The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients

BACKGROUND: Patients with chronic exertional compartment syndrome have pain during exercise that usually subsides at rest. History and physical examination may raise suspicion of the syndrome; diagnosis is usually confirmed with intracompartmental pressure measurement after exercise. Studies have shown that magnetic resonance imaging and near-infrared spectroscopy have diagnostic ability in this syndrome. HYPOTHESIS: Magnetic resonance imaging and near-infrared spectroscopy can be used to diagnose chronic exertional compartment syndrome. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients were enrolled if there was clinical suspicion of chronic exertional compartment syndrome, and a fasciotomy was performed based on this suspicion. Before fasciotomy, intracompartmental pressure, near-infrared spectroscopy, and magnetic resonance imaging data were collected during and after exercise on a treadmill. Near-infrared spectroscopy and intracompartmental pressure values were recorded in the same manner after fasciotomy. Retrospective proof that diagnosis of the syndrome had been correct was the absence of exertional complaints from the preoperative examination during exercise at postfasciotomy visit. RESULTS: Fifty patients (100 legs) participated in the prefasciotomy visit; 3 refused fasciotomy; 2 were lost to follow-up. Of 45 patients who completed the postfasciotomy visit, the diagnosis of chronic exertional compartment syndrome was retrospectively confirmed in 42 patients and discarded in 3 patients. The sensitivity for intracompartmental pressure (cutoff point, 35 mmHg) found in this study was 77% (67%-86%, exact 95% confidence interval), lower than estimates from the literature (93%). The sensitivity (previously defined cutoff) for near-infrared spectroscopy was 85% (76%-92%, exact 95% confidence interval), validating the estimate found in the literature (85%). Sensitivity of magnetic resonance imaging was comparable to that of intracompartmental pressure and near-infrared spectroscopy; associated specificity at a given sensitivity appeared to be lower with magnetic resonance imaging. CONCLUSION: This study validates the sensitivity of near-infrared spectroscopy and provides estimates for the sensitivity and specificity of magnetic resonance imaging in chronic exertional compartment syndrome in a large group of patients. The sensitivity of noninvasive near-infrared spectroscopy is clinically equivalent to that of invasive intracompartmental pressure measurements.     

Analysis of pre- and postexercise compartment pressures in the medial compartment of the foot

Growing awareness of chronic exertional compartment syndrome of the foot has led to the need for site-specific analysis of normative resting and postexertional intracompartment pressures. Thirty-four asymptomatic athletes underwent pressure testing of the medial foot compartment with an intracompartmental pressure measurement apparatus. Pressure measurements were recorded before exercise and after 20 minutes of running. Mean resting intracompartment pressure was 7.7 mm Hg, whereas mean pressures 1 and 5 minutes after exercise were 19.1 mm Hg and 10.7 mm Hg, respectively. These data were then compared with data from compartment pressure studies performed in nine symptomatic subjects, each with a clinical history suggestive of chronic exertional compartment syndrome of the medial foot compartment. The results demonstrated normative compartment pressures of the medial foot compartment are comparable with previously measured pressures of the leg. This study shows that previously defined criteria for diagnosis of chronic exertional compartment syndrome of the leg may also be used for diagnosis of chronic exertional compartment syndrome of the foot.     

A prospective blinded evaluation of exercise thallium-201 SPET in patients with suspected chronic exertional compartment syndrome of the leg.

This study compared the quantitative and qualitative results of leg thallium-201 single-photon emission tomography (SPET) imaging in patients with and without raised intracompartmental pressure associated with exercise-related leg pain. The purpose of this study was to clarify the aetiology of chronic exertional compartment syndrome (CECS), and to investigate the diagnostic applications of 201Tl SPET in CECS. Thirty-four study participants underwent compartment pressure testing (CPT) between March and August 2000. There were 25 positive CPT results (patient group), and nine negative CPT results (control group). All 34 participants underwent scintigraphy. Quantitative and qualitative assessments were performed for the anterolateral and deep posterior compartments of the lower leg. There was no significant difference in either quantitative or qualitative assessments of perfusion between those compartments with and those without CECS. In contrast, a marked effect of exercise type upon compartment perfusion pattern was noted. Results of this study indicate that there is no compartment perfusion deficit in those patients with raised intracompartmental pressure associated with CECS, and suggest a non-ischaemic basis for the pain associated with CECS. They also suggest no role for exercise perfusion scintigraphy in the diagnosis of this syndrome.     

