Anterior tibial pain

Chronic Exertional Compartment Syndrome in Athletes: An Overview of the Current Literature

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.

Chronic Exertional Compartment Syndrome in Athletes

Chronic exertional compartment syndrome (CECS) refers to exercise-induced, reversible increases in pressure within well-defined inelastic fascial compartments leading to compromised tissue perfusion followed by functional loss, ischemic pain, and neurologic symptoms. Symptoms typically resolve when the activity ceases and there are usually no permanent sequelae. In the upper extremity, this condition most commonly affects athletes during sports requiring repetitive and vigorous gripping, such as rowers. In addition to clinical history and examination, a number of methods aid diagnosis, including compartment pressure measurements, magnetic resonance imaging, and near infrared spectroscopy. When symptoms persist despite conservative treatment, multiple operative techniques have been described to treat CECS including open, mini-open, and endoscopic release of involved compartments. We review the pathophysiology, diagnostic modalities, treatment strategies, and outcomes data for CECS of the upper extremity while highlighting areas of residual controversy.

Investigation of interaction phenomena between crural fascia and muscles by using a three-dimensional numerical model

The focus of this work is the numerical modeling of the anterior compartment of the human leg with particular attention to crural fascia. Interaction phenomena between fascia and muscles are of clinical interest to explain some pathologies, as the compartment syndrome. A first step to enhance knowledge on this topic consists in the investigation of fascia biomechanical role and its interaction with muscles in physiological conditions. A three-dimensional finite element model of the anterior compartment is developed based on anatomical data, detailing the structural conformation of crural fascia, composed of three layers, and modeling the muscles as a unique structure. Different constitutive models are implemented to describe the mechanical response of tissues. Crural fascia is modeled as a hyperelastic fiber-reinforced material, while muscle tissue via a three-element Hill's model. The numerical analysis of isotonic contraction of muscles is performed, allowing the evaluation of pressure induced within muscles and consequent stress and strain fields arising on the crural fascia. Numerical results are compared with experimental measurements of the compartment radial deformation and intracompartmental pressure during concentric contraction, to validate the model. The numerical model provides a suitable description of muscles contraction of the anterior compartment and the consequent mechanical interaction with the crural fascia.

Exertional Leg Pain

Exertional leg pain is a common condition seen in runners and the general population. Given the broad differential diagnosis of this complaint, this article focuses on the incidence, anatomy, pathophysiology, clinical presentation, diagnostic evaluation, and management of common causes that include medial tibial stress syndrome, tibial bone stress injury, chronic exertional compartment syndrome, arterial endofibrosis, popliteal artery entrapment syndrome, and entrapment of the common peroneal, superficial peroneal, and saphenous nerves. Successful diagnosis of these conditions hinges on performing a thorough history and physical examination followed by proper diagnostic testing and appropriate management.

Numerical modelling of crural fascia mechanical interaction with muscular compartments

The interaction of the crural fascia with muscular compartments and surrounding tissues can be at the origin of different pathologies, such as compartment syndrome. This pathology consists in the onset of excessive intracompartmental pressure, which can have serious consequences for the patient, compromising blood circulation. The investigation of compartment syndrome etiology also takes into account the alteration of crural fascia mechanical properties as a cause of the syndrome, where the fascial stiffening would result in the rise of intracompartmental pressure. This work presents a computational approach toward evaluating some biomechanical aspects of the problem, within the context of a more global viewpoint. Finite element analyses of the interaction phenomena of the crural fascia with adjacent regions are reported here. This study includes the effects of a fascial stiffness increase along the proximal-distal direction and their possible clinical implications. Furthermore, the relationship between different pre-strain levels of the crural fascia in the proximal-distal direction and the rise of internal pressure in muscular compartments are considered. The numerical analyses can clarify which aspects could be directly implied in the rise of compartment syndrome, leading to greater insight into muscle-fascia mechanical phenomena, as well as promoting experimental investigation and clinical analysis of the syndrome.

