eMedicine Specialties > Sports Medicine > Introductory Topics in Sports Medicine

Compartment Syndromes

Gregory A Rowdon, MD, Associate Clinical Professor, Department of Medicine, Division of Family Practice, Indiana University Medical Center; Team Physician, Purdue University
Basim Abdelkarim, MD, Staff Physician, Department of Internal Medicine, University of California at Irvine Medical Center; Federico E Vaca, MD, FACEP, Team Physician, Department of Emergency Medicine, University of California Irvine; Clinical Assistant Professor, University of California at Irvine School of Medicine
Contributor Information and Disclosures

Updated: Oct 29, 2008

Introduction

Background

Chronic exertional compartment syndrome (CECS) is a condition in athletes that can occur from repetitive loading or exertional activities. It can occur in any compartment of the extremities, but chronic exertional compartment syndrome (CECS) is most commonly recognized in the lower legs. 

Although physicians have been aware of chronic exertional compartment syndrome (CECS) symptoms since the early part of the 20th century, it was not until the late 1950s that the first reports on chronic exertional compartment syndrome (CECS) were documented. Unlike acute compartment syndrome, which usually results from trauma, the pathophysiology of chronic exertional compartment syndrome (CECS) is not well understood, and multiple theories and mechanisms have been suggested as to its etiology.

Mavor was the first to describe the entity in 1956 in a patient who experienced recurrent anterior leg pain with exertion that was associated with herniation of the muscle and numbness of the affected extremity.¹

In 1975, Reneman defined the clinical manifestations of chronic exertional compartment syndrome (CECS) and identified increased intracompartmental pressure as the cause. Case studies of chronic exertional compartment syndrome (CECS) in the forearm, thigh, and gluteal regions have been described, but they are rare. The lower leg remains the most common site of involvement. Chronic exertional compartment syndrome (CECS) is a not uncommon problem among runners and is frequently misdiagnosed.

For excellent patient education resources, visit eMedicine's Sports Injury Center.

Related eMedicine topics:
Compartment Syndrome [in the Physical Medicine and Rehabilitation section]
Compartment Syndrome, Lower Extremity [in the Orthopedic Surgery section]
Compartment Syndrome, Upper Extremity [in the Orthopedic Surgery section]
Nerve Entrapment Syndromes [in the Neurosurgery section]
Nerve Entrapment Syndromes of the Lower Extremity [in the Orthopedic Surgery section]

Related Medscape topics:
Specialty Site Emergency Medicine
Specialty Site Neurology & Neurosurgery
Specialty Site Orthopaedics
CME McArdle Disease: What do Neurologists Need to Know?
Pulmonary Medicine - Case Reports - Bilateral Lower Extremity Compartment Syndrome and Anterior Tibial Stress Fractures Following an Army Physical Fitness Test

Frequency

United States

The true prevalence of chronic exertional compartment syndrome (CECS) is uncertain; however, one study found a 14% prevalence rate of anterior chronic exertional compartment syndrome (CECS) in individuals who reported lower leg pain. Males and females are affected equally, with bilateral involvement common, although involvement of a single extremity may also occur. Chronic exertional compartment syndrome (CECS) usually occurs in well-conditioned athletes younger than 40 years. Athletes with chronic exertional compartment syndrome (CECS) who markedly increase their training are at risk of developing exacerbation of this condition, as are inactive patients who initiate rigorous training.

International

The true international prevalence of chronic exertional compartment syndrome (CECS) is unknown.

Functional Anatomy

A firm grasp of lower extremity anatomy is central to understanding the pathophysiology, diagnosis, and treatment of chronic exertional compartment syndrome (CECS).

The lower leg is divided into 4 compartments. A fifth compartment has been documented, but the clinical significance of this compartment has yet to be established. The 5 compartments are as follows:

• Anterior: This consists of the tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius. The borders of this compartment are the tibia, fibula, interosseous membrane, and anterior intermuscular septum.
• Lateral: The lateral compartment includes the peroneus longus and brevis. Within the compartment lie the common peroneal nerve and its superficial and deep branches. This compartment is bordered by the anterior intermuscular septum, the fibula, the posterior intermuscular septum, and the deep fascia.
• Superficial posterior: The superficial posterior compartment is surrounded by the deep fascia of the leg and contains the gastrocnemius, soleus, and plantaris.
• Deep posterior: The deep posterior compartment lies between the tibia, fibula, deep transverse fascia, and interosseous membrane. The muscles within the deep posterior compartment are the flexor digitorum longus, flexor hallucis longus, popliteus, and tibialis posterior. Also within this compartment lie the posterior tibial artery and vein and the tibial nerve.
• Tibialis posterior: This compartment (a subdivision of the deep posterior compartment) is more recently described and consists of the tibialis posterior, which has recently been shown to have its own fascial layer.

