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Shankar DS, Blaeser AM, Gillinov LA, Vasavada KD, Fariyike BB, Mojica ES, Borowski LE, Jazrawi LM, Cardone DA. Paresthesia Is Predictive of Symptom Recurrence After Fasciotomy for Exertional Compartment Syndrome of the Leg. Sports Health 2024; 16:396-406. [PMID: 36951383 PMCID: PMC11025501 DOI: 10.1177/19417381231160164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Exertional compartment syndrome (ECS) is an underdiagnosed cause of lower extremity pain among athletes. The condition can be managed operatively by fasciotomy to relieve excess compartment pressure. However, symptom recurrence rates after fasciotomy are considerable, ranging from 3% to 17%. HYPOTHESIS Leg paresthesia and its distribution during ECS episodes would be a significant predictor of outcomes after fasciotomy. STUDY DESIGN Retrospective cohort study. LEVEL OF EVIDENCE Level 4. METHODS We conducted a retrospective chart review of patients who underwent fasciotomy for ECS at our center from 2010 to 2020 (institutional review board no. 21-00107). We measured postoperative outcomes including pain frequency and severity, Tegner activity level, and return to sport. Significant predictors of outcomes were identified using multivariable linear and logistic regression. P values <0.05 were considered significant. RESULTS A total of 78 legs (from 42 male and 36 female participants) were included in the study with average follow-up of 52 months (range, 3-126 months); 33 participants (42.3%) presented with paresthesia. Paresthesia was an independent predictor of worse outcomes, including more severe pain at rest (P = 0.05) and with daily activity (P = 0.04), reduced postoperative improvement in Tegner scores (P = 0.04), and lower odds of return to sport (P = 0.05). Those with paresthesia symptoms in the tibial nerve distribution had worse outcomes than those without paresthesia in terms of preoperative-to-present improvement in pain frequency (P < 0.01), pain severity at rest (P < 0.01) and with daily activity (P = 0.04), and return to sport (P = 0.04). CONCLUSION ECS patients who present with paresthesia have worse pain and activity outcomes after first-time fasciotomy, but prognosis is worst among those with tibial nerve paresthesia. CLINICAL RELEVANCE Paresthesia among ECS patients is broadly predictive of more severe recurrent leg pain, reduced activity level, and decreased odds of return to sport after fasciotomy.
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Affiliation(s)
- Dhruv S. Shankar
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Anna M. Blaeser
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Lauren A. Gillinov
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Kinjal D. Vasavada
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Babatunde B. Fariyike
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Edward S. Mojica
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Lauren E. Borowski
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Laith M. Jazrawi
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Dennis A. Cardone
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, New York
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Dean RS, Farley KX, Waterman BR, Guettler J, Bicos J. Chronic exertional compartment syndrome is frequently diagnosed through static compartment pressure measurements and managed with fasciotomy: A systematic review. J ISAKOS 2024; 9:71-78. [PMID: 37778507 DOI: 10.1016/j.jisako.2023.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/30/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Chronic exertional compartment syndrome (CECS) can be diagnosed either clinically or with intra-compartmental pressure monitor measurements and can be treated surgically or conservatively. METHODS A systematic review was performed on diagnostic and treatment modalities for CECS. Included studies were those that reported both their specific diagnostic modality and treatment regimens. Both surgical and conservative treatment strategies were considered. Demographic variables, diagnostic modalities, patient satisfaction and return to sport, the number of surgical incisions used for the anterior compartment fasciotomy, and the specific conservative treatment regimens were also recorded. Diagnostic modalities were grouped into one of three groups: 1) static compartment pressure monitor, 2) dynamic pressure monitoring, and 3) strictly clinical diagnosis. RESULTS The literature search identified 373 studies, of which 29 were included for final analysis. In total, there were 1270 total patients. Twenty-four studies used static compartment pressure monitors, 5 studies used dynamic pressure monitors and 2 studies used a strictly clinical diagnosis. Surgical management with fasciotomy was performed in 25 studies with a total of 1018 patients, while conservative management was used in 252 patients in 9 studies (5 studies included surgical and conservative treatments). Among surgical studies, 15 used a single-incision technique for anterior compartment fasciotomy, while 6 used a 2-incision technique. The reported satisfaction after fasciotomy was 42-94% while the return to sport was 26-100%. The reported return to sport in conservative management studies was 25-35%. CONCLUSION This systematic review found that the majority of clinical reports utilize static compartment pressure measurements to diagnose CECS, with fewer studies using dynamic intra-compartment pressure monitors. Additionally, surgical fasciotomy using a single-incision technique was the most common treatment strategy for anterior compartment CECC, with some studies reporting success with the two-incision technique. STUDY DESIGN Systematic review, level 4.
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Affiliation(s)
| | | | - Brian R Waterman
- Wake Forest University School of Medicine, Winston-Salem, NC, 27103 USA
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Bilichtin E, Choufani C, Derkenne C, Vioujard C, Pacull R. First Case of Surgically Treated Chronic Exertional Compartment Syndrome of the Arm. Mil Med 2024; 189:e454-e456. [PMID: 37651584 DOI: 10.1093/milmed/usad349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/26/2023] [Accepted: 08/26/2023] [Indexed: 09/02/2023] Open
Abstract
This paper reports the first case of chronic exertional compartment syndrome in the arm treated surgically. The diagnosis was made in a patient who is under 30 years old, military, and very athletic, with recurrent exertional pain in the anterior compartment of the arms associated with rhabdomyolysis. The high-pressure measurements in the arms' anterior compartment after exertional exercise confirmed the diagnosis. Given the patient's functional demands, a surgical treatment of fasciotomy of the anterior compartment by miniapproach was performed and allowed the resolution of symptomatology with a return to sport at the same level after 3 months.
