Diagnosis of exercise-induced pain in the anterior aspect of the lower leg

Ninety-eight patients with chronic exercise-induced pain in the anterior compartment of the lower leg underwent extensive clinical and laboratory investigations to establish the diagnosis. They all were referred because of a putative chronic compartment syndrome (CCS). Intramuscular pressure was recorded bilaterally during exercise in the anterior tibial muscle in all of them. Conduction-velocity recordings of the deep and superficial peroneal nerves were performed in 29 patients. Other investigations included radiography, plethysmography, and scintigraphy. CCS was diagnosed in 26 of the 98 patients. Other diagnoses included periostitis in 41 patients, compression of the superficial peroneal nerve in 13, and miscellaneous other diagnoses in 18. CCS seems to be an uncommon reason for anterior pain in the lower legs.     

Simultaneous intramuscular pressure and surface electromyography measurement in diagnosing the chronic compartment syndrome

We investigated the value of surface electromyography (EMG) as an aid to diagnosing the chronic compartment syndrome (CCS) by detecting elevated intramuscular pressure (IMP) at rest after an exercise test that was caused by remaining muscle contraction. IMP and EMG were measured in the anterior tibial muscle in 37 patients who were suspected to have CCS after an exercise test. At rest after the test, the EMG signal was positive in five of 37 (14%) patients, indicating that patients had remaining muscle contractions that elevated IMP. IMP exceeded 30 mmHg in 16 of 37 patients (43%). In 13 of these 16 patients, the EMG signal was silent, confirming that they had CCS. In the remaining three patients, the EMG signal was initially positive (5–34% of maximal voluntary contraction), and then became silent after communicating with the patients to relax their legs. Only one of the three patients was proven to have CCS. Other reasons for leg pain were diagnosed in 23 patients. The results demonstrated that simultaneous measurements of IMP and EMG differentiate elevated IMP at rest after exercise due to the volumetric load of the compartment muscles seen in patients with CCS and due to the remaining muscle contraction, thereby preventing a false diagnosis of CCS.     

Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg

One hundred fifty-nine patients were referred to the authors for evaluation of chronic exertional leg pain from 1978 to 1987. The records of 131 patients were complete and available for retrospective review. Forty-five patients were diagnosed as having a chronic compartment syndrome (CCS) and seventy-five patients had the syndrome ruled out by intramuscular pressure recordings. The only significant difference found between the two groups on history and physical examination was a 45.9% incidence of muscle herniae in the patients with CCS, compared to a 12.9% incidence in those without the syndrome. One-third of the patients with the syndrome and over one-half of those without it reported persistent, moderate to severe pain at 6 month to 9 year followup. Modified, objective criteria were developed for the diagnosis of CCS. The criteria were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CCS. In the presence of appropriate clinical findings, we consider one or more of the following intramuscular pressure criteria to be diagnostic of chronic compartment syndrome of the leg: 1) a preexercise pressure greater than or equal to 15 mm Hg, 2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or 3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.     

The magnitude of intramuscular deoxygenation during exercise is an unreliable measure to diagnose the cause of leg pain

We measured intramuscular oxygenation in the anterior tibial muscle of 176 patients with exercise‐induced leg pain by noninvasive near‐infrared spectroscopy before, during, and after an exercise test that elicited the symptoms. Clinical investigation was performed after each test. Intramuscular pressure was measured in patients with nonconclusive findings. Chronic anterior compartment syndrome (CACS) was diagnosed in 47 patients, and other causes for the leg pain were diagnosed in 129 patients by clinical means. The mean level of oxygenation decreased to 33 ± 19% in patients with CACS and to 34 ± 19% in patients without CACS compared with baseline level (100%) at rest before exercise. The level of oxygenation was below 20% during the exercise test in 12 of 47 (26%) patients with CACS and in 30 of 129 (23%) patients without CACS. The time required for reoxygenation after the cessation of exercise was 61 ± 34 s in patients with CACS and 46 ± 20 s in patients without CACS (P < 0.05). We conclude that the magnitude of intramuscular deoxygenation during exercise is an unreliable measure to diagnose CACS. However, the time for reoxygenation returning to baseline level following an exercise test is a valuable adjunct in diagnosing CACS.     

