1
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Gawel RJ, Kemler BR, Coladonato C, Freedman KB. Rehabilitation and return to activity criteria after operative management of chronic exertional compartment syndrome of the leg: a systematic review. PHYSICIAN SPORTSMED 2024; 52:125-133. [PMID: 37191583 DOI: 10.1080/00913847.2023.2214192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Endurance athletes with chronic exertional compartment syndrome (CECS) frequently require fasciotomy to return to activity, but there are no existing comprehensive evidence-based rehabilitation guidelines. We aimed to summarize rehabilitation protocols and return to activity criteria after CECS surgery. METHODS Through a systematic literature review, we identified 27 articles that explicitly defined physician-imposed restrictions or guidelines for patients to resume athletic activities following CECS surgery. RESULTS Common rehabilitation parameters included running restrictions (51.9%), postoperative leg compression (48.1%), immediate postoperative ambulation (44.4%), and early range of motion exercises (37.0%). Most studies (70.4%) reported return to activity timelines, but few (11.1%) utilized subjective criteria for guiding return to activity. No studies utilized objective functional criteria. CONCLUSIONS Rehabilitation and return to activity guidelines after CECS surgery remain poorly defined, and further investigation is needed to develop such guidelines that will enable endurance athletes to safely return to activities and minimize recurrence.
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Affiliation(s)
- Richard J Gawel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Bryson R Kemler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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2
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Schuster M, Kappenschneider T, Meyer M, Holzapfel DE. Acute compartment syndrome of the thigh after total knee arthroplasty: a case report. J Med Case Rep 2024; 18:65. [PMID: 38374059 PMCID: PMC10877870 DOI: 10.1186/s13256-024-04378-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/12/2024] [Indexed: 02/21/2024] Open
Abstract
INTRODUCTION Acute compartment syndrome of the thigh after total knee arthroplasty is a rarely described complication. After the assessment of the diagnosis, immediate surgical intervention is necessary to prevent further tissue damage. Since only a few cases have been described and because of the high complication rate, early detection is essential for ensuring patient outcomes. CASE PRESENTATION After total knee arthroplasty in a high-volume university hospital, a 57-year-old Caucasian female patient experienced strong, disproportional pain in the ventromedial thigh of the affected leg, which did not respond to an adequate adjustment in pain medication. Imaging revealed a distinct swelling of the vastus intermedius muscle. This resulted in acute compartment syndrome of the thigh, which was immediately surgically treated. Apart from receiving surgery distal from the affected compartment and continuous intake of acetylsalicylic acid, the patient had no risk factors for developing compartment syndrome. The patient's recovery was uneventful, with timely wound closure and discharge to outpatient care without significant functional limitations. CONCLUSION Acute compartment syndrome of the thigh represents a rare, but severe complication that can occur after orthopedic surgery. In our case, no triggering factors for the development of acute compartment syndrome, such as the use of a tourniquet, were detected. Even in unusual locations, compartment syndrome should be considered as a differential diagnosis. With sufficient evidence, immediate fasciotomy should be indicated.
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Affiliation(s)
- Marie Schuster
- Department of Orthopaedic Surgery, University of Regensburg, Asklepios Klinikum, Bad Abbach, Germany.