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Affiliation(s)
- Emilie Bilichtin
- Orthopedic Surgery Department, Saint-Anne Army Instruction Hospital, Toulon 83000, France
- Toulon Mediterranean Orthopedic and Sport Trauma (TMOST) association, Toulon 83000, France
| | - Camille Choufani
- Orthopedic Surgery Department, Saint-Anne Army Instruction Hospital, Toulon 83000, France
- Toulon Mediterranean Orthopedic and Sport Trauma (TMOST) association, Toulon 83000, France
| | - Clément Derkenne
- Battalion of the Paris Fire Brigade, 3rd Group, Caserne Champerret, Paris 75017, France
| | - Clotilde Vioujard
- Medical imaging department, Saint-Anne Army Instruction Hospital, Toulon 83000, France
| | - Romain Pacull
- Orthopedic Surgery Department, Saint-Anne Army Instruction Hospital, Toulon 83000, France
- Toulon Mediterranean Orthopedic and Sport Trauma (TMOST) association, Toulon 83000, France
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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 (
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| | - 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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Novel Use of Botulinum Toxin in Long-Standing Adductor-Related Groin Pain: A Case Series. Clin J Sport Med 2022; 32:567-573. [PMID: 36070357 DOI: 10.1097/jsm.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 07/28/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Adductor-related groin pain (ARGP) is the most common groin injury in athletes. If conservative treatment fails, then adductor tenotomy to relieve tension can be considered. The use of botulinum toxin A (BoNT-A) has shown good results in other musculoskeletal pathologies. OBJECTIVE Assess the effectiveness of BoNT-A injections in ARGP in cases where usual treatment has failed. DESIGN Retrospective cohort study. SETTING Orthopedic Medicine and Rehabilitation Unit, University of Bordeaux. PARTICIPANTS Fifty patients treated by BoNT-A injection in ARGP after failure of medical and/or surgical treatment were included in this study. INTERVENTIONS One or several adductor muscles were injected with BoNT-A, according to clinical evaluation using ultrasound and electrical stimulation guidance. Patients were followed up at 1, 3, 6, and 12 months. MAIN OUTCOME MEASURES The primary assessment criterion was the improvement of Hip and Groin Outcome Score subscales at day 30. Secondary outcomes included pain intensity and impact on sport, work, and quality of life (QoL), the Blazina scale, and side effects. RESULTS All the first 50 injected patients (45 male and 5 female patients) were included. A significant improvement was noted regarding the majority of Hip and Groin Outcome Score subscales at day 30 ( P < 0.05). Pain intensity and its impacts were both significantly reduced ( P < 0.001): less sport and professional disability and lower impact on QoL. Severity of symptoms assessed by the Blazina scale was significantly reduced ( P < 0.001). The improvements remained significant until 1-year postinjection. CONCLUSIONS BoNT-A is promising as a new treatment for ARGP but should be fully assessed in a randomized controlled trial.
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Lu C, Yoo M, De Luigi AJ. Chronic exertional compartment syndrome in a patient with restrictive cardiomyopathy and portal hypertension. J Osteopath Med 2022; 122:631-634. [PMID: 36102848 DOI: 10.1515/jom-2022-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Chronic exertional compartment syndrome (CECS) is a condition that produces exercise-induced pain and swelling due to a transient increase in compartment pressures. It is thought to be due to muscle hypertrophy and is classically associated with young athletes under 30, overtraining, anabolic steroid use, and aberrant running biomechanics. We present a unique case of CECS in a patient without the traditional risk factors but rather diagnosed with cardiac cirrhosis and portal hypertension. This patient’s exercise-induced bilateral leg pain met the CECS criteria for leg compartment pressure testing and was attributed to fluid retention secondary to his comorbidities. His symptoms significantly improved after initiating diuretic pharmacotherapy. Based on our literature review, there is a dearth of literature associating CECS with specific chronic cardiac or hepatic conditions as well as describing its incidence in these conditions.
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Affiliation(s)
- Christopher Lu
- Montefiore Medical Center , Department of Physical Medicine & Rehabilitation , Bronx , NY , USA
| | - Min Yoo
- Spine Care and Department of Physical Medicine & Rehabilitation , Mayo Clinic Arizona , Phoenix , AZ , USA
| | - Arthur J. De Luigi
- Spine Care, Sports Medicine, and Department of Physical Medicine & Rehabilitation , Mayo Clinic Arizona , Phoenix , AZ , USA
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Botulinum Toxin A for Chronic Exertional Compartment Syndrome: A Retrospective Study of 16 Upper- and Lower-Limb Cases. Clin J Sport Med 2022; 32:e436-e440. [PMID: 34282061 DOI: 10.1097/jsm.0000000000000958] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/09/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess initial and mid-term efficacy of botulinum toxin A (BoNT-A) injections in patients with chronic exertional compartment syndrome (CECS) in the lower and upper limbs. DESIGN Retrospective monocentric study. SETTING A University Hospital Department of Physical Medicine and Rehabilitation. PATIENTS Sixteen patients with CECS of the lower and upper limbs treated with BoNT-A injections (first-line treatment) were included. INTERVENTIONS, MAIN OUTCOME MEASURES We collected data from a follow-up consultation (initial pain reduction [complete, partial, or ineffective] and specific activities triggering CECS) and a subsequent phone questionnaire (mid-term efficacy, pain recurrence, and adverse effects). RESULTS Sixteen patients were included (median age: 25.5 years), and 68.75% reported initial efficacy (4 partial and 7 complete); 8/16 patients were able to resume the activity that triggered CECS. All the patients with initial partial efficacy had pain recurrence (median time of 2.25 months). Among patients with initial complete efficacy, 57.14% had recurrence (median time of 5 months). Minor adverse effects were observed, but with no functional impact. CONCLUSION In 16 individuals with CECS treated with BoNT-A injections, we observed moderate efficacy without major adverse effects, but an initial improvement was often followed by recurrence, especially among those with partial initial efficacy.
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Berrigan WA, Wickstrom J, Farrell M, Alter K. Botulinum Toxin A for Chronic Exertional Compartment Syndrome Evaluated With Shear Wave Elastography: A Case Report. Clin J Sport Med 2022; 32:e178-e180. [PMID: 33417341 PMCID: PMC8666157 DOI: 10.1097/jsm.0000000000000910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/23/2020] [Indexed: 02/02/2023]
Abstract
ABSTRACT This case presentation offers supportive evidence that shear wave elastography may provide an alternative method of diagnosis of chronic exertional compartment syndrome (CECS). A 39-year-old female runner presented with bilateral anterior shin pain on exertion. She initially underwent compartmental pressure testing confirming the diagnosis of CECS but declined fasciotomy. When her symptoms recurred, she was referred for botulinum toxin therapy. Shear wave muscle elastography was performed in the bilateral anterior and lateral compartments following symptom provocation treadmill testing and compared with 2 control subjects. At 6 weeks and 7 months after onabotulinumtoxinA injections, she was asymptomatic, and elastography measurements revealed a reduction in muscle stiffness from initial treadmill testing.