Pathophysiology and diagnosis of chronic compartment syndrome

Chronic compartment syndrome (CCS) should be considered in the differential diagnosis of exertional leg pain. Currently, the pathophysiology of CCS and the mechanisms of pain production are not completely understood. It may be difficult to differentiate CCS from other etiologies of leg pain based on the history and physical examination. Objective diagnosis of CCS is facilitated by direct measurements of intramuscular pressure before, during, and after exercise. This article reviews current understanding of the pathophysiology and diagnosis of CCS.     

Intramuscular pressures in exercise-induced lower leg pain

Intramuscular pressures were measured in 12 patients with symptoms of medial tibial syndrome and in 12 patients with chronic anterior compartment syndrome. Measurements were performed with the wick catheter technique simultaneously in the deep posterior and the anterior tibial muscle compartments before, during, and after exercise. In the deep posterior compartment there was no pressure increase during or after exercise as compared to controls in either patient group. However, a significant pressure increase was present in the anterior tibial compartment during and after exercise in the patients with chronic anterior compartment syndrome as compared to normal resting values. The medial tibial syndrome patients demonstrated in the anterior tibial muscle compartment, exercise and post-exercise pressures, which were between those of the healthy controls and the chronic anterior compartment syndrome patients. The so-caLled medial tibial syndrome is probably not a compartment syndrome in the deep posterior muscle compartment. Intramuscular pressure measurement is a valuable tool in diagnosing a chronic compartment syndrome and in selecting patients in whom fasciotomy of the affected compartment is indicated.     

Anterior tibial compartment pressure during race walking

In 14 race walkers the intramuscular pressure in the anterior tibial muscle was measured with a wick catheter. At rest the pressure was 10 to 15 mmHg and increased by a factor of 10 during full speed walking. Those walkers who experienced pain in the anterior tibial muscle also had a higher than average pressure. Fasciotomy decreased the intramuscular pressure and relieved the pain.     

Posteromedial pain in the lower leg

Intramuscular pressure was recorded in 28 patients with exercise-induced posteromedial pain in the lower leg. Pressure was recorded simultaneously in the posterior tibial muscle and in the flexor digitorum muscle during an exercise test and at rest after exercise. This study shows that intramuscular pressures during exercise and the time period for normalization of the pressure at rest after exercise were within normal limits. The result of pressure recording depends on which muscle in the deep posterior compartment is investigated and on the type of work performed. This article describes some of the difficulties associated with pressure recording in the deep posterior compartment. Chronic compartment syndrome in the deep posterior compartment as a reason for pain in the posteromedial part of the lower leg could not be demonstrated.     

Long-term results of fasciotomy of the anterior compartment in patients with exercise-induced pain in the lower leg

This prospective study aims to describe the results of fasciotomy in patients with exercise-induced pain in the lower leg with suspected (chronic) exertional compartment syndrome. The diagnosis of (chronic) exertional compartment syndrome was made if pain in the lateral side of the lower leg after a standard physical load was accompanied by elevated tissue pressures in the anterior muscle compartment. Tissue measurements were performed in 114 patients. In 56 patients (106 compartments) increased tissue pressure was found (> 50 mmHg measured immediately after exercise, or > 30 mmHg if the pressure before exercise > 20 mmHg, or if the pressure five minutes after exercise is still > 30 mmHg). Two years after fasciotomy, (remaining) complaints were evaluated on the basis of a questionnaire: 87 % of the patients had significant reduction in complaints. Patients who were not found to have increased tissue pressure were also asked to report developments through the questionnaire. In 18 patients a fasciotomy was performed on the basis of the typical history, despite normal or slightly increased intramuscular pressures. Twelve of these patients (24 compartments) were asymptomatic after surgery. Fasciotomy in patients with a (chronic) exercise-induced compartment syndrome in the anterior compartment of the lower leg, based on our criteria, gave a marked reduction in symptoms in 87 % of the patients. Further research has to be done for the minimum tissue pressures above which fasciotomy may be successful in terms of reducing complaints.     