| | - Tobias Kappenschneider
- Department of Orthopaedic Surgery, University of Regensburg, Asklepios Klinikum, Bad Abbach, Germany
| | - Matthias Meyer
- Department of Orthopaedic Surgery, University of Regensburg, Asklepios Klinikum, Bad Abbach, Germany
| | - Dominik Emanuel Holzapfel
- Department of Orthopaedic Surgery, University of Regensburg, Asklepios Klinikum, Bad Abbach, Germany
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3
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Rothman R, Berke C, Jivanelli B, Casey E, Cheng J. Sex and gender differences in lower limb chronic exertional compartment syndrome: a systematic review. PHYSICIAN SPORTSMED 2024; 52:1-11. [PMID: 36698053 DOI: 10.1080/00913847.2023.2173489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Chronic exertional compartment syndrome (CECS) is a cause of exertional leg pain and has been reported in varying frequencies in males and females. Currently, it is unclear whether there are significant sex and gender differences in lower-limb CECS. Delineating sex and gender differences is vital in determining the causes of CECS and best treatments. This systematic review aimed to determine the sex/gender distribution of CECS and to assess for sex and gender differences in CECS diagnosis and outcomes. METHODS PubMed (Medline), Cochrane Library, and EMBASE databases were searched for studies that were published from January 2000-March 2022 and reported lower-limb CECS data in males and/or females. Data on CECS diagnosis (intracompartmental pressures) and outcomes (e.g. post-surgical return-to-sport, need for re-operation) with sex/gender breakdowns were extracted. The sex/gender distribution of CECS and prevalence of CECS by sex/gender were calculated. RESULTS Forty-one studies were included in the systematic review; there were 27 retrospective reviews, 8 prospective studies, and 6 retrospective studies with prospective follow-ups. Thirty studies involved surgical populations. Sex/gender distribution of CECS was calculated using data from 24 studies; 51% were female. Prevalence of CECS was available in five studies and ranged widely for males (54%-73%) and females (43%-65%). Intracompartmental pressure data varied by sex/gender. Male athletes were more likely than female athletes to return to sport following surgery for CECS, but variations in all other post-surgical outcomes were observed between sexes and genders in the general population. CONCLUSION Females represented 51% of the patients who were diagnosed with CECS among studies. Most CECS diagnosis and outcomes data varied by sex/gender, except for post-surgical outcomes data in athletes, which demonstrated that males had higher rates of return to sport than females. Future studies are needed to examine factors contributing to sex and gender differences in CECS diagnosis and outcomes.
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Affiliation(s)
- Rachel Rothman
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Chandler Berke
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, Hospital for Special Surgery, New York, NY, USA
| | - Ellen Casey
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Jennifer Cheng
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
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4
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Bosnina F, Padhiar N, Miller S, Girotra K, Massoura C, Morrissey D. Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review. J Foot Ankle Res 2023; 16:82. [PMID: 37990284 PMCID: PMC10662794 DOI: 10.1186/s13047-023-00680-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023] Open
Abstract
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.
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Affiliation(s)
- Fatma Bosnina
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Nat Padhiar
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
- London Sportswise, London, UK.
| | - Stuart Miller
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Krishna Girotra
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Chrysovalanto Massoura
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Dylan Morrissey
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Health NHS Trust Physiotherapy Department, London, UK
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Tarabishi MM, Almigdad A, Almonaie S, Farr S, Mansfield C. Chronic Exertional Compartment Syndrome in Athletes: An Overview of the Current Literature. Cureus 2023; 15:e47797. [PMID: 38022185 PMCID: PMC10676709 DOI: 10.7759/cureus.47797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Chronic exertional compartment syndrome is an incapacitating condition that primarily affects athletes and individuals with high activity levels. The exact etiology of the condition is unknown to date, but multiple factors play a role in its occurrence. The clinical presentation includes pain, tightness, muscle weakness, paresthesia, and cramps. Common tools utilized during the diagnostic approach include intramuscular compartment pressure measurement, advanced imaging to exclude other disorder entities, near-infrared spectrometry, and shear wave elastography, with the clinical diagnosis being the gold standard. Management includes both conservative and surgical options. Conservative treatment includes gait re-training and botulinum toxin injections. Further, the operative treatment has variable approaches and may be combined with conservative modalities. This article reviews the literature on chronic exertional compartment syndrome and elucidates future recommendations.
