndromes: III. Management. Instr Course Lect 1983;32:102-113.)

Superficial and Deep Posterior Leg Compartment Fasciotomy

The superficial posterior, deep posterior, and tibialis posterior muscle compartments can be released through either an extended dissection from the lateral approach (Fig. 4, D and E) or more easily through a separate 10-cm medial incision (Fig. 5). Once the muscular fascia is identified, the superficial posterior compartment can be released directly because it lies more posterior to the other compartments (Fig. 5, B). To reach the deep posterior compartment, it is necessary to undermine anteriorly to reach the posterior tibial margin, thereby avoiding the saphenous vein and nerve as well as reaching the soleus muscle. The soleus originates from the entire proximal upper half of the tibia and fibula, creating a soleus bridge under which the deep posterior compartment resides. The proximal soleus attachment to the tibia and fibula must be completely detached to visualize the deep posterior compartment. In addition to performing a fasciotomy of the deep posterior compartment, it is recommended that a specific fasciotomy of the tibialis posterior muscle compartment be done, as well.11,12

Figure 5
Figure 5:
Either or both incisions from the two-incision fasciotomy technique can be utilized depending on the number and location of affected compartments. A, Position of two incisions (dotted line = posteromedial incision). B, Cross section of lower leg showing the relationship of the two incisions to the four compartments. 1 = anterior compartment, 2 = lateral compartment, 3 = superficial posterior compartment, 4 = deep posterior compartment. C, The anterior intermuscular septum. D, The fascia is divided to separate the anterior and lateral compartments. The superficial peroneal nerve will be visualized. (Adapted with permission from Rorabeck CH: A practical approach to compartment syndromes: III. Management. Instr Course Lect 1983;32:102-113.)

Release of the deep posterior compartment of the leg has not been as successful as that of the superficial posterior compartment. The reasons for this are not clear. Published explanations11,12,18 for these reported failures include the fact that the patients did not have CECS; the fasciotomy was incomplete, specifically not identifying and releasing the posterior tibialis muscle within the deep compartment; and dense scar tissue had formed after surgery.

Thigh Compartment Fasciotomy

Tarlow et al28 described a twoincision fasciotomy release in which the lateral incision is through the fascia lata and the iliotibial band (Fig. 6, A). Both the anterior and posterior compartments can be addressed by releasing the lateral intermuscular septum (Fig. 6, B). After identification of the lateral intermuscular septum between the lateral and posterior compartments, the fascia is divided proximally and distally in both compartments under direct visualization. Care must be taken to identify and palpate the sciatic nerve. A separate medial incision is required to address the vastus medialis and the adductor muscles. After identification of the medial intermuscular septum between the anterior and posterior compartments, the fascia is divided proximally and distally in both compartments under direct visualization. Care must be taken to identify and palpate the femoral artery and nerve.

Figure 6
Figure 6:
Thigh compartment fasciotomy. A, Lateral incision site. B, Cross section of thigh showing opening of the anterior compartment and release of the posterior compartment through the lateral intermuscular septum. C, Lateral view of the thigh showing the two-incision fasciotomy release technique. (Panels A and B adapted with permission from Tarlow SD, Achterman CA, Hayhurst J, Ovadia DN: Acute compartment syndrome in the thigh complicating fracture of the femur: A report of three cases. J Bone Joint Surg Am 1986;68:1439-1443. Panel C adapted with permission from Azar FM, Pickering RM: Traumatic disorders, in Canale ST [ed]: Campbell's Operative Orthopaedics, ed 9. St. Louis, MO: Mosby, 1998, vol 2, p 1408.)

Forearm Compartment Fasciotomy

In a superficial volar forearm compartment fasciotomy, the incision begins just above the elbow over the medial antecubital fossa through the entire length of the volar forearm in a curvilinear fashion to the wrist. It is important to release the lacertus fibrosus at the elbow and the carpal tunnel at the wrist to decompress the median nerve. The mobile wad compartment also may be released through this incision and can be addressed as needed.29 In a dorsal compartment fasciotomy, a dorsal incision is made in a line with the lateral aspect of the forearm connecting the lateral epicondyle to the distal radioulnar joint.

Postoperative Care

Ice and elevation of the extremity are used for 3 to 5 days after surgery to help limit pain and excessive swelling. Active range-of-motion exercises should be instituted immediately after surgery. Crutches or an upperextremity sling may be used as necessary for the first few postoperative days, but patients should be encouraged to walk and perform light activities without assistance. Weight bearing as tolerated may be begun directly after fasciotomies of the lower extremity. Full activities may begin as soon as tolerated, usually 3 to 4 weeks after surgery.

Results

The results of compartment releases indicate that most patients surgically treated for CECS in the leg experience a high level of pain relief and are satisfied with the results of surgery. Reports of improvement range from 81% to 100%.4,11,12,18,26,30-32 However, authors who differentiate the results of anterior versus deep posterior compartment releases report notably different outcomes for the deep posterior compartment releases. Success of deep posterior compartment release of the lower extremity ranges from 50% to 65%.11,12,32 CECS in the deep posterior compartment is multifactorial, and a fasciotomy may not fully alleviate the cause of the pain.11,12,18 Therefore, these outcomes underscore the need to perform compartment pressure measurements before compartment releases are done so that the correct compartment or compartments can be identified and adequate expectations can be relayed to the patient.

Generally, patients have noted a high level of pain relief and satisfaction with the results of fasciotomy. In their report on the subjective percentage of pain relief experienced by patients, Howard et al32 stated that relief may come in increments of improvement from the preoperative level and is dependent on the individual. Patients can expect to return to light activity by 2 to 4 weeks and to full activity by 4 to 6 weeks.

Complications

Complications of surgery for CECS include hemorrhage, wound infection, nerve entrapment, swelling, artery injury, hematoma/seroma, lymphocele, peripheral cutaneous nerve injury, and deep vein thrombosis. Incidence ranges from 4.5% to 13%.4,11,12,19,31 In addition to postoperative complications, recurrence of symptoms has been reported in 7% to 17% of patients after surgical compartment release.11,12,18

Summary

Recurrent CECS is diagnosed with accuracy when there is a history of reproducible exertional pain associated with increased compartment pressure measurements at rest and/ or after exercise. In patients with recurrent CECS, fasciotomy is advisable to allow a return to all activities. At surgery, particular attention should be paid to the careful release of fascial defects anteriorly and laterally in the leg and posteriorly in the posterior tibialis muscle. As well, when releasing compartments, whether in the foot, leg, thigh, or forearm, care must be taken to avoid injuring the surrounding neurovascular structures.

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