A prospective blinded evaluation of exercise thallium-201 SPET in patients with suspected chronic exertional compartment syndrome of the leg

This study compared the quantitative and qualitative results of leg thallium-201 single-photon emission tomography (SPET) imaging in patients with and without raised intracompartmental pressure associated with exercise-related leg pain. The purpose of this study was to clarify the aetiology of chronic exertional compartment syndrome (CECS), and to investigate the diagnostic applications of ²⁰¹Tl SPET in CECS. Thirty-four study participants underwent compartment pressure testing (CPT) between March and August 2000. There were 25 positive CPT results (patient group), and nine negative CPT results (control group). All 34 participants underwent scintigraphy. Quantitative and qualitative assessments were performed for the anterolateral and deep posterior compartments of the lower leg. There was no significant difference in either quantitative or qualitative assessments of perfusion between those compartments with and those without CECS. In contrast, a marked effect of exercise type upon compartment perfusion pattern was noted. Results of this study indicate that there is no compartment perfusion deficit in those patients with raised intracompartmental pressure associated with CECS, and suggest a non-ischaemic basis for the pain associated with CECS. They also suggest no role for exercise perfusion scintigraphy in the diagnosis of this syndrome.     

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

BACKGROUND: The existence of a "fifth" compartment in the leg capable of developing distinct chronic exertional compartment syndrome remains a subject of controversy. HYPOTHESIS: Specific pressure recordings and dissection will confirm or disprove the existence of a fifth compartment. STUDY DESIGN: Empirical anatomic study. METHODS: Radiopaque dye was injected directly into the tibialis posterior muscle of 25 embalmed cadaveric legs while intracompartmental pressure was monitored. Radiographs demonstrated dye distribution, and dissection-documented fascial and epimysial layers. RESULTS: Evidence was found that the fibular origin of the flexor digitorum longus muscle, when present, could create subcompartments within the deep posterior compartment. The nature of this attachment varied from being absent, to small (<8 cm), to extensive (>8 cm). The attachment partially covered the tibialis posterior muscle in the majority of the 14 legs that developed high pressures, and it was limited or absent in the 11 legs that did not. Radiographs demonstrated that the dye was confined to the tibialis posterior muscle in four legs. CONCLUSIONS: No consistent fifth compartment exists in the leg; however, subcompartments within the deep posterior compartment created by the fibular origin of the flexor digitorum longus muscle may develop pressures congruent with chronic exertional compartment syndrome. Clinical Relevance: Potential deep posterior subcompartments demand accurate pressure investigation. A modified technique to decompress the entire deep posterior compartment, including the tibialis posterior muscle, is necessary for successful treatment of chronic exertional compartment syndrome.     

Intracompartmental pressure testing: results of an international survey of current clinical practice, highlighting the need for standardised protocols

Despite more recent non-invasive modalities generating some credence in the literature, intracompartmental pressure testing is still considered the 'gold standard' for investigating chronic exertional compartment syndrome (CECS). Intracompartmental pressure testing, when used correctly, has been shown to be accurate and reliable. However, it is a user-dependent investigation, and the manner in which the investigation is conducted plays a large role in the outcome of the test. Despite this, a standard, reproducible protocol for intracompartmental pressure testing has not been described. This results in confusion regarding interpretation of results and reduces the tests' reliability. A summary of the current understanding of CECS is presented, along with the results of a survey of specialists in Australia and New Zealand who perform intracompartmental pressure testing, which confirms that a uniform approach is currently not used in clinical practice. This highlights the need for a consensus and standardised approach to intracompartmental pressure testing.     