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Affiliation(s)
- Mohammed M Tarabishi
- Department of Reconstructive Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
- Department of Pediatric Orthopedic and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, AUT
| | - Ahmad Almigdad
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | - Shahd Almonaie
- Department of Orthopedic Surgery, Alfaisal University College of Medicine, Riyadh, SAU
| | - Sebastian Farr
- Department of Pediatric Orthopedics, Orthopaedic Hospital Speising, Vienna, AUT
| | - Clemens Mansfield
- Department of Pediatric Orthopedic and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, AUT
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6
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Vergeer R, Bloo H, Backx F, Scheltinga M, Bakker E. Reliability of 2D video analysis assessing running kinematic variables in patients with exercise-related leg pain in a primary care practice. Gait Posture 2023; 105:117-124. [PMID: 37541089 DOI: 10.1016/j.gaitpost.2023.07.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/21/2023] [Accepted: 07/18/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Suboptimal lower limb and trunk positionings is known to influence exercise-related leg pain (ERLP). It is unknown whether simple 2D video analysis is useful for recording and interpreting running variables in a primary care practice. RESEARCH QUESTION Is 2D video analysis a reliable instrument to assess running variables in patients with ERLP in a primary care practice? METHODS Participants undergoing an evaluation for ERLP in two primary care practices were studied. In this reliability study, analysis of running variables was performed by 4 blinded raters on one-stride videos captured with non-high speed cameras (30 fps). Intraclass correlation coefficients (two-way random; ICC 2,1) were calculated to determine the inter-rater reliability. The intra-rater reliability was presented by ICC type two-way mixed (3,1). Footstrike pattern was analyzed by calculating the Fleiss' kappa for inter-rater agreement and Cohen's kappa for intra-rater agreement. Sample size calculation indicated that 16 participants would be required for answering the research question. RESULTS Data of all 16 participants (9 males, age 31 ± 10 yr) were of sufficient quality for analysis. The 2D video analysis demonstrated excellent inter-rater reliability with an overall ICC value of 0.999 (95 % CI = 0.998-0.999). The ICC value of the eversion was 0.384 (95 % CI = 0.148-0.66) and after correction of the systematic error, 0.817 (95 % CI = 0.664-0.922). The agreement on footstrike was substantial with a Fleiss kappa of 0.737. The overall intra-rater reliability was excellent with an ICC value of 0.997 (95 % CI = 0.996-0.997). The intra-rater agreement of the footstrike was excellent with a Cohen's kappa of 0.868. SIGNIFICANCE 2D video analysis provides a highly reliable, relative inexpensive, feasible and suitable measuring instrument for determining running variables in patients ERLP in a primary care setting. This simple technique may identify possible running variables associated with different types of ERLP and may serve as an instrument for tailor-made gait retraining programs.
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Affiliation(s)
- Rob Vergeer
- Cureplus, Primary Care Physiotherapy Practice, Stadhoudersweg 1, 3136 BW Vlaardingen, the Netherlands; Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, the Netherlands.
| | - Hans Bloo
- PMI Rembrandt, Primary Care Physiotherapy Practice, Kerkewijk 92, 3904 JG Veenendaal, the Netherlands; Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, the Netherlands
| | - Frank Backx
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, the Netherlands
| | - Marc Scheltinga
- Department of Surgery, Maxima Medical Center, Veldhoven, the Netherlands
| | - Eric Bakker
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, University of Amsterdam, the Netherlands
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7
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Tønning LU, Mygind-Klavsen B, Kjeldsen T, Dalgas U, Brincks J, Mechlenburg I. Muscle Strength, Oxygen Saturation and Physical Activity in Patients with Chronic Exertional Compartment Syndrome Compared to Asymptomatic Controls. Int J Sports Phys Ther 2023; 18:348-357. [PMID: 37020455 PMCID: PMC10069367 DOI: 10.26603/001c.71357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/15/2023] [Indexed: 04/04/2023] Open
Abstract
Background One of the most common causes of exercise-induced pain in the lower leg is chronic exertional compartment syndrome (CECS). Research is limited on muscle strength, oxygen saturation and physical activity in patients with CECS. Purpose To compare muscle strength, oxygen saturation, and daily physical activity between patients with CECS and matched asymptomatic controls. A secondary purpose was to investigate the association between oxygen saturation and lower leg pain in patients with CECS. Study Design Case-control study. Method Maximal isometric muscle strength of the ankle plantar and dorsiflexors was tested in patients with CECS and sex- and age-matched controls using an isokinetic dynamometer and oxygen saturation (StO2) during running was tested by near infrared spectroscopy. Perceived pain and exertion were measured during the test using the Numeric Rating Scale and Borg Rating of Perceived Exertion scale and the exercise-induced leg pain questionnaire. Physical activity was assessed by accelerometry. Results Twenty-four patients with CECS and 24 controls were included. There were no differences in maximal isometric plantar or dorsiflexion muscle strength between patients and controls. Baseline StO2 was 4.5pp (95% CI: 0.7;8.3) lower for patients with CECS than for controls, whereas no difference existed when they experienced pain or reached exhaustion. No differences were found in daily physical activities, except that on average, patients with CECS spent less time cycling daily. During the StO2 measurement, patients experienced pain or reached exhaustion while running significantly earlier than the controls (p<0.001). StO2 was not associated with leg pain. Conclusion Patients with CECS have similar leg muscle strength, oxygen saturation and physical activity levels as asymptomatic controls. However, patients with CECS experienced significantly higher levels of lower leg pain than the controls during running, daily activities and at rest. Oxygen saturation and lower leg pain were not associated. Level of Evidence Level 3b.
