Chronic Exertional Compartment Syndrome of The Lower Leg

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Chronic Exertional Compartment Syndrome of The
Lower Leg

• MAJ Christopher G. Jarvis MD, FAAFP
• Senior Sports Medicine Fellow
• Primary Care Sports Medicine Fellowship
• Uniformed Services University of the Health
  Sciences

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Outline

• Overview
• Epidemiology
• Anatomy
• Pathophysiology
• Risk factors
• Clinical presentation

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Outline

• Differential diagnosis
• Diagnostic tests
• Treatment
• Return to play
• Take home messages throughout

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Definition

• Chronic clinical syndrome of predictably
  increasing symptoms, pain predominant, of the
  lower legs likely due to increasing pressures and
  relieved with rest

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History

• Mavor first described entity in 1956.
• Recurrent exertional leg pain
• Reneman desribed the condition in 1975 and
  related it to increased compartmental pressures

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Introduction

• Well-recognized cause of leg pain
• Most common in runners
• Pain!

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Epidemiology

• Young adult recreational and elite runners equal
• Percentage of all runners affected is uncertain
• Men bit more
• Usually under age 40

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Epidemiology

• Anterior and lateral compartments are most
  commonly affected
• Deep posterior compartment difficult to treat

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Anatomy

• 4-5 muscular compartments
• Anterior
• Lateral
• Superficial posterior
• Deep posterior
• 1-2 subcompartments
• Fascial defects

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Anatomy
5th compartment FDL Fibular Origin
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Anterior Compartment

• Muscles
• Tibialis anterior
• Extensor digitorum longus
• Extensor Hallucis longus
• Peroneus tertious
• Major nerve
• Deep peroneal
• Major vessels
• Ant. Tibial art./vein

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Lateral Compartment

• Muscles
• Peroneus longus and brevis
• Major nerve
• Sup. Peroneal
• Major vessels
• Branch off anterior tibial artery/vein

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Deep Posterior

• Muscles
• Flexor digitorum longus
• Flexor hallucis longus
• Popliteus
• Tibialis posterior
• Major Nerve
• Tibial
• Major vessels
• Post Tibial art./vein

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Superficial Posterior

• Muscles
• Gastrocnemius
• Soleus
• Plantaris
• Major nerve
• Sural
• Major vessels
• Branch off tibial artery/vein

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Pathophysiology

• Normal exercise
• Muscle volume increases by 20
• Intramuscular pressures exceed 500 mm Hg with
  contractions
• Perfusion during relaxation phase

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Gershuni et al., 1982

• Ultrasound study
• Muscles enlarge normally with exercise
• Non-compliant fascia prevents expansion
• Pressures build when gt 30 mm Hg arterial-venous
  perfusion gradient is lost
• Symptoms develop, but then dissipate with rest
  and resolution of pressures

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Pedowitz et al., 1990

• Thallium-201 SPECT scanning
• Decreased distribution in post exercise
  symptomatic muscles
• Suggests lack of perfusion with CECS
• (More recent studies are conflicting)

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Fugl-Meyer, 1981 Schepsis et al., 1999

• CECS of the anterior compartment due to secondary
  occlusion of large vessels in areas of local
  muscle herniation as they cross the interosseous
  membrane

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Hurschler et al.,1994

• Fascial biopsies
• 25 of 26 patients had abnormally thickened,
  non-compliant fascia

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Garcia-Mata et al., 2001

• 10-60 percent of symptomatic athletes had small
  fascial defects/hernias

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Why Pain?

• ?High pressure with ischemia?
• Stimulation of pain fibers in the fascia and/or
  periosteum
• Degree of pressure elevation does not correlate
  with the degree of pain
• Still unclear

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Summary of Pathophysiology

• Probably multifactorial
• Thickened, inelastic fascia
• Possible small muscle herniations
• Muscle hypertrophy
• (normal vs. other)
• -Still debatable

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Risk Factors

• Use of creatine supplementation
• Use of androgenic steroids
• Eccentric exercise in postpubertal athletes
  decreases fascial compliance?

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Clinical Presentation

• History
• One or several compartments
• gt85 bilateral
• Fairly predictable and reproducible

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Historical Case

• 45 year old male runner
• Runs 20-30 miles per week
• Recent increase in speed work
• Pain in legs and foot slap after 10 minutes of
  8 minute miles
• No symptoms at 9 minute miles

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Clinical Presentation

• Physical
• Often normal
• Tight, tender compartments when symptomatic
• Passive stretch increases the pain!