Biomechanical behavior of human crural fascia in anterior and posterior regions of the lower limb

The present work focuses on the numerical modeling of the mechanical behavior of the crural fascia, the deep fascia enwrapping the lower limb muscles. This fascia has an important biomechanical role, due to its interaction with muscles during contraction and its association with pathological events, such as compartment syndrome. The mechanical response of the crural fascia is described by assuming a hyperelastic fiber-reinforced constitutive model, with families of fibers disposed according to the spatial disposition of the collagen network, as shown in histological analyses. A two-dimensional finite element model of a lower limb transversal section has been developed to analyze deformational behavior, with particular attention on interaction phenomena between crural fascia and enwrapped muscles. The constitutive model adopted for the crural fascia well fits experimental data taken along the proximal-distal and medial-lateral directions. The finite element analysis allows for interpreting the relation between change in volume and pressure of muscle compartments and the crural fascia deformation.

Return to duty after elective fasciotomy for chronic exertional compartment syndrome

BACKGROUND

Civilian literature has reported excellent outcomes after elective fasciotomy for chronic exertional compartment syndrome (CECS). Our study's purpose was to objectively investigate the functional outcome of fasciotomies performed for CECS in a high demand military population.

METHODS

A retrospective review of all fasciotomies performed for CECS at a single tertiary military medical center was performed. The primary outcome measure was the ability to return to full active duty. Diagnosis, operative technique, and number of compartments addressed were collected and analyzed. Patients were contacted and the visual analog scale (VAS) pain score, functional single assessment numeric evaluation (SANE) score, as well as overall satisfaction were reported. Return to duty status was collected on 70 of 70 (100%) consecutive operative extremities in 46 patients with an average follow-up of 26 months.

RESULTS

Only 19 patients (41.3%) were able to return to full active duty. Ten patients (21.7%) underwent a medical separation from the military and 17 patients (37%) remained in the military but were on restricted duty secondary to persistent leg pain. Thirty-five of 46 (76%) of the patients were contacted and provided subjective feedback. The average SANE score was 72.3, and there was a mean improvement of 4.4 points in VAS score postoperatively. Overall, 71% of patients were satisfied and would undergo the procedure again. Outcomes were correlated to operative technique, patient rank, and branch of military service.

CONCLUSION

Our study showed a return to full military duty in 41% of patients who underwent elective fasciotomy for CECS. Overall 78% of patients remained in the military, which is consistent with previous military literature. Subjective satisfaction rate was 71%. Both the return to activity and subjective outcomes in our study population were substantially lower than reported results in civilian populations.

LEVEL OF EVIDENCE

Level IV, case series.

The thickness of the anterior compartment does not indicate compartment syndrome in acutely traumatised legs?

BACKGROUND

The study was conducted to achieve early detection of increased compartment pressure by comparing the changes between the thickness and pressure within the musculofascial compartments after lower leg injury.

METHODS

We included cases of a lower-leg fracture between January and December 2007. Bilateral lower leg compartment pressure and thickness were measured before the surgery and post-anaesthesia, and the surgery was performed within 12 h after the initial trauma. The intracompartment pressure (ICP) was measured with a Wick catheter pressure monitor. The thickness (width) of the anterior compartment of lower leg was measured using ultrasound.

RESULTS

All data were measured within 4-6h of the injury. The average thickness in injured legs versus uninjured was 30 mm (15-46 mm) versus 20.4 mm (13-30 mm), P<0.001. The average intracompartment pressure (ICP) in injured leg versus uninjured was 45.3 mmHg (26-80 mmHg) versus 17.5 mmHg (15-20 mmHg), P<0.001. The thickness and ICP were significantly increased for injured lower legs compared to the uninjured legs, but the increase in ICP did not show a significant relationship with the change in thickness of the injured lower leg.

CONCLUSION

In this study, the results of ICP and thickness changes of injury lower leg compared with uninjured leg revealed no statistically significant correlation. Some injuries showed a high ICP with only mild changes in thickness, while some showed a high ICP with significant changes. Although ultrasound has many advantages for the evaluation of soft tissue changes after trauma, this study revealed that thickness changes are not a predicable parameter for determining pressure on the acute fracture of lower leg.