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Affiliation(s)
- William A. Berrigan
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD
- Medstar Georgetown University Hospital-National Rehabilitation Hospital, Washington, DC
| | - Jordan Wickstrom
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD
| | - Michael Farrell
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD
- Medstar Georgetown University Hospital-National Rehabilitation Hospital, Washington, DC
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD
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Sommerfeldt M, Jack E, Playfair L, Satkunam L, Loh E, Rambaransingh B, Burnham R. Ultrasound-guided, minimally invasive looped thread fasciotomy for chronic exertional compartment syndrome of the lower leg: A cadaveric feasibility study. INTERVENTIONAL PAIN MEDICINE 2022; 1:100074. [PMID: 39238815 PMCID: PMC11373057 DOI: 10.1016/j.inpm.2022.100074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 09/07/2024]
Abstract
Background - Chronic exertional compartment syndrome (CECS) is an exertional pain syndrome that typically affects the lower legs of participants involved in high-intensity running or marching activities. Surgical open fasciotomy is the standard treatment for recalcitrant cases of CECS. Alternative, minimally invasive fasciotomy techniques are emerging which may reduce rates of procedural complications and expedite recovery. The standard fasciotomy procedure for CECS may be improved by looped thread release with additional image guidance. The aim of this study was to describe and evaluate a novel technique of ultrasound-guided, minimally invasive looped thread fasciotomy for release of anterior and lateral compartments of the leg in a cadaveric model. We hypothesized that a fasciotomy of this type would be effective in achieving a target fasciotomy length of 80% of the length of a muscle compartment while avoiding injury to neurovascular structures. Materials and methods - We conducted a controlled laboratory study. Two proceduralists performed anterior and lateral compartment fasciotomies on ten lightly embalmed cadaveric legs. A total of twenty compartment releases were completed, using an ultrasound-guided, percutaneous looped cutting thread technique. The specimens were evaluated for length and completeness of fasciotomy, as well as any inadvertent injury to muscle, tendon, or neurovascular structures. Completeness of fasciotomy was compared between the anterior and lateral compartments. Results - Eighteen of twenty (90%) fasciotomies were continuous. Fasciotomy length was consistently under target (72% complete). Completeness of lateral compartment release was significantly more likely to be under target compared to anterior compartment release (65% vs. 79%, p = 0.014). Sixteen of twenty (80%) fasciotomies incurred no iatrogenic soft tissue injury; no injuries to nerves or vessels were observed. Discussion – Ultrasound-guided, minimally invasive looped thread fasciotomy of the anterior and lateral leg compartments is feasible and can be successfully performed in a cadaveric model with low risk to neurovascular structures. However, further investigation is needed to improve completeness of release prior to recommendation for clinical use.
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Affiliation(s)
- Mark Sommerfeldt
- Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
| | - Elizabeth Jack
- Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Larry Playfair
- Central Alberta Pain and Rehabilitation Institute, Lacombe, Alberta, Canada
| | - Lalith Satkunam
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Eldon Loh
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Brian Rambaransingh
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Burnham
- Central Alberta Pain and Rehabilitation Institute, Lacombe, Alberta, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Vivo Cura Health, Calgary, Alberta, Canada
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Vogels S, Bakker EW, O'Connor FG, Hoencamp R, Zimmermann WO. Association Between Intracompartmental Pressures in the Anterior Compartment of the Leg and Conservative Treatment Outcome for Exercise-Related Leg Pain in Military Service Members. Arch Rehabil Res Clin Transl 2021; 4:100171. [PMID: 35282146 PMCID: PMC8904869 DOI: 10.1016/j.arrct.2021.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective To explore the relationship between a single the intracompartmental pressure (ICP) value in the anterior compartment of the leg 1 minute after provocative exercise and the outcome of a conservative treatment program in a cohort of military service members with chronic exercise-related leg pain. Design Retrospective cohort study. Setting Department of military sports medicine at a secondary care facility. Participants In the years 2015 through 2019, the conservative treatment program was completed by 231 service members with chronic exercise-related leg pain, of whom 108 patients with 200 affected legs met all inclusion criteria (N=108). Interventions All patients completed a comprehensive conservative treatment program, consisting of 4-6 individual gait retraining sessions during a period of 6-12 weeks. In addition, patients received uniform homework assignments, emphasizing acquisition of the new running technique. Main Outcome Measures The primary treatment outcome was return to active duty. The duration of treatment, occurrence of acute on chronic compartment syndrome, and patient-reported outcome measures were considered secondary treatment outcomes. Potential risk factors for the primary treatment outcome were identified with a generalized logistic mixed model. Results Return to active duty was possible for 74 (69%) patients, whereas 34 (31%) needed further treatment. The multivariable analysis showed that the absolute values of ICP in the anterior compartment were not associated with the treatment outcome (odds ratio, 1.01; P=.64). A lower Single Assessment Numeric Evaluation score at intake was negatively associated with the potential to successfully return to active duty (odds ratio, 0.95; P=.01). No acute on chronic compartment syndromes were reported. Conclusions A single postexercise ICP value in the anterior compartments of the lower leg of military service members with chronic exercise-related leg pain was not associated with the outcome of a secondary care conservative treatment program and can be safely postponed.
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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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Jensen M, Lystrup RM, Jonas CE. Chronic Exertional Compartment Syndrome Treated With Botulinum Toxin-A Yielding 36-Month Total Symptom Relief: A Case Report. Mil Med 2021; 188:e1310-e1313. [PMID: 34165149 DOI: 10.1093/milmed/usab253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 05/21/2021] [Accepted: 06/21/2021] [Indexed: 11/14/2022] Open
Abstract
Chronic exertional compartment syndrome (CECS) can be a debilitating condition observed in athletes, including military service members. Surgical fascial release, first described in 1956, has long been a standard treatment despite symptom recurrence in up to 45% of surgically treated military service members. A 2013 case series introduced intracompartmental Botulinum Toxin-A (BoNT-A) injections as a nonsurgical CECS treatment option, demonstrating efficacy for 15 of 16 patients. At the time of this submission, two additional case reports addressing BoNT-A injections for CECS have occurred. This case report describes a U.S. Military service member treated with ultrasound-guided BoNT-A for bilateral lower leg CECS. This patient achieved pain-free activities for 36 months with one treatment. This case, coupled with additional literature, supports consideration of BoNT-A as a potential long-term, nonsurgical alternative for CECS.
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Nwakibu U, Schwarzman G, Zimmermann WO, Hutchinson MR. Chronic Exertional Compartment Syndrome of the Leg Management Is Changing: Where Are We and Where Are We Going? Curr Sports Med Rep 2021; 19:438-444. [PMID: 33031210 DOI: 10.1249/jsr.0000000000000762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic exertional compartment syndrome (CECS) is one of the wide range of causes of exercise-related leg pain in athletes. It is defined as a transient increase in compartment pressures during activity, which causes pain, because of the inability of the fascial compartments to accommodate and is usually relieved by cessation of exercise. Exercise-induced leg pain in the athletic population is a common complaint, with reports of up to 15% of all runners arriving to initial evaluation with this presentation. Often, this lower-extremity exertional pain is grouped into the common term of "shin splints" by athletes, which is a nondiagnostic term that implies no specific pathology. It may, however, encompass much of the differential for CECS, including medial tibial stress syndrome, muscle strain, and stress fracture. Improving diagnostic techniques, as well as treatments, will continue to help athletes and patients with leg pain in the future.
