AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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 it is most commonly recognized in the lower legs. Even though physicians have been aware of CECS symptoms since the early part of the 20th century, it was not until the late 1950s that the first reports on CECS were documented. Unlike acute compartment syndrome, which usually results from trauma, the pathophysiology of 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 experiencing recurrent anterior leg pain with exertion associated with herniation of the muscle and numbness of the affected extremity.

CECS is characterized by exercise-induced pain which is relieved by rest. In severe cases, weakness and paresthesia may accompany the pain and may be the result of ischemic changes within the compartment.

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

Frequency

United States

True prevalence is uncertain; however, one study found a 14% prevalence rate of anterior CECS in individuals who reported lower leg pain. Males and females are affected equally, with bilateral involvement common. CECS usually occurs in well-conditioned athletes younger than 40 years. Athletes with CECS who markedly increase their training are at risk of developing exacerbation, as are inactive patients who initiate rigorous training.

International

The true prevalence is unknown.

Functional Anatomy

A firm grasp of lower extremity anatomy is central to understanding the pathophysiology, diagnosis, and treatment of CECS.

The lower leg is divided into 4 compartments. A fifth compartment has recently been documented, but the clinical significance of this has yet to be established. The 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 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 newly 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.

Sport Specific Biomechanics

CECS pain is thought to derive from the same pathologic processes that cause pain in acute compartment syndrome, ie, 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, an MRI study recently conducted by Amendola et al showed that significant tissue ischemia does not develop.

Other theories have been proposed and suggest that muscle hypertrophy and/or fascial inflexibility is the origin of pain in patients with CECS. However, not all athletes with muscle hypertrophy develop 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 CECS, 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 CECS, no single theory has been overwhelmingly accepted. Further investigation is needed, including the relationship between pain and compartment metabolites.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Patients report pain or tightness, cramping, burning, or aching over the affected compartment while exercising.



• 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 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 usually described as a loss of control of the affected extremity.



• Paresthesia or dysesthesia may develop in the distribution of the affected nerve.



• Symptoms may persist for minutes, hours, or days after an episode but 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 CECS are usually normal unless the patient has a history of recent exercise.

• 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 CECS and is more pronounced with dorsiflexion.



• If anterior CECS is a possibility, the patient may exhibit weakness of dorsiflexion and loss of sensation in the web of the first toe due to involvement of the deep peroneal nerve.



• 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.



• If the deep posterior compartment is affected, the patient may exhibit weakness in the foot muscles and loss of sensation in the foot arch.



• The patient should have normal distal pulses. If 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 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.
   
• In contrast to a stress fracture, in which patients typically present with focal tenderness with overlying edema, patients with CECS usually do not present in this fashion.

Causes

Suggested causes for 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.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Medial tibial stress syndrome
Stress fracture of the tibia or fibula
Tenosynovitis
Periostitis
Vascular and neurologic entrapment syndromes
Claudication
Infection
Myopathy (to include thyroid myopathy)
Tumor
Deep venous thrombosis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

Lab studies are generally not helpful in the case of a true CECS and are not usually ordered. However, some lab studies may be ordered to help rule out other causes of lower leg pain on an individual case-by-case basis. The diagnosis of CECS may be one of exclusion, based on the history, the physical examination findings, and the exclusion of various differential diagnoses.

• Serum creatine kinase and myoglobin level (myopathy or rhabdomyolysis)



• Urinalysis and urine myoglobin (rhabdomyolysis)



• D-dimer level (deep venous thrombosis)



• CBC count with differential (infection, osteomyelitis)



• Complete metabolic panel (metabolic derangements, acidosis, hypercalcemia, hyperkalemia)



• Thyroid-stimulating hormone (thyroid myopathy)



• Sedimentation rate (infection, rheumatologic conditions)

Imaging Studies

• Generally, imaging studies are not helpful in the diagnosis of CECS, but, similar to the physical examination, they may help rule out related disorders.
• • Radiography of the extremity: Anteroposterior, lateral, and oblique views may help rule out stress fractures. In addition, radiographs of the spine may help identify spinal stenosis or disk degeneration that may be the source of lower extremity pain.
  
  
  
  • Bone scan: This study helps exclude stress fracture, periostitis, and malignancy of the lower extremity.
  
  
  
  • Ultrasonography: This can be performed to visualize blood flow (ie, to rule out hematoma, deep venous thrombosis, or vascular entrapment).
  
  
  
  • CT scan and MRI: Findings can help rule other significant causes of chronic lower leg pain.
     
• MRI may be helpful in the diagnosis of CECS, although its exact role is unclear.