Characteristics of patients with chronic exertional compartment syndrome

BACKGROUND

Chronic exertional compartment syndrome (CECS) is a condition that causes reversible ischemia and lower extremity pain during exercise. To date there are few large studies examining the characteristics of patients with CECS. This study aimed to present these characteristics by examining the largest published series of patients with a confirmed diagnosis of the disorder.

METHODS

An IRB-approved, retrospective review was undertaken of patients with a suspected diagnosis of CECS undergoing pre- and postexercise compartment pressure testing between 2000 and 2012. Patients were evaluated for gender, age, duration of symptoms, pain level, specific compartments involved, compartment pressure measurements, and participation and type of athletics.

RESULTS

Two-hundred twenty-six patients (393 legs) underwent compartment pressure testing. A diagnosis of CECS was made in 153 (67.7%) patients and 250 (63.6%) legs with elevated compartment measurements; average age of the patients was 24 years (range, 13-69 years). Female patients accounted for 92 (60.1%) of those with elevated pressures. Anterior and lateral compartment pressures were elevated most frequently, with 200 (42.5%) and 167 (35.5%) compartments, respectively. One hundred forty-one (92.2%) patients reported participation in sports, with running being the most common individual sport and soccer being the most common team sport. Duration of pain prior to diagnosis averaged 28 months.

CONCLUSION

Although there is ample literature pertaining to the diagnostic criteria and treatment algorithm of the condition, few papers have described the type of patient most likely to develop CECS. This is the largest study to date to evaluate the type of patient likely to present with chronic exertional compartment syndrome.

LEVEL OF EVIDENCE

Level III, retrospective review.

Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg

OBJECTIVE

Although all intracompartmental pressure (ICP) measurement, magnetic resonance imaging, and near-infrared spectroscopy seem to be useful in confirming the diagnosis of chronic exertional compartment syndrome (CECS), no standard diagnostic procedure is currently universally accepted. We reviewed systematically the relevant published evidence on diagnostic criteria commonly in use for CECS to address 3 main questions: (1) Is there a standard diagnostic method available? (2) What ICP threshold criteria should be used for diagnosing CECS? (3) What are the criteria and options for surgical management? Finally, we made statements on the strength of each diagnostic criterion of ICP based on a rigorous standardized process.

DATA SOURCES

We searched for studies that investigated ICP measurements in diagnosing CECS in the leg of human subjects, using PubMed, Score, PEDRO, Cochrane, Scopus, SportDiscus, Web of Knowledge, and Google Scholar. Initial searches were performed using the phrase, "chronic exertional compartment syndrome." The phrase "compartment syndrome" was then combined, using Boolean connectors ("OR" and "AND") with the words "diagnosis," "parameters," "levels," "localisation," or "measurement." Data extracted from each study included study design, number of subjects, number of controls, ICP instrument used, compartments measured, limb position during measurements, catheter position, exercise protocol, timing of measurements, mean resting compartment pressures, mean maximal compartment pressures, mean postexercise compartment pressures, diagnostic criteria used, and whether a reference diagnostic standard was used. The quality of studies was assessed based on the approach used by the American Academy of Orthopaedic Surgeons in judging the quality of diagnostic studies, and recommendations were made regarding each ICP diagnostic criteria in the literature by taking into account the quality and quantity of the available studies proposing each criterion.

MAIN RESULTS

In the review, 32 studies were included. The studies varied in the ICP measurement techniques used; the most commonly measured compartment was the anterior muscle compartment, and the exercise protocol varied between running, walking, and ankle plantarflexion and dorsiflexion exercises. Preexercise, mean values ranged from 7.4 to 50.8 mm Hg for CECS patients, and 5.7 to 12 mm Hg in controls; measurements during exercise showed mean pressure readings ranging from 42 to 150 mm Hg in patients and 28 to 141 mm Hg in controls. No overlap between subjects and controls in mean ICP measurements was found at the 1-minute postexercise timing interval only showing values ranging from 34 to 55.4 mm Hg and 9 to 19 mm Hg in CECS patients and controls, respectively. The quality of the studies was generally not high, and we found the evidence for commonly used ICP criteria in diagnosing CECS to be weak.

