What is the workup and treatment for exertional compartment syndrome?

Workup and Treatment of Exertional Compartment Syndrome

Fasciotomy is the definitive treatment for chronic exertional compartment syndrome in patients who wish to continue their physical activities at the same level of intensity. 1

Diagnosis

Clinical Presentation

• Characteristic symptoms:
  • Sharp, reproducible pain during physical activity that subsides within minutes of rest 2
  • Pain typically occurs in the lower leg, especially the anterior compartment 2
  • Symptoms worsen with continued activity and improve with rest
  • May include sensations of tightness, burning, cramping, or weakness 1
  • Symptoms are predictable and occur at similar levels of exertion 3

Physical Examination

• Examine for:
  • Tender, firm compartments during or immediately after exercise
  • Fascial hernias (present in approximately 39% of cases) 4
  • Decreased sensation or weakness in the affected compartment
  • Normal pulses at rest (distinguishing from vascular claudication)

Diagnostic Testing

• Compartment pressure measurement is the gold standard for diagnosis 1, 2
  • Measure pressures before exercise and at 1,5, and 10 minutes post-exercise
  • Diagnostic criteria:
    • Resting pressure ≥10 mmHg and/or
    • Post-exercise pressure ≥25 mmHg at 5 minutes after exercise 4

Treatment Algorithm

1. Conservative Management

• Generally unsuccessful for most patients who wish to continue their activities 1, 3
• Options include:
  • Activity modification or cessation of provocative activities
  • Footwear changes or arch supports
  • Stretching protocols
  • Note: These approaches have limited efficacy and typically do not allow return to previous activity levels 2, 3

2. Surgical Management

• Fasciotomy is the treatment of choice for patients who wish to continue their activities 1, 3
• Surgical approaches:
  • Traditional open fasciotomy
  • Minimally invasive endoscopic fasciotomy 5
    • Uses small incisions and arthroscopic visualization
    • Allows excellent visualization of important structures (superficial peroneal nerve, perforating vessels)
    • Complete release of affected compartments with minimal soft tissue disruption
    • Earlier return to activities (approximately 6 weeks post-surgery) 5

3. Post-Surgical Rehabilitation

• Graduated return to activities starting at 6 weeks post-surgery 5
• Progressive strengthening and flexibility exercises
• Monitoring for recurrence of symptoms

Compartment-Specific Considerations

Lower Leg

• Most common location (especially anterior compartment) 2
• Four compartments may be affected:
  • Anterior (most common)
  • Lateral
  • Deep posterior
  • Superficial posterior
• May require release of multiple compartments based on pressure measurements

Other Locations

• Less commonly reported in:
  • Thigh
  • Foot
  • Upper extremity
  • Erector spinae musculature 1

Pitfalls and Caveats

1. Misdiagnosis: Chronic exertional compartment syndrome can be misdiagnosed as:

   • Medial tibial stress syndrome (shin splints)
   • Stress fractures
   • Tendinopathies
   • Vascular claudication

2. Surgical complications:

   • Inadequate fascial release can lead to symptom recurrence
   • Fascial closure instead of fasciotomy can cause acute compartment syndrome 4
   • Potential injury to superficial nerves during surgery

3. Monitoring for acute compartment syndrome:

   • Any patient who develops myoglobinuria should be monitored for compartment syndrome
   • Clinical monitoring includes assessment for pain, swelling, muscle firmness, and peripheral pulses
   • If suspected, compartment pressures should be measured
   • Treatment for acute compartment syndrome is immediate fasciotomy 6

4. Distinguishing from acute compartment syndrome:

   • Chronic exertional compartment syndrome: pain resolves with rest
   • Acute compartment syndrome: requires immediate surgical intervention to prevent tissue necrosis

By following this diagnostic and treatment algorithm, clinicians can effectively manage exertional compartment syndrome and help patients return to their desired level of physical activity.