• Thallous chloride scintigraphy with single-photon emission computed tomography scanning has recently been studied in the diagnosis of CECS. One recent study showed that thallous chloride scintigraphy with single-photon emission computed tomography scanning was a sensitive method of diagnosis. The study was able to show (1) reversible areas of ischemia in the affected compartment during exercise testing and (2) multiple compartments with elevated pressures. However, larger studies need to be conducted to prove its efficacy.

Other Tests

• Compartment pressure readings with and without exercise are the gold standard for diagnosis. Pain reproduced during exercise in combination with elevated compartment pressures can confirm the diagnosis of CECS. If symptoms are not reproduced with exertion, the diagnosis is questionable.



• Nerve conduction studies may be helpful for detecting neurological involvement of affected compartments. However, its role is questionable in aiding the diagnosis of CECS. Such studies may be helpful for excluding other related disorders such as peripheral nerve entrapment.  In fact, a recent study by the primary author et al only demonstrated a loss of the post exercise amplitude potentiation in patients with CECS vs. controls when pre and post exercise EMGs were completed. 

Procedures

• Compartment pressure testing is considered the criterion standard for diagnosing CECS. A large-bore needle or a wick catheter is inserted into the affected muscular compartment and is then connected to a solid-state pressure monitor.
  
  
  • Testing must be performed under sterile conditions. The needle tip location, the depth of penetration, and the knee and ankle position are controlled to obtain reliable measurements. The anterior, lateral, and superficial posterior compartments are relatively easy to test; testing the deep posterior compartment is more difficult. The generally accepted method of testing is to measure the resting compartment pressure, exercise the patient until a symptomatic level is reached, and then measure again noting pressure readings at 1 minute and 5 minutes postexercise.
  
  
  
  • Not all centers have facilities to perform this test, but most Sports Medicine centers do have this capability. Occasionally, the clinician may have to rely on history and physical examination findings. However, history and examination findings alone are not usually sufficient to confirm the diagnosis.
     
• Pedowitz et al defined the criteria for the diagnosis of CECS in the leg. They are (1) a preexercise/rest pressure of greater than 15 mm Hg, (2) a 1-minute postexercise pressure of greater than 30 mm Hg, and (3) a 5-minute postexercise pressure of greater than 20 mm Hg. Although the diagnosis can be made if just 1 of the above criteria is met, the greater the number of criteria satisfied, the greater the confidence level of the diagnosis.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Conservative therapy has been attempted but generally is unsuccessful once the patient returns to normal activity. Massage therapy and physical therapy have been reported to be successful, but these reports remain largely anecdotal in regard to successful treatment.  Discontinuance of sports participation is an option but usually a choice most athletes refuse.

Medical Issues/Complications

One must perform a full evaluation and assessment to appropriately diagnose CECS. An error in diagnosis can lead to unnecessary surgical procedures (eg, fasciotomy, fasciectomy), which may lead to further complications.

Surgical Intervention

Once a patient has been diagnosed with CECS, surgical intervention is usually initiated. Fasciotomy may be performed once consultation with a surgeon has been obtained. Fasciotomy of the anterior compartment has a better outcome than fasciotomy of the posterior compartment.

Furthermore, the rehabilitation phase is prolonged for patients who undergo deep posterior compartment fasciotomy compared with those who undergo anterior compartment fasciotomy. The reasons for this difference in outcome remain unclear. Acute compartment syndrome requires fasciotomy immediately upon diagnosis.

Multiple techniques have been described for fasciotomy of the lower leg. Newer techniques have been developed to minimize the skin incision and maximize the fascial release.

Recurrence after fasciotomy is rare. If fasciotomy fails, the diagnosis of CECS should be fully reevaluated. Repeat pressure measurements are usually required. For a true recurrence, a second decompression is performed via fasciectomy and is usually successful. 

Consultations

Orthopedist, vascular surgeon, radiologist (imaging specialist)

Recovery Phase

Rehabilitation Program

Physical Therapy

This includes rest, muscle stretching prior to exercise, shoe modification, and NSAIDs to reduce inflammation. Do not cast, splint, or compress the affected limb.

Recreational Therapy

Presurgical therapy includes reduction of activity with encouragement of cross-training exercises (eg, swimming, bicycling, other low-impact activities).

Surgical Intervention

Consider fasciotomy if symptoms persist and compartment pressures are elevated.

Consultations

Orthopedist, vascular surgeon

Maintenance Phase

Rehabilitation Program

Physical Therapy

Postsurgical therapy includes assisted weightbearing with some variation dependent on surgical technique. Some physicians recommend immediate postsurgical range-of-motion activity that may include walking (unaided by 3-5 d). Early mobilization as soon as is feasible is recommended by many surgeons to avoid or prevent scarring leading to adhesions. 