Acute and recurrent effort-related compartment syndrome in sports

An effort-related compartmental syndrome is a condition in which increased pressure in a muscle compartment impedes blood flow and compromises metabolic demands of the tissues within that space. One can clinically distinguish acute irreversible and chronic reversible types. The aetiology relates in most instances to a limiting noncompliant fascia surrounding the affected muscle compartment. Sports activity leads to increased muscle volume and if there is a noncompliant fascia this will result in an excessive intracompartmental pressure which interferes with muscle blood flow. As a consequence of a reduced intracompartmental blood flow a reversible (recurrent) or irreversible (acute) exercise ischaemia, a so-called 'compartmental syndrome' occurs. A compartment syndrome is typically encountered in the lower leg, but it can be also observed in the upper leg and even in the forearm. Clinical history plays a key role in the diagnosis. Pain, muscle tightness and cramp-like feeling are the most common complaints. Weakness, paralysis and numbness are seen, especially in the acute syndrome. Symptoms appear at a certain intensity of activity and disappear at rest in the chronic compartment syndrome, but in the acute type pain will persist and will be severe. It is clearly an effort-related pain syndrome. Physical examination is not always useful in diagnosing a recurrent syndrome, but in the acute syndrome one will find high sensitivity to pressure and tenseness over the involved muscle compartment. Decreased or loss of active motion and sensation in the involved compartment are frequently seen. Tissue pressure monitoring can confirm the diagnosis for both types.(ABSTRACT TRUNCATED AT 250 WORDS)     

Minimally invasive fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg: short- and long-term results

This study evaluated the efficacy of a minimally invasive percutaneous fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg (N = 118). Approximately one-third of symptomatic legs (n = 41) demonstrated fascial herniation and underwent fasciotomy without compartment pressure measurements via a small percutaneous incision using a fasciotome. Symptomatic legs with an intact fascia (n = 77) received similar operative treatment based on pressure measurements. Relief of symptoms was obtained in all but two patients. Postoperative complications included hematoma (9%), superficial peroneal nerve injury (2%), anterior ankle pain (5%), and recurrence (2%). Most patients (96%) reported unlimited exercise after a mean follow-up of 62 months. However, mild symptoms associated with nerve injury as well as ankle pain persisted (4%). A minimally invasive fasciotomy of the anterior lower leg harboring fascial hernias or a chronic exertional compartment syndrome is effective. Complications such as nerve injury and anterior ankle pain may be related to a too distally performed fasciotomy.     

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.     

Chronic exertional compartment syndrome after minor injury to the lower extremity

Since the 1950s, chronic exertional compartment syndrome of the lower leg has been thoroughly reported in the literature. The predisposing factors and pathophysiology of this condition, however, still are not fully understood. We present a case of a well-conditioned individual who developed a chronic exertional compartment syndrome of the left lower leg anterior compartment after a direct blow injury during a softball game. Trauma is not routinely implicated as a risk factor for chronic compartment syndrome, and the literature on this topic is scarce. We suggest that trauma, even low-velocity trauma, may precipitate a chronic exertional compartment syndrome. We review the literature regarding chronic exertional compartment syndromes preceded by trauma and offer explanations regarding the mechanisms by which a traumatic event may induce a chronic compartment syndrome.     

Chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome (CECS) is an overuse injury characterized by increased intracompartmental pressure during exercise. CECS has been described in the foot, thigh, and trunk, but 95% of cases occur in the lower leg. Interestingly, CECS may also affect the upper extremities and has been best described in the forearms. Unfortunately, due to the rarity of this condition, there is no consensus regarding its diagnosis and treatment. This review seeks to discuss the prevalence, etiology, diagnosis, and treatment of CECS of the forearms, which has been described in the literature.     

Exertional compartment syndrome in a Marine grunt.

Exercise-induced exertional compartment syndrome was first described by Vogt in 1945 as "march gangrene." The authors report a case of a 20-year-old United States Marine presenting with the florid findings of acute crural compartment syndrome. The patient's history of prior episodes of crural pain following long hikes led the authors to conclude that this patient had a chronic exertional compartment syndrome.     