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Affiliation(s)
| | | | | | | | - John Brincks
- Research Centre for Health and Welfare Technology, Programme for Rehabilitation & Department of Physiotherapy, VIA University College
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Lindorsson S, Zhang Q, Brisby H, Rennerfelt K. Intramuscular Pressure and Patient-Reported Outcomes in Patients Surgically Treated for Anterior Chronic Exertional Compartment Syndrome. Orthop J Sports Med 2023; 11:23259671221151088. [PMID: 36846814 PMCID: PMC9947687 DOI: 10.1177/23259671221151088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background Chronic exertional compartment syndrome (CECS) causes exercise-induced leg pain. The diagnosis is confirmed by intramuscular pressure (IMP) measurements. Fasciotomy has been demonstrated to be a successful treatment for CECS; however, few studies have examined postoperative IMP and long-term outcomes. Purpose To evaluate long-term outcomes and postoperative IMP in patients surgically treated for anterior CECS, and to identify possible preoperative or postoperative factors associated with overall satisfaction with treatment at follow-up. Study Design Case-control study; Level of evidence, 3. Methods A consecutive series of 209 patients who underwent fasciotomy of the anterior compartment for CECS between 2009 and 2019 and had at least 1 year of follow-up were approached for inclusion. A total of 144 patients (69%), with a follow-up time of 1 to 11.5 years, were ultimately included. All patients underwent preoperative and postoperative 1-minute postexercise IMP measurements of the anterior compartment and completed a questionnaire covering pain and activity parameters at both time points. The follow-up questionnaire included an additional question on overall satisfaction with treatment, and surgical details were collected from the patient's medical records. Results The median IMP was significantly lower at follow-up than at baseline (17 mm Hg [range, 5-91 mm Hg] vs 49 mm Hg [range, 25-130 mm Hg]; P < .001). The overall satisfaction rate was 77%, and 83% reported a decreased pain level. The group of patients who were satisfied with the treatment included more men and had a higher ΔIMP and a lower revision rate (P < .05). Among the 16 patients (11%) who had undergone revision fasciotomies before follow-up, the satisfaction rate was 56%, and 64% reported a decrease in pain level. Conclusion Fasciotomy significantly reduced 1-minute postexercise IMP in patients with CECS and resulted in satisfaction and decreased pain in more than three-quarters of the patients at long-term follow-up. The male sex and a significant decrease in IMP were both positively associated with treatment satisfaction. Patients who underwent revision surgery before the follow-up had lower satisfaction rates and less pain reduction than the overall group.
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Affiliation(s)
- Sophia Lindorsson
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sophia Lindorsson, MD, Sahlgrenska University Hospital,
Ortopedmottagningen Mölndal, 431 80 Mölndal, Sweden (
)
| | - Qiuxia Zhang
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Brisby
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kajsa Rennerfelt
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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9
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Weiss C, Vogels S, Wee L, Janssen L, de Bie RA, Scheltinga MR. Two-Compartment or 4-Compartment Fasciotomy for Lower Leg Chronic Exertional Compartment Syndrome: A Systematic Review. J Foot Ankle Surg 2022; 61:1124-1133. [PMID: 35337738 DOI: 10.1053/j.jfas.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/15/2022] [Indexed: 02/03/2023]
Abstract
Patients with lower leg chronic exertional compartment syndrome are impaired due to exercise-related pain. Fasciotomy is the surgical gold standard. However, it is unknown whether number of simultaneously opened compartments affects outcome. The purpose of this systematic review was to compare patient-reported outcomes of a 2-compartment fasciotomy with a 4-compartment fasciotomy. Controlled clinical trials (randomized/nonrandomized), cohort studies and case series reporting on outcome following either 2-compartment or 4-compartment fasciotomy for lower leg chronic exertional compartment syndrome were searched until May 31, 2021 in PubMed, EMBASE, and Cochrane. Results were qualitatively synthesized. Risk of bias and levels of evidence were determined. Seven studies reporting on altogether 194 athletes and military personnel (mean age 24 y) were included. Quality assessment revealed a high risk of bias in all studies. Both 2-compartment and 4-compartment fasciotomy were associated with a 50% to 100% "return to activity" rate (in studies reporting group results separately: 2-compartment 90%-100%; 4-compartment 50%-100%) and a 41% to 100% "return to previous activity" rate (in studies reporting group results separately: 2-compartment 82-100%; 4-compartment 50%-100%) without significant differences. Mean Marx activity score of 1 study found a small significant standardized mean difference (0.196 [0.524,0.916]) favoring 4-compartment fasciotomy. Rate of satisfaction (2-compartment 74%-89%; 4-compartment 75%-100%) and residual symptoms (2-compartment 0%-36%; 4-compartment 0%-50%) indicated no group differences. In conclusion, a 2-compartment fasciotomy or a 4-compartment fasciotomy for lower leg chronic exertional compartment syndrome appears to be equally successful. However, included studies were hampered by methodological shortcomings (low sample size, selection bias, heterogeneity and no uniform outcome measures).
