What is the best course of treatment for a patient with a history of runner's compartment syndrome, currently taking Adderall (amphetamine and dextroamphetamine) and 7oh, presenting with bilateral leg pain, worse on the left side, radiating up to the left thigh and down to the shin, with sharp pain upon standing and locking of the leg, accompanied by numbness, tingling, and paresthesia (pins and needles sensation) for approximately one week?

Urgent Evaluation for Acute-on-Chronic Compartment Syndrome with Possible Nerve Compression

This patient requires immediate clinical assessment with compartment pressure measurement and urgent surgical consultation, as the combination of a week-long progression of pain, paresthesias, and sharp pain with leg locking suggests evolving acute compartment syndrome superimposed on chronic exertional compartment syndrome, or alternatively, a nerve compression syndrome requiring urgent intervention. 1, 2

Immediate Diagnostic Approach

Critical Clinical Signs Present

• Pain out of proportion (sharp pain upon standing) is the earliest and most reliable warning sign of acute compartment syndrome 1, 2
• Paresthesias and numbness (pins and needles for one week) indicate nerve ischemia and represent a concerning progression 1, 2
• Pain with passive stretch (implied by "locking leg" and pain behind knee) is the most sensitive early sign, with 68% positive predictive value when combined with severe pain 2
• The one-week duration distinguishes this from typical chronic exertional compartment syndrome, which resolves with rest 3, 4

Urgent Actions Required

• Remove any constricting garments or compression wear immediately 2
• Position limbs at heart level (not elevated, as elevation decreases perfusion pressure and worsens compartment syndrome) 2
• Measure compartment pressures urgently using needle manometry or transducer-tipped monitors 2
• Fasciotomy is indicated if compartment pressure ≥30 mmHg or differential pressure (diastolic BP minus compartment pressure) ≤30 mmHg 2

Differential Diagnosis Considerations

Acute-on-Chronic Compartment Syndrome

• History of runner's compartment syndrome creates baseline elevated pressures (chronic exertional compartment syndrome typically >20 mmHg vs normal <15 mmHg) 3
• The week-long progression with persistent symptoms at rest indicates this is not typical chronic exertional compartment syndrome, which resolves with activity cessation 3, 4
• High clinical suspicion warranted given the progression from exercise-related to constant symptoms 1, 2

Alternative Diagnosis: Nerve Compression

• Sharp pain behind knee with leg locking suggests possible popliteal fossa pathology or peroneal nerve compression 2
• Bilateral presentation with worse left-sided symptoms could indicate lumbar radiculopathy, but the "locking" phenomenon and sharp localized pain favor peripheral pathology 2

Medication Considerations

• Adderall (amphetamine) can cause vasoconstriction, potentially exacerbating compartment syndrome or vascular insufficiency 1
• 7-hydroxymitragynine (7-OH, kratom derivative) has limited safety data but may affect pain perception, potentially masking early compartment syndrome symptoms 2

Management Algorithm

If Compartment Pressures ≥30 mmHg or Differential Pressure ≤30 mmHg:

1. Immediate fasciotomy of all involved compartments (likely all four leg compartments given bilateral symptoms) 1, 2
2. Monitor for myoglobinuria and maintain urine output >2 ml/kg/h to prevent acute kidney injury from rhabdomyolysis 1, 2, 5
3. Check CPK levels (>1000 IU/L indicates rhabdomyolysis; >75,000 IU/L associated with high acute kidney injury risk) 1
4. Post-fasciotomy wound care with consideration for early delayed primary closure or negative pressure wound therapy 2, 5

If Compartment Pressures Normal (<30 mmHg):

1. Urgent vascular surgery or orthopedic consultation for evaluation of popliteal artery entrapment syndrome or nerve compression 2
2. MRI of lumbar spine and lower extremities to evaluate for nerve compression, mass lesions, or vascular pathology 2
3. Nerve conduction studies and EMG can assist with prognostication but should not delay surgical intervention if clinical suspicion remains high 6

Critical Pitfalls to Avoid

• Never wait for late signs (pulselessness, pallor, paralysis)—these indicate irreversible tissue damage has already occurred 1, 2, 7
• Never rely solely on palpation (sensitivity only 54%, specificity 76%) 2, 7
• Never elevate the limbs excessively—this further decreases perfusion pressure 2, 7
• Never delay surgical consultation while ordering imaging studies if compartment syndrome is clinically suspected 2
• Do not assume this is simple chronic exertional compartment syndrome given the persistent symptoms at rest for one week 3, 4

Monitoring During Evaluation

• Repeat clinical assessment every 30 minutes to 1 hour during the first 24 hours, checking for pain, pain with passive stretch, paresthesia, and paresis 1
• Serial compartment pressure measurements if initial pressures borderline or patient unable to reliably report symptoms 1, 2
• Continuous monitoring for compartment syndrome recurrence after any intervention, particularly in severe cases 2

Prognosis and Return to Activity

• If this represents chronic exertional compartment syndrome without acute progression, fasciotomy has high success rates for return to sport in civilian athletes 4, 8
• Conservative management with gait retraining may be considered only if acute compartment syndrome is definitively ruled out and symptoms are purely exertional 9, 4
• However, given the one-week duration of constant symptoms, surgical intervention is likely necessary 1, 2