CONCLUSIONS

Studies in which an independent, blinded comparison is made with a valid reference standard among consecutive patients are yet to be undertaken. There should also be an agreed ICP test protocol for diagnosing CECS because the variability here contributes to the large differences in ICP measurements and hence diagnostic thresholds between studies. Current ICP pressure criteria for CECS diagnosis are therefore unreliable, and emphasis should remain on good history. However, clinicians may consider measurements taken at 1 minute after exercise because mean levels at this timing interval only did not overlap between subjects and controls in the studies we analyzed. Levels above the highest reported value for controls here (27.5 mm Hg) along with a good history, should be regarded as highly suggestive of CECS. It is evident that to achieve an objective recommendation for ICP threshold there is a need to set up a multi-center study group to reach an agreed testing protocol and modify the preliminary recommendations we have made.

Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom

OBJECTIVE

To investigate current practice in the diagnosis and management of chronic exertional compartment syndrome (CECS) of the lower leg among orthopedic surgeons in the United Kingdom.

DESIGN

Questionnaire survey.

SETTING

Secondary care (NHS and private).

PARTICIPANTS

Two hundred six orthopedic surgeons affiliated with one of the following specialist associations: British Association of Sports and Exercise Medicine (BASEM), United Kingdom Association of Doctors in Sport (UKADIS), British Orthopedic Sports and Trauma Association (BOSTA) and British Orthopedic Foot Surgery Society (BOFSS).

INTERVENTIONS

Self-administered questionnaire.

MAIN OUTCOME MEASURES

Current practice in diagnosis and treatment of CECS.

RESULTS

Sixty percent (124/206) of the surveyed population replied and 53% (66/124) see patients with CECS. To confirm the diagnosis, 83% (55/66) use intra-compartmental pressure measurements (ICPs). Of these, 42% use maximal ICP during exercise greater than 35 mmHg as a criterion for anterior CECS diagnosis and 35% use Pedowitz's modified criteria. Of all the respondents, 88% would be willing to adopt a National Framework document for diagnosis, 30% (20/66) always try conservative treatment following diagnosis, 93% (57/60) perform superficial fasciotomy as the first line surgical procedure, 55% (33/60) use a one incision technique for anterior fasciotomy and 60% (36/60) undertake a repeat fasciotomy following failed decompression.

CONCLUSIONS

There is agreement among orthopedic surgeons on the role of ICPs for diagnosis and the choice of fasciotomy as a first-line surgical procedure. In contrast, there is a divergence of opinions regarding the ICP diagnostic thresholds, the role of conservative management and the surgical techniques for fasciotomy and failure of decompression.

Non-traumatic lower limb vascular complications in endurance athletes. Review of literature

OBJECTIVES

To review the importance, clinical features, investigations, management and prognosis of non-traumatic vascular injuries, affecting the lower limbs of endurance athletes.

DESIGN

Review of literature.

MATERIALS AND METHODS

A literature search was conducted from Medline, Pubmed, the National Electronic Library for Health, Google and Yahoo search engines for related articles and case reports regarding non-traumatic vascular complications involving the lower limb of endurance athletes.

CONCLUSIONS

Non-traumatic vascular complications affecting the lower limbs include endofibrosis, stenosis/kinking of iliac arteries, dissection of external iliac artery, adductor canal syndrome, popliteal entrapment syndrome, chronic exertional compartment syndrome and effort-induced venous thrombosis. These are important as they affect athletes at the peak of their career and can be confusing to diagnose. The management is relatively well documented and produces good results in short term but the long term results are not known.

Arterial problems in athletes

Background

Athletes may present with arterial problems that are unusual in the typical patient with peripheral vascular disease. They are often handicapped only at the extremes of physical exertion and may have normal arterial pulses beyond any arterial occlusion.