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Affiliation(s)
- Chris Weiss
- Department of Surgery, Máxima MC, Veldhoven, DB, The Netherlands; Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, ER, The Netherlands.
| | - Sanne Vogels
- Department of Surgery, Alrijne Hospital, Leiderdorp, GA, The Netherlands; Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, GD, The Netherlands
| | - Leonard Wee
- Clinical Data Science, Maastricht University and Department of Radiotherapy (MAASTRO), GROW School of Oncology, Maastricht University Medical Centre, Maastricht, ER, The Netherlands
| | - Loes Janssen
- Department of Surgery, Máxima MC, Veldhoven, DB, The Netherlands
| | - Rob A de Bie
- Department of Epidemiology, Caphri Care and Public Health Institute, Maastricht University, Maastricht, MD, The Netherlands
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10
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Vogels S, Ritchie ED, van der Burg BLSB, Scheltinga MRM, Zimmermann WO, Hoencamp R. Clinical Consensus on Diagnosis and Treatment of Patients with Chronic Exertional Compartment Syndrome of the Leg: A Delphi Analysis. Sports Med 2022; 52:3055-3064. [PMID: 35904751 DOI: 10.1007/s40279-022-01729-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 10/16/2022]
Abstract
AIM Defining universally accepted guidelines for the diagnosis and treatment of chronic exertional compartment syndrome (CECS) is hampered by the absence of high-quality scientific research. The aim of this Delphi study was to establish consensus on practical issues guiding diagnosis and treatment of CECS of the leg in civilian and military patient populations. METHODS An international expert group was queried using the Delphi technique with a traditional three-round electronic consultation. Results of previous rounds were anonymously disclosed in the questionnaire of rounds 2 and 3, if relevant. Consensus was defined as > 70% positive or negative agreement for a question or statement. RESULTS The panel consisted of 27 civilian and military healthcare providers. Consensus was reached on five essential key characteristics of lower leg CECS. The panel achieved partial agreement regarding standardization of the diagnostic protocol, including muscle tissue pressure measurements. Consensus was reached on conservative and surgical treatment regimens. However, the experts did not attain consensus on their approach of postoperative rehabilitation and preferred treatment approach of recurrent or residual disease. A summary of best clinical practice for the diagnosis and management of CECS was formulated by experts working in civilian and military healthcare facilities. CONCLUSION The Delphi panel reached consensus on key criteria for signs and symptoms of CECS and several aspects for conservative and surgical treatment. The panel did not agree on the role of ICP values in the diagnostic process, postoperative rehabilitation guidelines protocol, or the preferred treatment approach for recurrent or residual disease. These aspects serve as a first attempt to initiate simple guidelines for clinical practice.
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Affiliation(s)
- Sanne Vogels
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA, Leiderdorp, The Netherlands. .,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - E D Ritchie
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA, Leiderdorp, The Netherlands
| | | | | | - W O Zimmermann
- Department of Sports Medicine, Royal Netherlands Army, Utrecht, The Netherlands.,Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - R Hoencamp
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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11
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Kaplan S, Olivier B, Obiora OL. Effectiveness of surgical and non-surgical management strategies in patients with chronic exertional compartment syndrome of the anterior compartment of the leg: a systematic review protocol. JBI Evid Synth 2021; 19:3198-3205. [PMID: 34132238 DOI: 10.11124/jbies-20-00324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this review is to evaluate the effectiveness of surgical management versus non-surgical management on pain, range of motion, intracompartmental pressure values, patient satisfaction, recurrence of symptoms, return to activity, function, strength, and sensation in patients diagnosed with chronic exertional compartment syndrome of the anterior compartment of the leg. INTRODUCTION Chronic exertional compartment syndrome is the most prevalent cause of exercise-induced leg pain in athletes. Current evidence suggests that the best methods for management include activity modification or cessation, injection of botulinum toxin into the affected compartment, or surgical intervention. Due to the limited number and quality of studies available, the evidence needs to be synthesized to pool findings from current research and to identify gaps in the literature. INCLUSION CRITERIA This review will consider studies that include people with chronic exertional compartment syndrome of the anterior compartment of the leg diagnosed through a combination of elevated intracompartmental pressure values and patient history. Studies that include patient-reported outcome measures will be included. METHODS MEDLINE, SPORTDiscus, Physiotherapy Evidence Database, MasterFILE Premier, CINAHL Complete, ProQuest Health and Medical Complete, Scopus, and Science Direct will be searched from 1956 to date. Gray literature databases will also be searched. Two reviewers will independently retrieve and screen full-text studies, critically appraise included studies, and extract data. Meta-analyses will be performed where possible. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020189661.
