Relieving the Pain of Shin Splints

The pain and swelling associated with exertional compartment syndrome is caused by raised intracompartmental pressures possibly induced by muscle swelling or increased osmotic pressure. Although either the acute or chronic form of exertional compartment syndrome may occur, chronic is more common. Patients typically experience pain and swelling and may also have sensory deficits or paresthesias, and motor loss or weakness. Diagnosis is confirmed by intracompartmental pressure measurements before and after exercise. Although activity modification may alleviate symptoms, fasciotomy may be required.     

Effort-related chronic compartment syndrome of the lower extremity

Effort-related chronic compartment syndrome (ERCCS) of the lower extremity is often misdiagnosed, requiring repeated visits to the physician and subsequent delay in definitive treatment. The most significant causes of chronic leg pain in physically active individuals are stress fractures, shin splints, and "exercise-induced" or effort-related chronic compartment syndrome. In patients susceptible to ERCCS, the fascial compartments are too small to accommodate the associated 20% increase in muscle mass that typically occurs with heavy exercise. The increased pressure within a small unyielding compartment limits circulation and subsequent muscle function. The only appropriate conservative treatment is cessation of the offending activity. Early suspicion of the condition is paramount, because the definitive treatment is fasciotomy. ERCCS has only recently been recognized, and therefore it may be underdiagnosed. Family physicians and general medical officers caring for otherwise healthy soldiers and athletes should be aware of ERCCS so that prompt orthopedic referral for evaluation and definitive treatment will not be delayed.     

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.     

The evaluation and treatment ofexertional compartment syndrome

Exertional compartment syndrome (ECS) is becoming increasingly recognized as a cause of exercise-induced legpain in the athletic population. Unfortunately, the pathophysiology is not clearly understood. The use of 31P-NMR has shown that ischemia is not a significant component of ECS because it is in the acute syndrome. A primary diagnosis can be made after a thorough history and physical examination. In a young patient with leg pain that is only exercise induced, reproducible and associated with a normal physical examination, a diagnosis of ECS is likely and does not need to be a diagnosis of exclusion. Confirmation with intracompartmental pressure measurement still remains the gold standard before further management. Nonoperative management is usually ineffective and fasciotomies of the affected leg(s) and compartment is the recommended treatment in the symptomatic patient. At our center, the use of a two-incision anterior and lateral compartment release, and a one-incision posterior compartment release has been very successful in returning athletes symptom free to their sporting level.     

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.     

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.     

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.     

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.     

Exercise induced compartment syndrome in a professional footballer

Recurrent pain in the lower leg caused by exercise is a common problem in athletes. The main causes are exercise induced compartment syndrome, periostitis of the tibia, stress fracture, venous diseases, obliterative arterial diseases, and shin splints. Exercise induced compartment syndrome is the least common. A recurrent tightening or tense sensation and aching in anatomically defined compartments is pathognomonic. The symptoms are caused by abnormally high pressure in compartments of the leg during and after exercise. In this report, a case of exercise induced compartment syndrome in a professional footballer is described.     

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.     

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.     

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.     

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.     

Acute leg compartment syndrome after exertion

A case of a 22-year old soldier, with a history of pain in the leg during heavy exercise, which desisted at rest, was presented. One day before admission, the patient had felt an extreme exertion-induced pain in his right leg which had not lessenned at rest. At the same time, the patient noticed persistent severe leg edema. On physical examination, the intracompartmental pressure was 62 mmHg (> 30 mmHg). The patient was urgently operated on, and fasciotomy according to Mubarak was used. At second surgery, the debridement of the muscles of the posterior group of the leg, and the evacuation of hemathoma from the anterior and lateral group of the right leg muscles were perfomed. Postoperative recovery was uneventful. Fasciotomy wounds were closed within 14 days of the surgery. The complete physical treatment was done. Follow-up examinations 1, 3, and 6 months afterwards were satisfactory. The soldier completed his compulsory military service without any sequelae. Laboratory results were normal. Overlooked, unrecognized or surgically untreated compartment syndrome can cause severe damage, including even the loss of the extremity.     

Chronic compartment syndrome caused by aberrant fascia in an aerobic walker

The following is a case presentation of a 36-yr-old female athlete who presented with the symptoms and signs of chronic anterior compartment syndrome. Pre-exercise and post-exercise tissue pressure measurements revealed increased compartment pressures in both of her anterior leg compartments. Aberrant fascial bands overlying and compressing the anterior compartments were discovered at the time of surgery. Fasciotomies led to complete recovery and return to previous levels of athletic activity. This is the first report of aberrant fascia as a cause of chronic anterior 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.     

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.     

MRI findings in crural compartment syndrome: a case series

Compartment syndrome occurs when the pressure inside a closed fascial compartment increases to a level that compromises the blood supply to the structures. Untreated compartment syndrome commonly leads to muscle necrosis, limb amputation, and, if it is severe, which is seen in large compartments, renal failure and death may occur. We discussed MRI findings of crural compartment syndrome based on the case series.