Typically, the anterior compartment of the leg is the most frequently affected compartment in cases of chronic exertional compartment syndrome (CECS).

Sport-Specific Biomechanics

Chronic exertional compartment syndrome (CECS) pain is thought to derive from the same pathologic processes that cause pain in acute compartment syndrome, that is, compromise of the vascular supply, which leads to myoneural ischemia. Various mechanisms are suggested as to the cause of this tissue ischemia. These mechanisms include arterial spasm, capillary obstruction, arteriovenous collapse, or venous outflow obstruction. However, a magnetic resonance imaging (MRI) study conducted by Amendola et al showed that significant tissue ischemia does not develop.²

Other theories have been proposed for chronic exertional compartment syndrome (CECS) and suggest that muscle hypertrophy and/or fascial inflexibility is the origin of pain in patients with this condition. However, not all athletes with muscle hypertrophy develop compartment syndrome. Chronic exertional compartment syndrome (CECS) is associated with increased pressure in muscles at rest. Transient increases in compartmental pressure have been demonstrated in patients as a normal response to exercise. These pressures usually normalize within 5 minutes after cessation of exercise. In patients with chronic exertional compartment syndrome (CECS), however, pressures may remain elevated for 30 minutes or longer.

Another theory, known as the mechanical damage theory, states that exercise results in myofibril damage and release of protein-bound ions. Frequent damage, such as that occurring in the anterior compartment of runners, results in an increased release of ions, increased osmotic pressure, and decreased blood flow within the compartment.

Despite these various explanations for the cause of pain in chronic exertional compartment syndrome (CECS), no single theory has been overwhelmingly accepted. Further investigation is needed, including that regarding the relationship between pain and compartment metabolites.

Clinical

History

• Patients with chronic exertional compartment syndrome (CECS) report pain or tightness, cramping, burning, or aching over the affected compartment during exercise.
• Fullness in the compartment typically has a gradual onset, which usually worsens as activity progresses.
• Pain is constant, related directly to exertion.
• Pain typically begins at a predictable time after starting exercise or after reaching a certain intensity level.
• Pain is relieved or diminished with rest, but it may recur upon resuming exercise.
• Pain may be increased with active contraction and passive stretching during symptomatic episodes.
• The affected extremity may develop muscle weakness during activity, but more commonly, the patient notes the sensation of weakness, which is usually described as a loss of control of the affected extremity.
• Paresthesia or dysesthesia may develop in the distribution of the affected nerve.
• Symptoms of chronic exertional compartment syndrome (CECS) may persist for minutes, hours, or days after an episode, but they are usually of much less intensity.
• The patient may note bumps or herniations over the affected compartment.
• The patient usually denies any edema, temperature changes, or color changes of the affected extremity.

Physical

Physical examination findings from persons with chronic exertional compartment syndrome (CECS) are usually normal, unless the patient has a history of recent exercise.

• The musculature may feel firm or tense to palpation over the affected compartment.
• Evidence of muscle hernias is present in 20-60% of patients with anterior chronic exertional compartment syndrome (CECS) and is more pronounced with dorsiflexion.
• If anterior chronic exertional compartment syndrome (CECS) is a possibility, the patient may exhibit weakness on dorsiflexion and loss of sensation in the web of the first toe due to involvement of the deep peroneal nerve.³
• If the lateral compartment is affected, the patient may exhibit weakness upon inversion, with loss of sensation on the anterolateral part of the shin and the dorsum of the foot due to involvement of the superficial peroneal nerve.
• If the deep posterior compartment is affected, the patient may exhibit weakness in the foot muscles and loss of sensation in the foot arch due to involvement of the tibial nerve.
• The patient should have normal distal pulses. If the pulses are decreased, an arterial source should be considered, and evaluation for arterial insufficiency including popliteal artery entrapment should be undertaken.
• The patient should have a normal neurologic examination. If not, then a primary neurologic process should be considered.
• Patients with chronic exertional compartment syndrome (CECS) usually do not have tenderness over the posterior medial tibial cortex in the distal leg, which contrasts with medial tibial stress syndrome in which the tenderness is typically located in this area.
• Patients with chronic exertional compartment syndrome (CECS) usually do not present with focal tenderness with overlying edema, which is more indicative of a stress fracture.

Causes

Suggested causes for chronic exertional compartment syndrome (CECS) include repetitive loading or exertional activities, rapidly increased vigorous activity by the unconditioned individual, or a rapid increase of training level in conditioned athletes.

References