Functional knee braces increase intramuscular pressures in the anterior compartment of the leg.

The effect of three different functional knee braces on intramuscular pressures in the anterior compartment of the leg was investigated in 8 healthy subjects. Pressures were recorded with the microcapillary infusion technique while the subjects were either supine, sitting, or standing. Pressures at rest in the anterior tibial muscle increased significantly following application of each of the three knee braces regardless of posture. Similarly, muscle relaxation pressure during exercise also increased significantly on brace application. A pressure of 40 mm Hg was exceeded in 9 of 18 intramuscular pressure measurements with the subject standing. The tested functional knee braces increased muscle pressures at rest and muscle relaxation pressure during exercise to levels that, according to other studies, might decrease muscle blood flow significantly. External compression from a knee brace on leg muscles might, therefore, induce premature muscle fatigue because of local insufficient perfusion of the working muscle.     

Chronic exercise-induced pain in the anterior aspect of the lower leg. An overview of diagnosis

Clinical examination following an exercise test that elicits the symptoms of lower leg pain is most helpful in diagnosing the causes. Location of swelling, pain, impaired muscle function and impaired nerve function should all be analysed. History and clinical signs alone are insufficient to establish the diagnosis of chronic anterior compartment syndrome, and for this reason intramuscular pressure recordings have an important role in diagnosis. Different techniques for pressure recording and different pressure parameters are reviewed. Muscle relaxation pressure during exercise and intramuscular pressure at rest after exercise are the best parameters to study. Fasciotomy relieves pain in between 60% and 100% of patients. Closure of a fascial defect is never indicated, because it decreases the compartment size and may precipitate an acute compartment syndrome. Recording of nerve conduction velocity is a helpful complement in the diagnosis and evaluation of superficial peroneal nerve compression. Decompression by local fasciectomy and fasciotomy of the lateral compartment gives good results in more than 50% of patients. The value of periostitis as a clinical sign and the possibility of chronic pain following eccentric exercise are discussed.     

A Primary Care Perspective of Chronic Compartment Syndrome of the Leg

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

The role of tissue pressure measurement in diagnosing chronic anterior compartment syndrome

Pressure studies were performed in 55 patients (24 with chronic anterior leg pain and 31 asymptomatic recreational athletes). Pressure measurements were recorded at rest, during, and after exercise, using the slit catheter system. Seventeen of the twenty-four patients with symptomatic anterior leg pain were diagnosed on the basis of tissue pressure studies as having chronic exertional compartment syndrome. The increased tissue pressures at rest and after exercise are most helpful in distinguishing those patients likely to benefit from a surgical fasciotomy.     

Athletes'' leg pains.

The frequency and nature of exertion pains of the leg in athletes were studied in 2,750 cases of overuse injuries treated at the Sports Clinic of the Deaconess Institute of Oulu, Finland, during the years 1972-1977. 465 cases of exertion pain (18%) were located in the shin. The medial tibial syndrome was the most common overuse injury among these athletes, comprising 9.5% of all exertion injuries and 60% of the leg exertion pains. Together with stress fracture of the tibia, the second most common exertion pain of the leg, it accounted for 75% of the total leg pains. There are certain difficulties in differentiating between the medial tibial syndrome and stress fracture of the tibia. They both occur at the same site with similar symptoms. Radiological examination and isotope scanning are needed. The medial tibial syndrome is an overuse injury at the medial tibial border caused by running exercises. The pain is elicited by exertional ischaemia. The pathogenesis is explained by increased pressure in the fascial compartment of the deep flexor muscles due to prolonged exercise. Similar chronic ischaemic pains from exercise are also found in other fascial compartments of the leg, especially in the anterior compartment. The only treatment needed for stress fractures is rest from training. Fascial compartment pains also usually subside. If chronic fascial syndromes prevent training, fasciotomy is recommended as a reliable method to restore the athlete to normal training without pains.     

