What is the appropriate action for an athlete with pain on dorsiflexion of the foot and decreased sensation in the first web space after vigorous exercise?

Immediate Fasciotomy is Required for Athlete with Exertional Compartment Syndrome

The appropriate action for an athlete with pain on dorsiflexion of the foot and decreased sensation in the first web space after vigorous exercise is immediate fasciotomy (option c).

Clinical Presentation and Diagnosis

The athlete's symptoms strongly suggest chronic exertional compartment syndrome (CECS), a condition characterized by:

• Pain on dorsiflexion after vigorous exercise 1
• Decreased sensation (paresthesia) in the first web space, indicating nerve compression 2
• Symptoms occurring after vigorous physical activity 3

These clinical findings are classic for anterior compartment syndrome, which is the most common site for CECS in the lower limbs 3.

Rationale for Immediate Fasciotomy

Immediate fasciotomy is indicated because:

• Paresthesia (decreased sensation) is a significant predictor of worse outcomes if treatment is delayed 2
• Nerve and muscle ischemia are already occurring, as evidenced by the sensory changes 4
• Delayed treatment can lead to irreversible muscle ischemia and permanent nerve damage 4
• The combination of pain on dorsiflexion and sensory changes indicates advanced compartment pressure elevation 4

Why Other Options Are Incorrect

• Option A (color duplex scan and immediate heparinization): This would be appropriate for vascular occlusion, but the clinical presentation is consistent with compartment syndrome, not arterial thrombosis 4
• Option B (leg elevation, ice packs, and NSAIDs): Conservative measures are insufficient when neurological symptoms are present, as they do not address the underlying increased compartment pressure 3
• Option D (immediate femoral arteriogram): This would diagnose arterial issues but would delay treatment of compartment syndrome, which is the more likely diagnosis based on symptoms 4

Management Algorithm

1. Recognize the signs of compartment syndrome:

   • Pain out of proportion to injury 4
   • Pain on passive stretch of affected muscle compartment 4
   • Paresthesia (decreased sensation) 4
   • Affected compartment swelling and firmness 4

2. Understand that the presence of both severe pain and paresthesia has a high predictive value for compartment syndrome 4

3. Proceed directly to fasciotomy when:

   • Neurological symptoms (paresthesia) are present 2
   • Pain on dorsiflexion occurs after exercise 1
   • Symptoms are consistent with anterior compartment syndrome 3

Expected Outcomes After Fasciotomy

• 80% or more of patients experience relief following fasciotomy 1
• Athletes typically return to training in approximately 8 weeks 1
• Minimally invasive techniques allow return to training in a median of 8 weeks and return to sport in 13 weeks 3
• 94% of athletes can return to pre-injury or higher levels of sport participation 3

Important Considerations

• Delayed diagnosis and treatment can lead to permanent muscle and nerve damage 4
• Paresthesia is associated with worse outcomes and higher recurrence rates after fasciotomy, emphasizing the need for immediate intervention 2
• Minimally invasive fasciotomy techniques may offer quicker healing time while being equally effective 5