Recurrent Anterior Compartmental Syndromes

Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review

BACKGROUND

Numerous conditions are grouped under the generic term exercise-induced leg pain (EILP), yet clear diagnostic guidelines are lacking. This scoping review was conducted to clarify the definition and diagnostic criteria of nine commonly occurring EILP conditions.

METHODS

Three online databases were searched from inception to April 2022 for any English language original manuscripts identifying, describing, or assessing the clinical presentation and diagnostic criteria of the nine most common conditions that cause EILP. We included manuscripts considering all adults with any reported diagnostic criteria for EILP in any setting. Methodological quality was assessed using the Mixed Method Appraisal tool. Condition definitions were identified and categorised during data charting. Twenty-five potential elements of the history, 24 symptoms, 41 physical signs, 21 investigative tools, and 26 overarching diagnostic criteria, were identified and coded as counts of recommendation per condition, alongside qualitative analysis of the clinical reasoning. Condition definitions were constructed with 11 standardised elements based on recent consensus exercises for other conditions.

RESULTS

One hundred nineteen retained manuscripts, of which 18 studied multiple conditions, had a median quality of 2/5. A combination of the history, pain location, symptoms, physical findings, and investigative modalities were fundamental to identify each sub-diagnosis alongside excluding differentials. The details differed markedly for each sub-diagnosis. Fifty-nine manuscripts included data on chronic exertional compartment syndrome (CECS) revealing exertional pain (83% history), dull aching pain (76% symptoms), absence of physical signs (78% physical findings) and elevated intercompartment pressure (93% investigative modality). Twenty-one manuscripts included data on medial tibial stress syndrome (MTSS), revealing persistent pain upon discontinuation of activity (81% history), diffuse medial tibial pain (100% pain location), dull ache (86% symptoms), diffuse tenderness (95% physical findings) and MRI for exclusion of differentials (62% investigative modality). Similar analyses were performed for stress fractures (SF, n = 31), popliteal artery entrapment syndrome (PAES, n = 22), superficial peroneal nerve entrapment syndrome (SPNES, n = 15), lumbar radiculopathy (n = 7), accessory/low-lying soleus muscle syndrome (ALLSMS, n = 5), myofascial tears (n = 3), and McArdle's syndrome (n = 2).

CONCLUSION

Initial diagnostic frameworks and definitions have been developed for each condition of the nine most common conditions that cause EILP, suitable for clinical consideration and consensus confirmation.

Release of the Tibialis Posterior Muscle Osseofascial Sheath Improves Results of Deep Exertional Compartment Syndrome Surgery: A Comparative Analysis and Long-term Results

Background:

Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present.

Purpose:

Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction.

Results:

Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release.

Conclusion:

The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.

Chronic Exertional Compartment Syndrome

Increased tissue pressure within a fascial compartment may be the result from any increase in volume within its contents, or any decrease in size of the fascial covering or its distensibility. This may lead to symptoms of leg tightness, pain or numbness brought about by exercise. There are multiple differential diagnoses of exercise induced leg pain and the proper diagnoses of chronic exertional compartment syndrome (CECS) is made by a careful history and by exclusion of other maladies and confirmed by compartment syndrome testing as detailed in this text. Surgical fasciotomies for the anterior, lateral, superficial and deep posterior compartments are described in detail along with ancillary procedures for chronic shin splints that should allow the athlete to return to competitive activity.

Chronic exertional compartment syndrome: the controversial "fifth" compartment of the leg

BACKGROUND

The existence of a "fifth" compartment in the leg capable of developing distinct chronic exertional compartment syndrome remains a subject of controversy.

HYPOTHESIS

Specific pressure recordings and dissection will confirm or disprove the existence of a fifth compartment.

STUDY DESIGN

Empirical anatomic study.

METHODS

Radiopaque dye was injected directly into the tibialis posterior muscle of 25 embalmed cadaveric legs while intracompartmental pressure was monitored. Radiographs demonstrated dye distribution, and dissection-documented fascial and epimysial layers.

RESULTS

Evidence was found that the fibular origin of the flexor digitorum longus muscle, when present, could create subcompartments within the deep posterior compartment. The nature of this attachment varied from being absent, to small (<8 cm), to extensive (>8 cm). The attachment partially covered the tibialis posterior muscle in the majority of the 14 legs that developed high pressures, and it was limited or absent in the 11 legs that did not. Radiographs demonstrated that the dye was confined to the tibialis posterior muscle in four legs.

CONCLUSIONS

No consistent fifth compartment exists in the leg; however, subcompartments within the deep posterior compartment created by the fibular origin of the flexor digitorum longus muscle may develop pressures congruent with chronic exertional compartment syndrome.