The validity of the diagnostic criteria used in chronic exertional compartment syndrome: a systematic review

Chronic exertional compartment syndrome (CECS) of the lower limb is part of a group of overuse lower limb injuries with common presenting features. It is commonly diagnosed by the measurement of raised intramuscular pressures in the lower limb. The pathophysiology of the condition is poorly understood, and the criteria used to make the diagnosis are based on small sample sizes of symptomatic patients. We carried out a systematic review to compare intramuscular pressures in the anterior compartment of healthy subjects with commonly used criteria for CECS. Thirty-eight studies were included. With the exception of relaxation pressure, the current criteria for diagnosing CECS, considered to be the gold standard, overlap the range found in normal healthy subjects. Several studies reported mean pressures that would prompt a positive diagnosis for CECS, despite none of the subjects reporting any symptoms. The intramuscular pressure at all time points has also shown to vary in relation to a number of other factors other than the presence of CECS. Taken together, these data have major implications on the ability to use these published criteria for diagnosis and question the underlying pathophysiology. Clinicians are recommended to use protocol-specific upper confidence limits to guide the diagnosis following a failed conservative management.     

Medial opening wedge tibial osteotomy and the sagittal plane: the effect of increasing tibial slope on tibiofemoral contact pressure

BACKGROUND: Altering the tibial slope in an anterior cruciate ligament-deficient knee has been shown to affect anterior-posterior tibial translation. The effects on articular contact pressure of altering tibial slope during a high tibial osteotomy are unknown. HYPOTHESES: Performing an opening wedge osteotomy anterior to the midaxial line will increase tibial slope. Increasing tibial slope with a high tibial osteotomy in an anterior cruciate ligament-deficient knee redistributes tibiofemoral joint contact pressures onto the posterior tibial plateau. STUDY DESIGN: Controlled laboratory study. METHODS: Medial opening wedge high tibial osteotomies were performed, and a plate fixation with a known diameter inset was placed along the medial tibia in an anterior position and a posterior position on 9 cadaveric knees. Medial and lateral tibiofemoral contact pressures were measured at the resulting 2 different tibial slopes in both ligament-intact and ligament-deficient states using thin electronic sensors. RESULTS: Anterior plate application resulted in an increase in posterior tibial slope by an average of 6.6 degrees (P < .001) compared with posterior plate placement. After medial opening wedge high tibial osteotomy, the mean peak lateral tibiofemoral contact pressure (3.4 MPa) was significantly greater (P = .002) than was the mean peak medial pressure (2.6 MPa). In ligament-intact specimens, altering the tibial slope did not significantly shift peak contact pressures. However, in ligament-deficient knees, increasing tibial slope by an average of 5.5 degrees significantly redistributed the location of peak intra-articular pressure, shifting it posteriorly by 24% (P = .003). CONCLUSION: Increasing tibial slope in anterior cruciate ligament-deficient knees with a high tibial osteotomy redistributes pressure into the posterior tibial plateau. CLINICAL RELEVANCE: In knees with chronic anterior cruciate ligament deficiency, posteromedial compartment degeneration is observed. Inadvertent redistribution of contact pressure into this area may be a cause of pain and premature clinical failure after medial opening wedge tibial osteotomy.     