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Affiliation(s)
- Uzoma Nwakibu
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Garrett Schwarzman
- Department of Orthopaedics, University of Illinois at Chicago College of Medicine, Chicago, IL
| | | | - Mark R Hutchinson
- Department of Orthopaedics, University of Illinois at Chicago College of Medicine, Chicago, IL
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Nico MAC, Carneiro BC, Zorzenoni FO, Ormond Filho AG, Guimarães JB. The Role of Magnetic Resonance in the Diagnosis of Chronic Exertional Compartment Syndrome. Rev Bras Ortop 2020; 55:673-680. [PMID: 33364643 PMCID: PMC7748934 DOI: 10.1055/s-0040-1702961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 12/05/2019] [Indexed: 11/16/2022] Open
Abstract
Chronic compartment syndrome is a common and often underdiagnosed exercise-induced condition, accounting on average for a quarter of cases of chronic exertional pain in the leg, second only to the fracture/tibial stress syndrome spectrum. It traditionally occurs in young runner athletes, although more recent studies have demonstrated a considerable prevalence in low-performance practitioners of physical activity, even in middle-aged or elderly patients. The list of differential diagnoses is extensive, and sometimes it is difficult to distinguish them only by the clinical data, and subsidiary examinations are required. The diagnosis is classically made by the clinical picture, by exclusion of the differential diagnoses, and through the measurement of the intracompartmental pressure. Although needle manometry is considered the gold standard in the diagnosis, its use is not universally accepted, since there are some important limitations, apart from the restricted availability of the needle equipment in Brazil. New protocols of manometry have recently been proposed to overcome the deficiency of the traditional ones, and some of them recommend the systematic use of magnetic resonance imaging (MRI) in the exclusion of differential diagnoses. The use of post-effort liquid-sensitive MRI sequences is a good noninvasive option instead of needle manometry in the diagnosis of chronic compartment syndrome, since the increase in post-exercise signal intensity is statistically significant when compared with manometry pressure values in asymptomatic patients and in those with the syndrome; hence, the test can be used in the diagnostic criteria. The definitive treatment is fasciotomy, although there are less effective alternatives.
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Affiliation(s)
| | - Bruno Cerretti Carneiro
- Serviço de Radiologia do sistema Musculoesquelético, Fleury Medicina & Saúde, São Paulo, SP, Brasil
| | | | | | - Julio Brandão Guimarães
- Serviço de Radiologia do sistema Musculoesquelético, Fleury Medicina & Saúde, São Paulo, SP, Brasil
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15
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Vogels S, Ritchie ED, Hundscheid HP, van Someren K, Janssen L, Hoencamp R, Scheltinga MR. Chronic Exertional Compartment Syndrome in the Leg: Comparing Surgery to Conservative Therapy. Int J Sports Med 2020; 42:559-565. [PMID: 33176383 DOI: 10.1055/a-1273-7777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The aim of this nonrandomized cohort study was to compare the clinical effectiveness of an elective fasciotomy with conservative treatment for chronic exertional compartment syndrome of the leg. Patients diagnosed with chronic exertional compartment syndrome who opted for surgery (n=188) completed a preoperative questionnaire and a 12-month postoperative questionnaire. Patients who continued conservative treatments (n=23) served as controls. Gender, age, sports activity or affected compartments were comparable, but intensity of pain was higher in the surgical group (at rest: 2.5±0.1 vs. 2.0±0.2, during exercise: 4.2±0.1 vs. 3.8±0.2; both p<0.05). Following treatment, surgical patients demonstrated a larger drop in intensity levels of pain (surgery 1.6±0.1, conservative 0.9±0.2, p=0.01) and tightness (surgery 1.4±0.1, conservative 0.4±0.3, p=0.00) during exercise. Success (good or excellent treatment effect) was attained in 42% of the surgical group compared to only 17% in the conservatively treated group (p=0.02). However, previous activity level was achieved in a mere 26% in the surgical treatment group and 35% in the conservative treatment group (p=0.33). A fasciotomy for chronic exertional compartment syndrome in the leg results in significantly decreased levels of pain and tightness and better satisfaction compared to patients who continued a conservative treatment regimen.
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Affiliation(s)
- Sanne Vogels
- Surgery Department, Alrijne Hospital, Leiderdorp, the Netherlands.,Surgery Department, Máxima Medical Center, Veldhoven, the Netherlands
| | - Ewan D Ritchie
- Surgery Department, Alrijne Hospital, Leiderdorp, the Netherlands
| | | | - Kim van Someren
- Surgery Department, Máxima Medical Center, Veldhoven, the Netherlands
| | - Loes Janssen
- Surgery Department, Máxima Medical Center, Veldhoven, the Netherlands
| | - Rigo Hoencamp
- Surgery Department, Alrijne Hospital, Leiderdorp, the Netherlands.,Defence Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marc R Scheltinga
- Surgery Department, Máxima Medical Center, Veldhoven, the Netherlands
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16
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Velasco TO, Leggit JC. Chronic Exertional Compartment Syndrome: A Clinical Update. Curr Sports Med Rep 2020; 19:347-352. [PMID: 32925373 DOI: 10.1249/jsr.0000000000000747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic exertional compartment syndrome is a debilitating condition primarily associated in highly active individuals with an estimated incidence of approximately 1 in 2000 persons/year. The etiology remains unclear to date. The differential diagnosis includes, but is not limited to stress fractures, medial tibial stress syndrome, and popliteal artery entrapment syndrome. Clinical signs and symptoms include pain in the involved compartment with exertion dissipating quickly after activity. Diagnostic tests include intramuscular compartment pressure testing, magnetic resonance imaging, near-infrared spectrometry as well as shear wave electrography. Treatments consist of nonsurgical, surgical, or the combination of the two. Gait retraining and the use of botulinum toxin appear most promising. Diagnostic lidocaine injections are emerging as a prognostic and mapping tool. Minimal invasive surgical options are being utilized allowing quicker return to activity and decreased morbidity. This article reviews the anatomy, clinical signs and symptoms, diagnostics, nonsurgical, and surgical treatments for chronic exertional compartment syndrome.
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Affiliation(s)
| | - Jeffrey C Leggit
- Uniformed Services University of the Health Sciences, Bethesda, MD
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17
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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: 14] [Impact Index Per Article: 3.5] [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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18
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Moore C, Hulsopple C, Boyce B. Utilization of Botulinum Toxin for Musculoskeletal Disorders. Curr Sports Med Rep 2020; 19:217-222. [PMID: 32516192 DOI: 10.1249/jsr.0000000000000720] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rehabilitation from musculoskeletal injuries is challenging with multiple intrinsic and extrinsic factors influencing athletes, conditions, and length of recovery. Multidisciplinary treatment strategies aim to address pathophysiology, mechanical, and psychosocial factors of injuries. An essential element in the recovery from musculoskeletal injuries is pain control and the return of physiologic function. There have been significant advancements in the understanding of pain and, therefore, new techniques and management strategies are being used. Botulinum neurotoxin (BoNT) has demonstrated valuable biopharmaceutical properties to provide neuromuscular blockade, which, in some cases, can help to return biomechanical and functional physiologic loss. There is developing literature in BoNT's ability to block pain in the treatment of painful musculoskeletal conditions. Critical analysis of the literature is necessary given the paucity of high-quality, evidence-based literature in the treatment of these conditions. This article reviews the utilization of BoNT in chronic exertional compartment syndrome, osteoarthritis, lateral epicondylosis, plantar fasciopathy, and myofascial pain syndrome.