CLINICAL RELEVANCE

Potential deep posterior subcompartments demand accurate pressure investigation. A modified technique to decompress the entire deep posterior compartment, including the tibialis posterior muscle, is necessary for successful treatment of chronic exertional compartment syndrome.

Anatomical dissection of the deep posterior compartment and its correlation with clinical reports of chronic compartment syndrome involving the deep posterior compartment

Patients with clinical presentation of deep posterior chronic compartment syndrome (CCS) frequently have symptoms limited to either proximal or distal components of the deep posterior compartment. In this study the posterior aspect of 15 cadaver legs was dissected to document anatomical separations and delineate boundaries, if any, of the deep posterior compartment and to correlate the findings to these patients. Origins of flexor hallucis longus (FHL), flexor digitorum longus (FDL), and tibialis posterior (TP), as well as whether TP existed in its own osseofascial compartment, were noted. Ten specimens had an identifiable distinct layer of tissue separating the deep posterior compartment into two potentially clinically relevant components. Much of this layer was derived from origins of FDL and its anatomical position in relation to the TP muscle. In seven of these cases, FDL had a significant fibular origin in addition to the well-established tibial origin. This essentially compartmentalized the distal third of the tibialis posterior as it descends anterior and medial to FDL in the lower one-third of the leg in five specimens. No cadaver possessed a significant fascial septum encasing TP and separating it from other deep posterior muscles. This study confirms the existence of a proximal and distal sub-compartment of the deep posterior compartment as a variant and supports the most frequent clinical presentation of deep posterior CCS as involving either the distal or proximal deep compartment, rather than the entire deep posterior compartment. The anatomic arrangement of muscles in the deep posterior compartment creates sub-compartments, which may explain the successful outcomes following a deep compartment release limited to symptomatic portion(s) of the deep compartment.

A review of chronic exertional compartment syndrome in the lower leg

Chronic exertional compartment syndrome (CECS) in the lower leg has been described as early as 1956. This review describes the five relevant anatomical compartments and the important clinical features on presentation used in diagnosis. Compartment pressure testing using various types of catheter is useful as a confirmatory investigation. Although the pathophysiology of this condition is poorly understood, current hypotheses are discussed. Surgical treatment is usually definitive and techniques for decompression of the five compartments are presented with comparison to available conservative treatments.

Lower extremity compartment syndrome. When to suspect acute or chronic pressure buildup

Acute compartment syndrome is a surgical emergency. A high index of suspicion is needed in cases of severe contusion, especially if patient complaints seem to outweigh physical findings. Acute surgical fasciotomy is an effective treatment and should be carried out expeditiously if compartment pressures are elevated over 70 mm Hg in order to avoid complications such as chronic disability due to contractures or rhabdomyolysis with acute renal failure. Chronic exertional compartment syndrome most often occurs in the anterior or the lateral compartment. Patients have only exercise-related symptoms and recover quickly after resting from the inciting activity. Diagnosis is difficult, but the anterior compartment pressure may be checked fairly readily with a handheld pressure catheter. Deep posterior compartment problems are harder to check because of the difficulty in reaching this area. Thallium stress testing appears promising for diagnosing both anterior and posterior problems and may augment, or even replace, the catheter measurement in the deep posterior and perhaps even the anterior compartment. Thallium stress testing is noninvasive and may be a more physiologic measurement. Fasciotomy may be indicated if conservative treatment lacks efficacy. For unknown reasons, the deep posterior compartment does not respond as quickly, or as well, to fasciotomy as the anterior compartment.

The effect of locomotion speed on the anterior tibial intramuscular pressure of normal humans

We examined the hypothesis that anterior tibial intramuscular pressure increases with the speed of locomotion. A solidstate pressure transducer was placed near the tip of an intramuscular fluid-filled catheter and each of ten normal subjects walked, jogged and ran barefoot, at 1.5, 2.5 and 3.5 m s-1 respectively, on a treadmill to which they had been previously familiarized. The pressure signals during ten gait cycles from each subject were sampled at 600 Hz and were averaged at each speed. The peak pressures increased in magnitude as a function of increasing locomotion speed, while the mean pressure remained constant.

A Primary Care Perspective of Chronic Compartment Syndrome of the Leg

In brief: Chronic compartment syndrome (CCS) of the leg is a recently recognized cause of recurrent leg pain in the exercising patient. Apart from rest, the only effective treatment is fasciotomy. This study reviews 39 fasciotomies that were performed on 16 patients with clinically determined CSS. Fourteen (88%) of the patients returned to full activity with few or no residual complaints. These results indicate that clinically identified features can distinguish CCS from other forms of recurrent leg pain. Compartment pressure measurements taken during exercise can confirm the diagnosis of CCS and determine the need for fasciotomy.