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Affiliation(s)
- Sean Kaplan
- The Wits-JBI Centre for Evidence-Based Practice: A JBI Affiliated Group, Johannesburg, South Africa.,Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Benita Olivier
- The Wits-JBI Centre for Evidence-Based Practice: A JBI Affiliated Group, Johannesburg, South Africa.,Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Oluchukwu Loveth Obiora
- The Wits-JBI Centre for Evidence-Based Practice: A JBI Affiliated Group, Johannesburg, South Africa.,Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Lovelock T, Claydon M, Dean A. Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management. Int J Sports Med 2021; 42:1159-1166. [PMID: 34341975 DOI: 10.1055/a-1524-1703] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.
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Affiliation(s)
- Thomas Lovelock
- Department of Vascular Surgery, Alfred Hospital, Melbourne, Australia
| | - Matthew Claydon
- Department of Vascular Surgery, Alfred Hospital, Melbourne, Australia
| | - Anastasia Dean
- Department of Vascular Surgery, Alfred Hospital, Melbourne, Australia
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13
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Vogels S, VAN Ark W, Janssen L, Scheltinga MRM. Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg. Med Sci Sports Exerc 2021; 53:1549-1554. [PMID: 33731658 DOI: 10.1249/mss.0000000000002631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial. METHODS Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result. RESULTS Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14-37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2-65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity. CONCLUSION An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.
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Affiliation(s)
| | - Wendela VAN Ark
- Department of Surgery, Máxima MC, Veldhoven, THE NETHERLANDS
| | - Loes Janssen
- Department of Surgery, Máxima MC, Veldhoven, THE NETHERLANDS
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14
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Vogels S, Ritchie ED, van Dongen TTCF, Scheltinga MRM, Zimmermann WO, Hoencamp R. Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg. Scand J Med Sci Sports 2020; 30:1827-1845. [PMID: 32526086 PMCID: PMC7540008 DOI: 10.1111/sms.13747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022]
Abstract
Objective Surgery is the gold standard in the management of chronic exertional compartment syndrome (CECS) of the lower extremity, although recent studies also reported success following gait retraining. Outcome parameters are diverse, and reporting is not standardized. The aim of this systematic review was to analyze the current evidence regarding treatment outcome of CECS in the lower leg. Material and Methods A literature search and systematic analysis were performed according to the PRISMA criteria. Studies reporting on outcome following treatment of lower leg CECS were included. Results A total of 68 reports fulfilled study criteria (n =; 3783; age range 12‐70 year; 7:4 male‐to‐female ratio). Conservative interventions such as gait retraining (n =; 2) and botulinum injection (n =; 1) decreased ICP (x- =; 68 mm Hg tox- =; 32 mm Hg) and resulted in a 47% (±42%) rate of satisfaction and a 50% (±45%) rate of return to physical activity. Fasciotomy significantly decreased ICP (x- =; 76 mm Hg to x- =; 24 mm Hg) and was associated with an 85% (±13%) rate of satisfaction and an 80% (±17%) rate of return to activity. Return to activity was significantly more often achieved (P < .01) in surgically treated patients, except in one study favoring gait retraining in army personnel. Conclusion Surgical treatment of CECS in the lower leg results in higher rates of satisfaction and return to activity, compared to conservative treatment. However, the number of studies is limited and the level of evidence is low. Randomized controlled trials with multiple treatment arms and standardized outcome parameters are needed.
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Affiliation(s)
- Sanne Vogels
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewan D Ritchie
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thijs T C F van Dongen
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
| | | | - Wes O Zimmermann
- Department of Sports Medicine, Royal Netherlands Army, Utrecht, The Netherlands.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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