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Affiliation(s)
- Clint Moore
- Uniformed Services University of the Health Sciences, Bethesda, MD
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19
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Salzler M, Maguire K, Heyworth BE, Nasreddine AY, Micheli LJ, Kocher MS. Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners. Sports Health 2020; 12:304-309. [PMID: 32163722 DOI: 10.1177/1941738120907897] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running. HYPOTHESIS Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy. STUDY DESIGN Case series. LEVEL OF EVIDENCE Level 4. METHODS Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy. RESULTS A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively. CONCLUSION Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery. CLINICAL RELEVANCE Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.
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Affiliation(s)
- Matthew Salzler
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Kathleen Maguire
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Adam Y Nasreddine
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
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20
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Wise SR, Trigg SD. Optimizing Health, Wellness, and Performance of the Tactical Athlete. Curr Sports Med Rep 2020; 19:70-75. [PMID: 32028351 DOI: 10.1249/jsr.0000000000000684] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Tactical athletes are individuals in service occupations with significant physical fitness and performance requirements such as law enforcement, firefighters, emergency responders, and military service members. Tactical athletes also may have specific administrative requirements related to documenting physical injuries. Musculoskeletal injuries are a large burden on the tactical athlete population, with incident rates varying based on the specific profession. Chronic exertional compartment syndrome (CECS) is difficult to manage in the tactical athlete population due to their limited ability to reduce impact activities and poor surgical outcomes. Botulinum neurotoxin-A and gait retraining show promise as alternative treatments for CECS. Heat injuries are frequent in the tactical athlete populations, and a graduated return to play process helps to prevent morbidity. Management of musculoskeletal injuries in tactical athletes requires consideration of operational schedules and adequate reconditioning, in addition to traditional injury evaluation.
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Affiliation(s)
- Sean R Wise
- National Capital Consortium Military Primary Care Sports Medicine Fellowship, Uniformed Services University of Health Sciences, Bethesda, MD
| | - Steven D Trigg
- National Capital Consortium Military Primary Care Sports Medicine Fellowship, Uniformed Services University of Health Sciences, Bethesda, MD
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21
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Nakano N, Shoman H, Khanduja V. Treatment strategies for ischiofemoral impingement: a systematic review. Knee Surg Sports Traumatol Arthrosc 2020; 28:2772-2787. [PMID: 30426139 PMCID: PMC7471170 DOI: 10.1007/s00167-018-5251-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 10/22/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE There has been relatively little information about the treatment for ischiofemoral impingement (IFI) because of its rarity as well as the uncertainty of diagnosis. The aim of this study was to provide the reader with the available treatment strategies and their related outcomes for IFI based on the best available evidence, whilst highlighting classically accepted ways of treatment as well as relatively new surgical and non-surgical techniques. METHODS A systematic review of the literature from Medline, Embase, AMED, Cochrane and Google Scholar was undertaken since inception to December 2017 following the PRISMA guidelines. Clinical outcome studies, prospective/retrospective case series and case reports that described the treatment outcome for IFI were included. Animal or cadaveric studies, trial protocols, diagnostic studies without any description of treatments, technical notes without any results, and review articles were excluded. RESULTS This systematic review found 17 relevant papers. No comparative studies were included in the final records for qualitative assessment, which means all the studies were case series and case reports. Eight studies (47.1%) utilised non-surgical treatment including injection and prolotherapy, followed by endoscopic surgery (5 studies, 29.4%) then open surgery (4 studies, 23.5%). Mean age of the participants was 41 years (11-72 years). The mean follow-up was 8.4 months distributed from 2 weeks to 2.3 years. No complications or adverse effects were found from the systematic review. CONCLUSION Several treatment strategies have been reported for IFI, and most of them have good short- to medium-term outcomes with a low rate of complications. However, there are no comparative studies to assess the superiority of one technique over another, thus further research with randomised controlled trials is required in this arena. This study explores the wide variety and categories of different treatments used for IFI to guide physicians and shed light on what can be done for this challenging cohort of patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Naoki Nakano
- grid.24029.3d0000 0004 0383 8386Department of Trauma and Orthopaedic Surgery - Young Adult Hip Service, Addenbrooke’s-Cambridge University Hospitals NHS Foundation Trust, Hills Road, Box 37, Cambridge, CB2 0QQ UK
| | - Haitham Shoman
- grid.24029.3d0000 0004 0383 8386Department of Trauma and Orthopaedic Surgery - Young Adult Hip Service, Addenbrooke’s-Cambridge University Hospitals NHS Foundation Trust, Hills Road, Box 37, Cambridge, CB2 0QQ UK
| | - Vikas Khanduja
- Department of Trauma and Orthopaedic Surgery - Young Adult Hip Service, Addenbrooke's-Cambridge University Hospitals NHS Foundation Trust, Hills Road, Box 37, Cambridge, CB2 0QQ, UK.
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22
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de Bruijn J, Winkes M, van Eerten P, Scheltinga M. [Chronic exertional compartment syndrome as a cause of anterolateral leg pain-German version]. Unfallchirurg 2019; 122:840-847. [PMID: 31628498 DOI: 10.1007/s00113-019-0642-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Exercise-induced leg pain (ELP) and tightness may be caused by a chronic exertional compartment syndrome (CECS). Although CECS can develop in any muscle compartment, most individuals suffer from an anterior tibial muscle CECS (ant-CECS). Typically, a patient with ant-CECS experiences discomfort toward the end of sports activity or in the hours thereafter. Physical examination may reveal tenderness upon palpation of the anterior tibial muscle belly. The gold standard diagnostic tool is a dynamic intracompartmental pressure (ICP) measurement demonstrating elevated muscle tissue pressures. Duplex analysis and imaging may be indicated for exclusion of concomitant entities such as entrapment of the popliteal artery or nerves. Conservative treatments including modification of the patient's running technique can be successful. A fasciotomy must be considered in recalcitrant cases. Residual or recurrent disease may necessitate partial removal of the fascia. The aim of this overview is to discuss the management of CECS in the anterolateral portion of the leg.