Recreational Therapy

Postsurgical therapy includes cycling and swimming after healing of the surgical wounds (weeks later). Running can be performed at 3-6 weeks and full activity within approximately 6-12 weeks.

Medical Issues/Complications

The surgical result in a true case of CECS is usually good, with significant improvement of exertional pain.

• Pain can recur, and, if so, consider the possibility of an error in the initial diagnosis.



• Additionally, if pain persists with activity, consider the possibility of incomplete or incorrect decompression of a muscle compartment. 



• Complication rates of surgery have been reported in the 11-13% range and include hemorrhage, wound breakdown, pain recurrence, and complications from anesthesia.

Surgical Intervention

In the case of recurrent exertional pain, a repeat fasciotomy/fasciectomy may be needed.

Consultations

Orthopedist

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Analgesics may be warranted in patients with CECS, but they play a minimal role in treatment.  

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Return to Play

For the athlete with CECS, return to play may not be a viable option without surgical intervention. Consultation with a primary care sports medicine specialist and/or sports medicine orthopedic specialist is usually needed.

After surgical intervention to release the involved compartment, range-of-motion activity often begins immediately.

Weightbearing begins within the first week by means of aided or unaided walking. Upgrade activity to stationary cycling or swimming after wounds heal. Isokinetic muscle strengthening exercises begin at 3-4 weeks. Running is integrated into the activity program at 5-6 weeks. Full activity is introduced at approximately 6-12 weeks, with focus on speed and agility.

Complications

Surgical intervention generally has good success in persons with CECS, with success being defined as the return to athletics without significant symptoms. In the anterior compartment of the leg, success rates usually exceed 85%. In the deep posterior compartment, success rates are approximately 70%.

For unknown reasons, the deep posterior compartment does not respond as quickly or as well to fasciotomy as the anterior compartment. The majority of complications can be attributed to surgical intervention or misdiagnosis. Other reasons include postoperative hemorrhage, postoperative infection, recurrent compartment syndrome, Volkmann contracture, and permanent disability.

Prevention

Limited information is available on true prevention of CECS. Encourage cross-training exercises (eg, swimming, bicycling, other low-impact activities) and muscle stretching prior to exercise.

Prognosis

The postsurgical prognosis is good if the initial diagnosis of CECS is correct.

Education

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

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to make the correct initial diagnosis: This is key to the successful management and treatment of CECS. Misdiagnosis can lead to complications resulting from unnecessary surgery.

Special Concerns

• Consider the significant overlap between CECS and other lower extremity pain syndromes and entities. These may include periostitis, tibial stress fracture, and anterior tibial pain syndrome (ie, medial tibial stress syndrome, lateral tibial stress syndrome).

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Abramowitz AJ, Schepsis AA. Chronic exertional compartment syndrome of the lower leg. Orthop Rev. Mar 1994;23(3):219-25. [Medline].
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• Black KP, Taylor DE. Current concepts in the treatment of common compartment syndromes in athletes. Sports Med. Jun 1993;15(6):408-18. [Medline].
• Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. Mar 2000;32(3 Suppl):S4-10. [Medline].
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• Edwards PH Jr, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med. Aug 2005;33(8):1241-9. [Medline].
• Fronek J, Mubarak SJ, Hargens AR, et al. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res. Jul 1987;(220):217-27. [Medline].
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• Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. Jan-Feb 1990;18(1):35-40. [Medline].
• Raikin SM, Rapuri VR, Vitanzo P. Bilateral simultaneous fasciotomy for chronic exertional compartment syndrome. Foot Ankle Int. Dec 2005;26(12):1007-11. [Medline].
• Rorabeck CH. Exertional tibialis posterior compartment syndrome. Clin Orthop Relat Res. Jul 1986;(208):61-4. [Medline].
• Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med. May-Jun 1988;16(3):224-7. [Medline].
• Rowdon GA, Richardson JK, Hoffmann P, Zaffer M, Barill E. Chronic anterior compartment syndrome and deep peroneal nerve function. Clin J Sport Med. Oct 2001;11(4):229-33. [Medline].
• Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med. Nov-Dec 1993;21(6):811-7; discussion 817. [Medline].
• Styf JR, Körner LM. Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. J Bone Joint Surg Am. Dec 1986;68(9):1338-47. [Medline].
• Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin J Sport Med. May 2006;16(3):209-13. [Medline].
• Veith RG, Matsen FA 3rd, Newell SG. Recurrent anterior compartmental syndromes. Phys Sportsmed. 1980;8(11):80-8.

Article Last Updated: Nov 30, 2006