Chronic Syndrome

CHRONIC EXERTIONAL COMPARTMENT SYNDROME 
By Robert H. Sheinberg, DPM, DABPS, FACFAS

The muscle in the lower leg is grouped into four compartments.  During exercise these muscles may engorge with blood, causing them to enlarge.  If the compartment that they are in is not able to expand, pain, weakness, numbness and tingling may develop in the front or outer part of the leg.

CAUSES:

  • Usually occurs in well-conditioned athletes with low blood pressure.
  • Tight fascial compartments that enclose the muscles.
  • Incomplete hernias of muscle through small fascial defects do not allow the pressure in the compartment to lessen.

SYMPTOMS:

  • Pain in the front, side or back part of the leg that occur at a specific time during an activity.
  • The athlete starts to have pain during the activity and with continued activity pain worsens to a point where the athlete cannot continue to walk or run.
  • Often relieved by rest.  However, will quickly recur once the activity is resumed.
  • Pain and tenseness to the involved compartment.  The leg will feel firm or even rock hard.
  • Numbness and tingling develop in the distribution of the nerves that are affected by this condition.
  • Tingling in the toes and even a footdrop (foot slaps on the ground) may develop during the activity.
  • Pain will almost completely resolve once the activity is completely over, only to recur the next day if the activity is resumed.

TREATMENT:

  • Identification of this condition is important at the earliest stages.
  • Activities may need to be modified to work below the threshold of pressure that causes the pain. 
  • Structural abnormalities to the lower extremity may need to be identified and treated with orthotics to lessen stress to the involved area.
  • Physical therapy to strengthen weak muscles and stretch tight muscles may provide some limited benefit.
  • Compartment pressures should be tested to evaluate the pressure relative to the diastolic blood pressure of the athlete.
  • Pressures that are elevated above the threshold that are unrelenting, disallowing an athlete to participate in sports may require a simple fasciotomy to release the compartment and allow full return to all activities.

PROGNOSIS:

  •  Prognosis for conservative care for extremely elevated compartment pressures is poor.  The athlete usually will need to cease the activity causing the symptoms, which is most likely a running sport.
  • Prognosis is excellent if surgery is performed to release the compartment, thus allowing the muscle to expand without any restriction.
  • Return to sports following surgery is usually 4-6 weeks. 

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Intra-operative image of open fasciiotomy for chronic exertional compartment muscle syndrome where the bulging muscle belly can seen at the center of the image from build up of pressure within the compartment.

 

The following is the fascial covering over a muscle compartment. The condition occurs when pressure within this compartment builds up after an injury or can also occur after excercise from the inability of the muscle to decompress naturally. This leads to pain that is unrelenting and could lead to decreas blood flow and oxygen to muscle tissue causing death of that tissue.

The picture below demonstrates the fascia overlying the tissue being lifted by the forceps at the top of the picture.

Below is demonstrates incision into the compartment exposing the muscle tissue that is a deeper red color where the retractor is to the left of the picture. The opening of the this fascial tissue is vital in releasing pressure in the compartment after injury or from excercise. It also important that this release be extensive as so the fascial tissue does not heal closed allowing build of pressure again.

Complete Release of the anterior and lateral compartment (below)

Intraop Pics oF Chronic Exertional Compartment Syndrome (CECS) Anterior and Lateral Release

Left Leg

Release of the Lateral Compartment. The muscle is seen in between the 2 hemostats that are hoding the fascia that has been released

Anomaly of the Superficial Peroneal Nerve pointed out with the hemostat and freed of any adhesions

RIght Leg

 Compartment Fascia Identified

Superficial Peroneal Nerve is Identified

Scissors beginning Release of the Lateral Compartment

Release towards the knee

Releasing towards the ankle

Complete release of the fascia (Being held by the hemostats)

Lateral has been released. A small stab can be seen at the top of the fascia under the large instrument. This is the guide hole for the anterior release.

Release towards the knee

Instruement used to clear the way for the scissors towards the ankle

Release of fascia towards ankle

Complete Release of the Anterior and Lateral Compartment

Intraoperative pics of anterior and lateral compartment release for Chronic Exertional Compartment Syndrome

  

Intraop Pics Of Plantar Medial Foot Release for Chronic Exertional Compartment Syndrome in the foot