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Affiliation(s)
- Johan de Bruijn
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande
| | - Michiel Winkes
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande
| | - Percy van Eerten
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande
| | - Marc Scheltinga
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande.
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23
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Buerba RA, Fretes NF, Devana SK, Beck JJ. Chronic exertional compartment syndrome: current management strategies. Open Access J Sports Med 2019; 10:71-79. [PMID: 31213933 PMCID: PMC6537460 DOI: 10.2147/oajsm.s168368] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/23/2019] [Indexed: 11/23/2022] Open
Abstract
Chronic exertional compartment syndrome (CECS) is an underdiagnosed condition that causes lower and upper extremity pain in certain at-risk populations. Lower-extremity CECS is most often observed in running athletes and marching military members. Upper-extremity CECS is most commonly seen in rowers and professional motorcyclists. Although early outcome research on CECS has been based mostly on adult male patients, there has been an increase in the number of studies in pediatric and adolescent patient populations, particularly in females. Evaluation of CECS must include a thorough history and physical exam to rule out other causes of exertional leg pain, but differential diagnosis must remain high on the list. Needle manometry can be used to confirm diagnosis of CECS by measuring intracompartmental pressure. Operative treatment of CECS with fasciotomy has been shown to be effective in resolution of CECS, and new surgical techniques are being developed. In the pediatric population, endoscopy-assisted compartment release has provided high success rates with low complication rates. Nonoperative management of CECS is more commonly described in the literature, and consists of cessation of activities, altering foot-strike pattern, physical therapy, taping, and injections of botulinum toxin A. Nonetheless, larger samples and a more diverse population are needed to better understand the outcomes of nonoperative management. There have been fewer studies on upper-extremity CECS, given its rarity. Success has been found in the treatment of upper-extremity CECS with open fasciotomy, but more studies are needed to understand the efficacy of minimally invasive techniques in the upper extremity. Further research also needs to be done to understand why a large portion (approximately 20%) of the patient population does not experience full resolution of symptoms after fasciotomy.
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Affiliation(s)
- Rafael A Buerba
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nickolas F Fretes
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sai K Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer J Beck
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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24
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de Bruijn J, Winkes M, van Eerten P, Scheltinga M. Chronic exertional compartment syndrome as a cause of anterolateral leg pain. Unfallchirurg 2019; 123:8-14. [DOI: 10.1007/s00113-019-0641-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Hutto WM, Schroeder PB, Leggit JC. Botulinum Toxin as a Novel Treatment for Chronic Exertional Compartment Syndrome in the U.S. Military. Mil Med 2018; 184:e458-e461. [DOI: 10.1093/milmed/usy223] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/11/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wesley M Hutto
- School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Paul B Schroeder
- School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Jeffery C Leggit
- Department of Family Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
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26
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Orta C, Petit J, Gremeaux V. Chronic exertional compartment syndrome in hands successfully treated with botulinum toxin-A: A case. Ann Phys Rehabil Med 2018; 61:183-185. [DOI: 10.1016/j.rehab.2018.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/10/2018] [Accepted: 02/11/2018] [Indexed: 10/17/2022]
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27
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Current Diagnosis and Management of Chronic Exertional Compartment Syndrome. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0184-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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28
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Abstract
This article is a comprehensive review of the current utilizations of ultrasound in the treatment of orthopedic conditions of the foot and ankle. It reviews the diagnostic and interventional applications to commonly encountered lower-extremity ailments, including plantar fasciosis, tendinosis, and peripheral nerve disorders. It also outlines minimally invasive ultrasound-guided procedures and emerging therapies as alternatives to current treatments. These emerging therapies can be used to assist surgeons and provide options for patients needing intervention. Techniques such as hydrodissection, injection, aspiration, tenotomy, and fasciotomy are discussed, giving readers insight into different treatment modalities and options to help manage their patients.
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Affiliation(s)
- Nahum Michael Beard
- Department of Family Medicine, University of Tennessee Health Science Center, Saint Francis Family Medicine, 1301 Primacy Parkway, Memphis, TN 38119, USA; Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue Suite 520, Memphis, TN 38104.
| | - Robert Patrick Gousse
- Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue Suite 520, Memphis, TN 38104
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29
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Fouasson-Chailloux A, Menu P, Allorent J, Dauty M. Determination of the predictive clinical parameters to diagnose chronic exertional compartment syndrome. Eur J Sport Sci 2017; 18:279-285. [PMID: 29169304 DOI: 10.1080/17461391.2017.1405078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chronic exertional compartment syndrome (CECS) is characterized by pain occurring during physical activity. As clinical examination is not sufficient to diagnose it, intracompartmental pressure (ICP) measure is used for CECS confirmation. Numerous clinical signs are reported but their diagnosis predictive ability has never been studied. We aimed to determine if the 12 classically reported clinical signs are predictive of CECS. We performed a single-centre retrospective cohort study on patients referred for CECS suspicion. Patients were asked to run on a treadmill. When pain occurred, post-exercise ICP was performed. We diagnosed CECS if the ICP was ≥30 mmHg and used a logistic regression to calculate the predictive value of clinical signs. One hundred twenty-five patients were evaluated. Ninety-six had CECS and 29 did not, according to the ICP 30 mmHg cut-off. Anterior and lateral compartments were the most frequently affected. After exercise, mean ICP was 58.6 mmHg ± 20.5 in the group with CECS versus 20.9 mmHg ± 4 in the group without (p < .001). Muscle hardness, muscle hernia after exercise, absence of pain at rest and pain recidivism for the same exercise were predictive of CECS. The predictive model associated muscle hardness (Odds Ratio (OR) = 2.18; p < .001) and muscle hernia after exercise (OR = 1.44; p < .001). This model identified 88.6% of CECS subjects. The ROC curve area was 0.808 [95% CI: 0.71-0.90]. This study confirmed the importance of clinical parameters to diagnose CECS. A better knowledge of the relevant parameters could help physicians to indicate invasive examinations.