Lateral compartment translation predicts the grade of pivot shift: a cadaveric and clinical analysis

Anterior translation of the lateral compartment was hypothesized to correlate with the clinical grade of a pivot shift maneuver. Using a computer-assisted navigation system, this hypothesis was tested by recording the maximum anterior tibial translation in the medial and lateral compartment as well as the arc of rotation during the pivot shift maneuver. One hundred and fifty-four pivot shift examinations were performed on cadavers with various degrees of instability, and 24 pivot shift exams were performed on patients under anesthesia before and after ACL reconstruction. In all positive pivot shift exams, anterior tibial translations were found to be higher on in the lateral compartment compared to the medial compartment. In addition, an excellent correlation was found between the amount of lateral compartment translation and the clinical grade of the pivot shift; medial compartment translations and amount of knee rotation could not distinguish between clinical grades. Finally, a threshold of 6–7 mm of anterior tibial translation in the lateral compartment was necessary to produce a positive pivot shift. Taken together, these data suggest that monitoring lateral compartment translations during a pivot shift exam may be a convenient means to evaluate the outcomes of ACL surgery and that requisite increases in anterior translation of the lateral compartment are necessary for each progressive clinical grade of the pivot shift examination.     

Venous obstruction in healthy limbs: a model for chronic compartment syndrome?

PURPOSE: Chronic exertional compartment syndrome (CECS) in the anterior tibial (AT) compartment is generally believed to be the result of reduced venous blood flow caused by restrictive compartments and increased intramuscular pressures. If this is so, then restricting venous flow in the muscles of healthy subjects during exercise should mimic CECS. METHODS: This hypothesis was tested in 10 control subjects (aged 19-41 yr, five males) with and without external venous occlusion induced by a sphygmomanometer cuff fitted just below the knee and inflated to 80 mm Hg. Twenty CECS patients (20-39 yr, 16 males) were studied without external occlusion. Subjects performed intermittent, isometric maximal voluntary contractions (MVC) of the AT for 20 min (1.6-s contractions, 0.5 duty cycle). MVC, tetanic force (2 s at 50 Hz), muscle thickness (ultrasound imaging), and pain were measured during exercise and 10 min of recovery. RESULTS: Venous occlusion in the controls induced greater pain, fatigue, and increase in muscle thickness (P < 0.01). Initially the patients fatigued more slowly than the occluded controls, but at the end of exercise, the fatigue and pain were similar in these two groups. The controls showed a greater increase in muscle size (P = 0.01). Recovery was similar in all three groups, although the size of the patients' muscles recovered rather more slowly. CONCLUSION: External venous occlusion of the AT muscles in control subjects induces changes very similar to those of CECS patients, although the different time courses indicate that different processes are involved. The AT compartment of CECS patients is capable of distension.     

The use of magnetic resonance imaging in exertional compartment syndromes

This prospective, double-blind study was carried out to assess the usefulness of magnetic resonance imaging (MRI) as a noninvasive method in the diagnosis of chronic compartment syndrome (CCS). As well, a new radiopharmaceutical known as methoxy isobutyl isonitrile that has been shown to be taken up by muscle in direct proportion to its blood flow was used to illustrate the possible pathophysiology of this syndrome. Twenty patients with a history of chronic leg pain and possible diagnosis of CCS and five normal volunteers had preexercise and postexercise MRI, nuclear medicine imaging, and static and dynamic slit catheter pressure studies. Nine patients had classic symptoms; only five of these nine had abnormal pressure studies. The other 11 patients had an element of pain at rest and had normal pressure studies. The nuclear blood flow studies were normal in all 25 legs tested in this study. Measurement of intrinsic MRI parameters T1 and T2 in the normal legs as well as in those with an atypical history showed a marked elevation with exercise and a gradual return to baseline postexercise that was similar to the pressure curves. In the five patients with a clinical history and elevated pressures, four had abnormal MRI studies with failure of T1 to return to baseline values. Although these results demonstrate the potential of MRI as a tool for noninvasively monitoring muscle status, clinical history and examination remain important in the diagnosis of CCS. This study indicates that the pathophysiology of exertional compartment syndrome does not appear to be related to ischemia.