Biomechanical differences between cases with chronic exertional compartment syndrome and asymptomatic controls during walking and marching gait

Chronic exertional compartment syndrome is a significant problem in military populations that may be caused by specific military activities. This study aimed to investigate the kinematic and kinetic differences in military cases with chronic exertional compartment syndrome and asymptomatic controls.20 males with symptoms of chronic exertional compartment syndrome of the anterior compartment and 20 asymptomatic controls were studied. Three-dimensional lower limb kinematics and kinetics were compared during walking and marching.Cases were significantly shorter in stature and took a relatively longer stride in relation to leg length than controls. All kinematic differences identified were at the ankle. Cases demonstrated increased ankle plantarflexion from mid-stance to toe-off. Cases also demonstrated less ankle inversion at the end of stance and early swing phases. Lower ankle inversion moments were observed during mid-stance.The anthropometric and biomechanical differences demonstrated provide a plausible mechanism for the development of chronic exertional compartment syndrome in this population. The shorter stature in combination with the relatively longer stride length observed in cases may result in an increased demand on the anterior compartment musculature during ambulation. The results of this study, together with clinical insights and the literature suggest that the suppression of the walk-to-run stimulus during group marches may play a significant role in the development of chronic exertional compartment syndrome within a military population. The differences in joint angles and moments also suggest an impairment of the muscular control of ankle joint function, such as a reduced effectiveness of tibialis anterior. It is unclear whether this is a cause or consequence of chronic exertional compartment syndrome.     

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.     

Diagnosis,treatment options,and rehabilitation of chronic lower leg exertional compartment syndrome

Chronic exertional compartment syndrome of the lower leg is a well-described and documented cause of exercise-related pain in recreational, elite, and military athletes. Although this condition is common, the exact underlying mechanisms, those most at risk, long-term effects on muscular strength if unrecognized, and prevention strategies are relatively uncertain. Runners are most commonly affected and can be markedly impaired by the recurrent, often predictable pain that develops with exercise. An accurate history, high index of suspicion, and compartment pressure testing before and after symptomatic exercise confirms the diagnosis. Conservative therapy is minimally effective. Fasciotomy is the treatment of choice for athletes who are unwilling to modify their exercise or sport.     

A practical approach for the differential diagnosis of chronic leg pain in the athlete

Chronic lower leg pain results from various conditions, most commonly, medial tibial stress syndrome, stress fracture, chronic exertional compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome. Symptoms associated with these conditions often overlap, making a definitive diagnosis difficult. As a result, an algorithmic approach was created to aid in the evaluation of patients with complaints of lower leg pain and to assist in defining a diagnosis by providing recommended diagnostic studies for each condition. A comprehensive physical examination is imperative to confirm a diagnosis and should begin with an inquiry regarding the location and onset of the patient's pain and tenderness. Confirmation of the diagnosis requires performing the appropriate diagnostic studies, including radiographs, bone scans, magnetic resonance imaging, magnetic resonance angiography, compartmental pressure measurements, and arteriograms. Although most conditions causing lower leg pain are treated successfully with nonsurgical management, some syndromes, such as popliteal artery entrapment syndrome, may require surgical intervention. Regardless of the form of treatment, return to activity must be gradual and individualized for each patient to prevent future athletic injury.     

Basic principles for measurement of intramuscular pressure

We review historical and methodological approaches to measurements of intramuscular pressure (IMP) in humans. These techniques provide valuable measures of muscle tone and activity as well as diagnostic criteria for evaluation of exertional compartment syndrome. Although the wick and slit catheter techniques provide accurate measurements of IMP at rest, their value for exercise studies and diagnosis of exertional compartment syndrome is limited because of low frequency response and hydrostatic (static and inertial) pressure artifacts. Presently, most information on diagnosis of exertional compartment syndromes during dynamic exercise is available using the Myopress catheter. However, future research and clinical diagnosis using IMP can be optimized by the use of a miniature transducer-tipped catheter such as the Millar Mikro-tip.     

A concept of duodenal compartment syndrome: report of three cases of duodenal stenosis due to periduodenal hematoma

Duodenal stenosis due to periduodenal hematoma is a rare condition. Although clinical presentations should vary among causes, symptoms of duodenal stenosis due to periduodenal hematoma commonly include abdominal pain, nausea, or vomiting. We describe three cases of duodenal stenosis due to periduodenal hematoma with similar clinical courses. All patients had mass-like hardness in the upper abdomen on physical examination and showed prolonged symptoms of duodenal stenosis given the usual time of hematoma resolution. On the basis of anatomic and embryologic background, hemorrhage presumably occurs in the duodenal compartment, which includes the distal part of the duodenum and its potential embryonic mesentery. Hematoma itself and the increased intracompartmental pressure result in distinctive clinical features, which suggest a concept of duodenal compartment syndrome.     

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.