Methods

A Medline search was undertaken for articles on arterial disease in athletes. Further papers were identified by cross-referencing from the reference lists.

Results

A variety of syndromes has been described that result from unusual trauma to arteries, causing occlusion or rupture. Frequently the blood flow and pressures distal to the arterial disease are normal at rest, and diagnosis is often confused with venous, musculoskeletal or nerve disease. A variety of operative interventions has been described.

Conclusion

Athletes may experience arterial problems that may jeopardize their careers. If recognized promptly, operative intervention may permit a return to the highest level of sporting achievement.

Chronic exertional compartment syndrome

Chronic exertional compartment syndrome is an often overlooked and uncommon cause of pain in the extremities of individuals who engage in repetitive physical activity. A thorough history, a careful physical examination, and compartment pressure testing are essential to establish the diagnosis. Catheter measurements can provide useful information on baseline resting compartment pressures as well as compartment pressures after exercise or trauma. Patients with chronic exertional compartment syndrome usually do not respond to nonsurgical therapy other than completely ceasing the activities that cause the symptoms. Surgical intervention entails fasciotomies of the involved compartments. Although obtaining accurate compartment pressure measurements can be difficult and fascial releases must be done carefully, patients typically have satisfactory functional results and are able to return to their usual physical activities after fasciotomy.

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.

Exercise induced leg pain-chronic compartment syndrome. Is the increase in intra-compartment pressure exercise specific?

Intra-compartment pressure studies remain the main investigative method in diagnosing chronic compartment syndrome (CCS). Standard exercise protocols have been used to cause the raise in pressure measured in the laboratories. This case suggests that CCS cannot be excluded without the specific sports activity being used to raise the intracompartmental pressure.

Evaluation of injection techniques in recording of intramuscular pressure

Recording of intramuscular pressure by using the injection technique in different ways has been evaluated in 12 healthy subjects and 12 patients with medial tibial syndrome. Pressure recording with an injection needle was compared to the recording by a Teflon catheter with multiple side holes at its tip. Following an injection of 0.07 ml, the intramuscular pressure was significantly higher when it was recorded with the injection needle. Pressure recorded with an injection needle by the "meniscus method" was found to be significantly closer to the preinjection pressure compared to the injection technique described by Whitesides et al. Pressure readings by the "meniscus method" after injection, and by a catheter or needle with multiple side holes, decrease the drawbacks of the injection technique.

Does oedema following lower limb revascularisation cause compartment syndromes?

Oedema of the leg, particularly the calf, is a well-recognised complication following lower limb reconstructive vascular surgery, but its effect on the limb is unknown. In this study, anterior compartment pressures and calf circumference were measured in both the operated and non-operated limbs following femoropopliteal bypass in 15 patients. All the patients developed lower limb swelling, which was significantly greater than the non-operated limb, P less than 0.05 paired t test (day 2-5). There was a significant difference in the mean anterior compartment pressures between the operated and non-operated limbs on the third and fourth postoperative days for the overall and below knee group, P less than 0.05 (paired t test). However, none of the patients developed signs, symptoms or pressures indicative of a compartment syndrome. These results suggest that the oedema following reconstructive vascular surgery is subcutaneous rather than compartmental in origin and that compartment pressure measurements should only be undertaken if a fasciotomy is being contemplated.

Compartment pressure following leg injury: the effect of diuretic treatment

Acute ischaemia in the tibial compartments is a recognized complication of fractures, vascular injury, vascular surgery, crush injuries and burns. The tissue pressure was measured in the first week after injury and the effect of diuretics has been evaluated in a double-blind randomized manner. The pressure in the anterior tibial compartment was measured in the first week after injury in a double-blind randomized manner in 40 patients who had sustained either accidental or surgical injury of the leg. The pressure in the group treated with placebos increased by 20 per cent in the first 24 hours, whereas the pressure fell by 25 per cent in those treated with diuretics. Diuretic treatment is recommended for patients with injury of the lower limbs.

