What is exertional compartment syndrome?

Exertional Compartment Syndrome

Exertional compartment syndrome is a condition characterized by transiently elevated intracompartmental pressures following repetitive motion or exercise, causing temporary, reversible ischemia, pain, weakness, and occasionally neurologic deficits in the affected compartment. 1

Clinical Presentation

• Pain out of proportion to activity that is relieved by rest is the earliest and most reliable warning sign 2
• Pain on passive stretch of the affected muscle compartment is considered a sensitive early sign 2
• Increasing firmness/tension of the compartment occurs as pressure rises 2
• Paresthesia (sensory changes) results from nerve ischemia 2
• Symptoms typically resolve when activity ceases with no permanent sequelae in chronic cases 3
• Paralysis, pulselessness, pallor, and decreased temperature are late signs indicating severe tissue damage and are more commonly seen in acute rather than exertional compartment syndrome 2

Pathophysiology

• Elevated intramuscular pressure leads to tissue ischemia, depletion of high-energy phosphate stores, and cellular acidosis 1
• Contributing anatomic factors may include:
  • Limited compartment size or constricted fascia 1
  • Increased intracompartmental volume 1
  • Loss of compartment elasticity 1
  • Poor venous return 1
  • Increased muscle bulk 1

Types and Locations

• Most commonly affects the lower leg compartments 4
• Can also occur in the thigh, foot, upper extremity, and erector spinae musculature 4
• Upper extremity cases most commonly affect athletes during sports requiring repetitive and vigorous gripping, such as rowers 3

Diagnosis

• Diagnosis is suspected based on history and confirmed with physical examination and compartment pressure measurements 1
• Intramuscular pressure evaluation before and after exercise (stress test) is the gold standard for diagnosis 1, 5
• Clinical signs alone have low sensitivity and positive predictive value but high specificity and negative predictive value 2
• Severe pain alone gives only approximately 25% chance of correctly diagnosing compartment syndrome 2
• Additional diagnostic modalities include:
  • Magnetic resonance imaging 3
  • Near infrared spectroscopy 3

Differential Diagnosis

• Claudication or other vascular abnormalities 1
• Myositis or tendinitis 1
• Periostitis 1
• Chronic strains or sprains 1
• Stress fracture 1
• Compression or systemic neuropathies 1
• Cardiac abnormalities with angina or referred extremity pain 1
• Spinal stenosis (presents with bilateral buttocks/posterior leg pain relieved by lumbar spine flexion) 6
• Venous claudication (characterized by tight, bursting pain that subsides slowly with leg elevation) 6

Management

• Initial treatment includes activity modification 1
• Nonoperative management may include:
  • Walking modification and shoe inserts 5
  • Nonsteroidal anti-inflammatory drugs 5
  • Physical therapy targeted at conditioning the affected extremity 5
• Nonoperative intervention has been shown to increase endurance in select patients, but most patients must either stop the activity associated with the compartment syndrome or proceed to surgery for complete resolution 5
• Surgical fasciotomy is recommended for patients with refractory symptoms who wish to continue exercise 1, 4
• Surgical options include:
  • Open fasciotomy - traditional approach with high success rates 5
  • Mini-open fasciotomy 3
  • Endoscopic release 3
  • Ultrasound-guided fasciotomy - emerging technique requiring minimal incision 7

Outcomes

• Surgical treatment of chronic exertional compartment syndrome with open fasciotomy is highly successful in civilian populations, with one study showing excellent return to activity/sport in 96% of cases 5
• Military personnel may experience less favorable outcomes, with one study showing only 41% able to return to full active duty postoperatively 5
• Recovery time varies by surgical technique:
  • Traditional fasciotomy typically requires 6+ weeks before return to unrestricted impact activities 7
  • Newer ultrasound-guided techniques may allow return to running within 1 week, though further research is needed 7

Monitoring and Complications

• Monitor for compartment syndrome recurrence, particularly in severe cases 2
• Potential complications of surgical management include:
  • Infection of fasciotomy wounds 2
  • Nerve injury resulting in dysesthesia 2
  • Incomplete resolution of symptoms 5