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Affiliation(s)
- Alban Fouasson-Chailloux
- a Physical Medicine and Rehabilitation Center , University Hospital of Nantes , Nantes , France.,b INSERM UMR 1229-RMES, Regenerative Medicine and Skeleton, Team STEP Skeletal physiopathology and joint regenerative medicine, Nantes University Hospital , Nantes , France
| | - Pierre Menu
- a Physical Medicine and Rehabilitation Center , University Hospital of Nantes , Nantes , France.,b INSERM UMR 1229-RMES, Regenerative Medicine and Skeleton, Team STEP Skeletal physiopathology and joint regenerative medicine, Nantes University Hospital , Nantes , France
| | - Jérémie Allorent
- a Physical Medicine and Rehabilitation Center , University Hospital of Nantes , Nantes , France
| | - Marc Dauty
- a Physical Medicine and Rehabilitation Center , University Hospital of Nantes , Nantes , France.,b INSERM UMR 1229-RMES, Regenerative Medicine and Skeleton, Team STEP Skeletal physiopathology and joint regenerative medicine, Nantes University Hospital , Nantes , France
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Chen YT, Jenkins KM. Ultrasound Finding of Ischiofemoral Impingement Syndrome and Novel Treatment With Botulinum Toxin Chemodenervation: A Case Report. PM R 2017; 10:665-670. [PMID: 29138040 DOI: 10.1016/j.pmrj.2017.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 10/12/2017] [Accepted: 11/05/2017] [Indexed: 10/18/2022]
Abstract
Ischiofemoral impingement syndrome (IFIS) is a rare and poorly understood condition that leads to deep gluteal pain, groin, and/or medial thigh pain. It has unique diagnostic challenges, with limited nonoperative treatment options. It is caused by the impingement of the quadratus femoris by the lesser trochanter and the ischium. Currently, there are no validated physical examination maneuvers for IFIS, and the value of ischiofemoral interval for establishing IFIS is also uncertain. Ultrasound-guided corticosteroid injections have been reported. Here, we present a case of novel treatment of IFIS with botulinum chemodenervation that led to long-term symptomatic and functional improvement in this patient, with the unique ultrasound findings of the "eruption sign." LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Yin-Ting Chen
- Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889; Department of Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
| | - Keyonna M Jenkins
- Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889; Department of Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
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Vajapey S, Miller TL. Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature. PHYSICIAN SPORTSMED 2017; 45:391-398. [PMID: 28952402 DOI: 10.1080/00913847.2017.1384289] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chronic exertional compartment syndrome (CECS) is a rare condition that usually affects distance runners and other running athletes. It is characterized by pain and pressure in one or multiple muscle compartments with repetitive physical activity. Reduction in pain typically occurs with cessation of activity. Evaluation of CECS consists of a thorough history of patient symptoms and ruling out of other causes of symptoms. Post-exercise pressure measurements can help confirm the diagnosis when symptoms are consistent and imaging evaluation negative for other causes. Non-operative treatment is a viable option for hindfoot runners and patients with anterior compartment syndrome of the leg. Limited-incision fasciotomy has been shown to be the most effective treatment and remains the gold standard for treatment. Minimal-incision open fasciotomy and endoscopic fasciotomy have surgical outcomes similar to wide-open fasciotomy. Military patients treated with fasciotomy have higher failure rates compared to civilians. Pediatric patients have similar outcomes compared to adults.
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Affiliation(s)
- Sravya Vajapey
- a Wexner Medical Center, Orthopaedics , Ohio State University , Columbus , OH , USA
| | - Timothy L Miller
- a Wexner Medical Center, Orthopaedics , Ohio State University , Columbus , OH , USA
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Wuellner JC, Nathe CD, Kreulen CD, Burnham KJ, Giza E. Chronic Exertional Compartment Syndrome: The Athleteʼs Claudication. OPER TECHN SPORT MED 2017. [DOI: 10.1053/j.otsm.2017.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Chronic exertional compartment syndrome (CECS) presents a unique therapeutic challenge. Fasciotomy, currently the most well accepted treatment approach, still has a significant number of treatment failures, demonstrating the need for additional options. Botulinum toxin has been introduced as a potential therapeutic agent, but long-term outcomes are unknown. We present the longest documented follow-up (14 months) of a CECS case treated with botulinum toxin injections. At 14 months follow-up, the patient reported continued pain relief and had resumed her active lifestyle without any adverse effects. Although more research is needed to optimize patient selection and treatment protocol, this case illustrates the potential for botulinum toxin as a long duration, low risk alternative treatment option for CECS.
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Isner-Horobeti ME, Muff G, Lonsdorfer-Wolf E, Deffinis C, Masat J, Favret F, Dufour SP, Lecocq J. Use of botulinum toxin type A in symptomatic accessory soleus muscle: first five cases. Scand J Med Sci Sports 2016; 26:1373-1378. [PMID: 26627136 DOI: 10.1111/sms.12616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 12/14/2022]
Abstract
Symptomatic accessory soleus muscle (ASM) can cause exercise-induced leg pain due to local nerve/vascular compression, muscle spasm, or local compartment syndrome. As intramuscular injections of botulinum toxin type A (BTX-A) can reduce muscle tone and mass, we investigated whether local BTX-A injections relieve the pain associated with symptomatic ASM. We describe five patients presenting peri/retromalleolar exertional pain and a contractile muscle mass in the painful region. Com-pression neuropathy was ruled out by electromyo-graphic analysis of the lower limb muscles. Doppler ultrasonography was normal, excluding a local vascular compression. ASM was confirmed by magnetic resonance imaging. After a treadmill stress test, abnormal intramuscular pressure values in the ASM, confirmed the diagnosis of compartment syndrome only in one patient. All five patients received BTX-A injections in two points of the ASM. The treatment efficacy was evaluated based on the disappearance of exercise-induced pain and the resumption of normal physical and sports activities. After BTX-A injection, exertional pain disappeared and all five patients resumed their normal level of physical and sports performances. Neither side effects nor motor deficits were observed. BTX-A is well tolerated in patients with ASM and could be used as a new conservative therapeutic strategy for the treatment of symptomatic ASM before surgery.
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Affiliation(s)
- M-E Isner-Horobeti
- Physical and Rehabilitation Medicine Department, Clémenceau University Institute of Rehabilitation, Strasbourg University, Strasbourg, France. .,Strasbourg Translational Medicine Federation (FMTS), EA 3072 "Mitochondria, oxidative stress and muscle protection", Strasbourg, France.
| | - G Muff
- Physical and Rehabilitation Medicine Department, Clémenceau University Institute of Rehabilitation, Strasbourg University, Strasbourg, France.,Strasbourg Translational Medicine Federation (FMTS), EA 3072 "Mitochondria, oxidative stress and muscle protection", Strasbourg, France
| | - E Lonsdorfer-Wolf
- Strasbourg Translational Medicine Federation (FMTS), EA 3072 "Mitochondria, oxidative stress and muscle protection", Strasbourg, France.,Physiology Institute, Medicine Faculty and Hospital, University Hospital, Strasbourg University, Strasbourg, France
| | - C Deffinis
- Physiology Institute, Medicine Faculty and Hospital, University Hospital, Strasbourg University, Strasbourg, France
| | - J Masat
- Strasbourg Translational Medicine Federation (FMTS), EA 3072 "Mitochondria, oxidative stress and muscle protection", Strasbourg, France.,Physiology Institute, Medicine Faculty and Hospital, University Hospital, Strasbourg University, Strasbourg, France
| | - F Favret
- Strasbourg Translational Medicine Federation (FMTS), EA 3072 "Mitochondria, oxidative stress and muscle protection", Strasbourg, France.,Faculty of Sports Sciences, Strasbourg University, Strasbourg, France
| | - S P Dufour
- Strasbourg Translational Medicine Federation (FMTS), EA 3072 "Mitochondria, oxidative stress and muscle protection", Strasbourg, France.,Faculty of Sports Sciences, Strasbourg University, Strasbourg, France
| | - J Lecocq
- Strasbourg Translational Medicine Federation (FMTS), EA 3072 "Mitochondria, oxidative stress and muscle protection", Strasbourg, France.,Physiology Institute, Medicine Faculty and Hospital, University Hospital, Strasbourg University, Strasbourg, France
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Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation. PM R 2016; 9:683-690. [DOI: 10.1016/j.pmrj.2016.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/24/2016] [Accepted: 09/03/2016] [Indexed: 11/22/2022]
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Abstract
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.