Reference values for intramuscular pressure in the lower leg in man

Intramuscular pressures in the anterior tibial and superficial posterior compartments of the lower leg were measured by the wick catheter technique in 34 healthy individuals (17 males and 17 females, mean age 42 years). The pressures were measured at rest, during and after exercise and during venous and arterial occlusion. The pressure was 1.1 (range 0.3-3.0) kPa in the anterior tibial and 0.5 (range 0.0-2.0) kPa in the superficial posterior compartment at rest. During exercise the intramuscular pressures rose to 3.5 (range 1.0-8.0) kPa and 0.9 (range 0.1-2.8) kPa respectively. The anterior tibial compartment pressures were lower in females than in males at exercise and lower in older than in younger persons at rest. After exercise the pressures were back to the pre-exercise levels within 5 min. Venous occlusion caused an increase in the pressure which was more marked in the anterior tibial compartment than in the superficial posterior compartment. Arterial occlusion did not cause any dramatic changes in intramuscular pressures, but there was a slight elevation during the period of reactive hyperaemia.

Exercise-induced anterior tibial compartment compression syndrome in the elderly

Exercise-induced anterior tibial compartment compression syndrome occurs predominantly in young males. The authors report a case in a 79-year-old female as a complication of rehabilitation.

March gangrene: deep pectoral myopathy, Oregon disease, green muscle disease

Images

Chronic anterior tibial compartment syndrome. A light-microscopic, histochemical and electronmicroscopic analysis

A case of chronic anterior tibial compartment syndrome is reported where the entity was accompanied with a primary neurogenic type of muscle atrophy. Histology, histochemistry and electronmicroscopy indicated the diagnosis. The authors concluded that in a moderate case of leg trauma with peroneal nerve involvement, when it is complicated by intermittent arterial spasm, the anterior tibial compartment syndrome may develop chronically.

Acute exertional superficial posterior compartment syndrome

This case report of an acute exertional compartment syndrome involving predominantly the superficial posterior compartment emphasizes several important facts: (1) The subacute recurring syndromes, if left untreated, may develop into an acute syndrome. (2) The diagnostic findings separating the acute syndrome from the chronic forms are marked pain with passive stretch of the involved muscles, paresis, and sensory deficit.8,12,15, (3) In the acute form, immediate fasciotomy is mandatory and often results in full recovery. (4) All four major compartments of the leg are susceptible to chronic or acute compartment syndromes initiated by exertion. These compartments can be decompressed as necessary through a limited skin incision as recently reported.11 (5) The need for an easily obtainable and reproducible method for measuring intracompartment pressures (e.g., the wick catheter technique) is indicated.

Anterior tibial compartment syndrome following prolonged tetany

A patient developed a persistent, disabling, bilateral anterior tibial compartment syndrome after salicylate self-poisoning. Prolonged tetany is postulated as the probable mechanism.

Intermittent claudication in athletes

All reported cases have occurred in the anterior tibial or rarely peroneal compartments. Case I and V in this series follow this same pattern. Case II and III are unusual in that they are the first recorded cases of this syndrome occuring in the calf of a leg. In Case IV the syndrome was present both in the anterior compartment as well as in the calf. Case III in addition, demonstrated arteriographic evidence of impairment of blood flow preoperatively which was relieved by fasciotomy. It is this author's opinion that this syndrome develops due to obstruction of venous drainage by a rise in pressure in the myofascial compartment with exercise. Perhaps it occurs in athletes because the muscle hypertrophy in these patients in greater than that in the general public and the margin of safety is reduced. It is not necessary to perform complicated or painful investigative studies to make the diagnosis. Kennelly and Blumberg state that "a convincing history is all that is necessary," and the author is in complete agreement with this statement. Fasciotomy gives complete relief and is earnestly recommended both to relieve symptoms and to prevent the catastrophic consequences of muscle necrosis. In fact, in severe cases it is best to advise cessation of physical exercise until the operation can be done in order that this severe complication does not develop.