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Clinical Presentation With Exertion (anterior
compartment)

• Pain along anterior leg/foot
• Ankle dorsiflexion weakness/foot drop
• Big toe extension weakness
• Numbness first dorsal web space
• Diminished dorsalis pedis pulse when symptomatic

Common peroneal nerve and its terminal
branches.1. Common peroneal nerve2. Superficial
peroneal nerve3. Deep peroneal nerve.
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Clinical Presentation With Exertion (lateral
compartment)

• Pain along lateral aspect of lower leg
• Numbness along lateral leg and dorsum of foot
• Weakness with attempted ankle eversion

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Clinical Presentation With Exertion (deep
posterior compartment)

• Deep aching pain, like classic claudication
• Numbness or paresthesias of
• foot arch
• Late diminished post. tibial pulse
• Weakness of foot plantar flexors

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Clinical Presentation With Exertion (superficial
posterior compartment)

• Deep aching pain
• Numbness or paresthesias in the lateral foot
• Weakness of ankle plantar flexors

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Differential Diagnosis of Exertional Lower Leg
Pain

• Stress fracture
• Medial tibial periostalgia (Stress Syndrome)
• CECS
• Peroneal nerve entrapment
• Atherosclerotic claudication
• Deep venous thrombosis

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Differential Diagnosis of Exertional Lower Leg
Pain

• Dynamic popliteal artery entrapment
• Tenosynovitis
• Aneursym
• Arterial occlusion
• Neurogenic claudication

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Differential Diagnosis of Exertional Lower Leg
Pain

• Metabolic myopathy
• Metabolic bone disease
• Muscle or bone neoplasm
• Osteomyelitis
• Effort-induced thrombosis

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Diagnostic Tests

• Plain x-rays
• Intracompartmental pressure testing at rest and
  when symptomatic Gold standard
• Implantable pressure sensors

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Compartment Pressure Checks

• Careful patient selection
• Informed consent
• Sterile prep
• Supine position
• Resting pressures
• Symptomatic pressures sport specific
• Be sure to zero

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Diagnostic Pressures(Touliopolous and Hershman,
1999.)

• Resting pressure gt 15 mm Hg
• 1 minute post exercise gt 30 mm Hg
• 5 minute post exercise gt 20 mm Hg
• Baseline pressure does not return for gt 15
  minutes. (suspicious)
• (Garcia-Mata et al., 2001)

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MRI

• Evolving and promising tool
• Detects fascial thickening, fatty infiltration,
  decreased T1 signal with fibrosis, and muscle
  atrophy
• Sensitive and reliable but not specific, and
  expensive

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MRI

• Lauder et al., 2002.
• Increase in T-2 weighted image intensity
  correlated well with elevated compartment
  pressures
• Sensitive but not specific

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Near-Infrared Spectroscopy

• Measures concentration of oxygenated and
  deoxygenated blood in the muscles
• Pre-exercise ratio compared to post exercise

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Near-Infrared Spectroscopy

• Greater ratio of deoxygenated muscle after
  exertion suggests CECS
• Observe recovery
• Pulse ox for tissue perfusion
• (Van den Brand et al., Am J Sports Med 2004,
  32452-456.)

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Thallium-201 SPECT

• Physiologic test
• Measures reversible ischemia
• Pre-exercise images taken
• Sport-specific exercise until symptomatic

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Thallium-201 SPECT

• Thallium injected
• Serial SPECT images taken at predetermined
  intervals
• Pre and post exercise SPECT images compared

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Thallium-201 SPECT

• Quantitative analysis of tracer redistribution
  after exercise
• Sensitivity is questionable
• Studies raise questions

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Treatment Options

• Conservative measures have unproven benefit but
  anecdotal support
• Hyperbaric oxygen and magnetic field therapy need
  study

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Treatment Options

• Activity modification for symptom relief
• Correct biomechanical problems - orthotics
• What about surgery?

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Fasciotomy

• Highly suspicious history /- documented high
  pressures
• Symptoms gt 6 months
• Acute syndrome

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Fasciotomy

• Anterior and lateral compartments
• gt80 success
• Deep posterior
• 50 success
• Superficial post
• Rare, but do well
• (Howard JL. Clin J Sport Med 2000,10176-184.)

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Complications and Limitations

• DVT
• Vascular injury
• Abnormal scarring of skin and fascia
• Overall complication rate is 13
• Overall additional surgery rate is 11

• 5 require second fasciotomy in another
  compartment
• 6 required partial fasciectomy
• Bleeding, infection, skin breakdown
• Nerve entrap or injury

(Howard JL. Clin J Sport Med 2000,10176-184.)
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Return to Play

• Pain and disability is best guide
• No more than 10 per week advancement
• Post fasciotomy
• Light jog at 4-6 weeks
• Full sports in 8-12 weeks post op
• Pain free with 90 strength

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Take Home Points

• Common in endurance runners
• Exertional leg pain know differential dx.
• Diagnosis history and compartment pressures
• Less invasive diagnostic measures coming
• Treatment activity modification, address
  biomechanical
• Surgery know risks

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Questions
Chronic Exertional Fatigue Overuse Getting Old
Syndrome!