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Affiliation(s)
- Sathish Rajasekaran
- Department of Orthopaedics and Rehabilitation, University of Iowa Sports Medicine, 2701 Prairie Meadow Drive, Iowa City, IA 52242, USA; Division of Physical Medicine and Rehabilitation, University of Alberta, 10230 111 Avenue Northwest, Edmonton, AB T5G 0B7, Canada.
| | - Jonathan T Finnoff
- Department of Physical Medicine and Rehabilitation, Mayo Clinic School of Medicine, 200 1st St SW, Rochester, MN 55905, USA; Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, 4860 Y Street, Sacramento, CA 95817, USA; Mayo Clinic Sports Medicine Center, Mayo Clinic Square, 600 Hennepin Avenue, Suite 310, Minneapolis, MN 55403, USA
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Ultrasound-Guided, Percutaneous Needle Fascial Fenestration for the Treatment of Chronic Exertional Compartment Syndrome: A Case Report. PM R 2016; 8:286-90. [DOI: 10.1016/j.pmrj.2015.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/20/2015] [Accepted: 08/24/2015] [Indexed: 11/15/2022]
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Rajasekaran S, Hall MM. Nonoperative Management of Chronic Exertional Compartment Syndrome. Curr Sports Med Rep 2016; 15:191-8. [DOI: 10.1249/jsr.0000000000000261] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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ISNER-HOROBETI MARIEEVE, MUFF GUILLAUME, MASAT JULIEN, DAUSSIN JEANLUC, DUFOUR STEPHANEP, LECOCQ JEHAN. Botulinum Toxin as a Treatment for Functional Popliteal Artery Entrapment Syndrome. Med Sci Sports Exerc 2015; 47:1124-7. [DOI: 10.1249/mss.0000000000000538] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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42
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Burrus MT, Werner BC, Starman JS, Gwathmey FW, Carson EW, Wilder RP, Diduch DR. Chronic leg pain in athletes. Am J Sports Med 2015; 43:1538-47. [PMID: 25157051 DOI: 10.1177/0363546514545859] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Chronic leg pain is commonly treated by orthopaedic surgeons who take care of athletes. The sources are varied and include the more commonly encountered medial tibial stress syndrome, chronic exertional compartment syndrome, stress fracture, popliteal artery entrapment syndrome, nerve entrapment, Achilles tightness, deep vein thrombosis, and complex regional pain syndrome. Owing to overlapping physical examination findings, an assortment of imaging and other diagnostic modalities are employed to distinguish among the diagnoses to guide the appropriate management. Although most of these chronic problems are treated nonsurgically, some patients require operative intervention. For each condition listed above, the pathophysiology, diagnosis, management option, and outcomes are discussed in turn.
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Affiliation(s)
- M Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jim S Starman
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Eric W Carson
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Robert P Wilder
- Physical Medicine and Rehabilitation Department, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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43
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Mathis JE, Schwartz BE, Lester JD, Kim WJ, Watson JN, Hutchinson MR. Effect of lower extremity fasciotomy length on intracompartmental pressure in an animal model of compartment syndrome: the importance of achieving a minimum of 90% fascial release. Am J Sports Med 2015; 43:75-8. [PMID: 25361856 DOI: 10.1177/0363546514554601] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been an increase in minimally invasive surgery for chronic exertional compartment syndrome (CECS), despite the potential for incomplete compartment release and iatrogenic injuries. To our knowledge, no study has examined the effect of the length of fascial release on compartment pressures. PURPOSE/HYPOTHESIS The purpose was to explain the high failure rate seen in fascial release for CECS by evaluating the effect of fasciotomy length on intracompartmental pressures. We hypothesized that complete fascial release would need to be performed to return pressures to baseline levels. STUDY DESIGN Controlled laboratory study. METHODS Five male swine (10 lower extremities) were anesthetized. A slit catheter, connected to a pressure monitor, was inserted into the anterior compartment and a solution containing 5% swine albumin was injected into the compartment until the compartment pressure was >25 mm Hg for 10 minutes. Pressures were measured at rest, after the injection, and after each 10% incremental fasciotomy release. RESULTS The mean resting intracompartmental pressure was 3.2 mm Hg (range, 0-6 mm Hg), which increased after the injection to a mean of 37 mm Hg (range, 26-67 mm Hg). After complete fasciotomy, the mean pressure was 1.1 mm Hg (range, 0-4 mm Hg). There was a strong negative correlation (r=-0.693) between fasciotomy length and intracompartmental pressure. In 90% of the specimens, the pressures were <15 mm Hg after 80% fascial release, and after 90% release, all pressures were ≤8 mm Hg. CONCLUSION This study demonstrates a strong correlation between fasciotomy length and a reduction in intracompartmental pressures in a swine model. Our study suggests that 90% fascial release may represent a possible watershed zone, returning the intracompartmental pressure to a value at or near baseline values. CLINICAL RELEVANCE The results suggest that even in cases with near complete fascial release, intracompartmental pressures may decrease enough to provide symptomatic relief and avoid possible iatrogenic injuries associated with percutaneous release. It is unknown whether the swine model may adequately translate to the clinical setting; thus, recommendations should be taken with caution, and future studies should be performed to examine the correlation in a human model.
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Affiliation(s)
- James E Mathis
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Brian E Schwartz
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jonathan D Lester
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Walter J Kim
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jonathan N Watson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mark R Hutchinson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Lecocq J, Muff G, Masat J, Blaes C, Isner-Horobeti M. Essai de traitement du syndrome de loge d’effort d’avant bras par toxine botulinique. Ann Phys Rehabil Med 2014. [DOI: 10.1016/j.rehab.2014.03.768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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45
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Lecocq J, Muff G, Masat J, Blaes C, Isner-Horobeti M. Trial to treat the exertional compartment syndrome of the forearm by botulinum toxin. Ann Phys Rehabil Med 2014. [DOI: 10.1016/j.rehab.2014.03.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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