Chronic exertional compartment syndrome
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f33 (Published 15 January 2013) Cite this as: BMJ 2013;346:f33All rapid responses
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I read Paik et al. well-written article on this common, easily missed and troublesome syndrome with much interest. I agree with earlier responses and the author’s own reference to Aweid et al. recent work questioning the reliability of intracompartmental pressure testing.1 Furthermore, unfortunately outcomes of conservative management are rarely acceptable and whilst surgical intervention can produce satisfactory results, at least in the short-term, it is not without potential complication.
I note with delight Dr. Strange’s successful ‘running re-education’ therapy. Forefoot striking has previously been associated with reduced anterior compartment pressures.2 Such a gait is often adapted by barefoot runners, which has attracted much recent attention following Lieberman et al. studies in habitually barefoot individuals.3 4 Work by Diebel et al. found significant improvements in intracompartmental pressure, running distance and pain following a 6-week intervention involving instruction and training to adopt a forefoot strike pattern in 10 patients diagnosed with chronic exertional compartment syndrome (CECS) with significant subjective and objective improvements remaining at 1-year follow-up.5
Whilst the syndrome remains poorly understood Franklyn-Miller et al. propose that the syndrome be considered a ‘biomechanical overload syndrome’.6 This is consistent with knowledge that the anterior compartment is highly active during eccentric dorsiflexion during a rearfoot (heel) strike (especially with the increased moment added by a shoe’s heel) and the association between this muscle activity and raised intra-compartmental pressure and reduced fascial compliance.7
With emerging evidence that forefoot strikers have lower injury rates and reports that CECS symptoms improve with the adoption of this gait, a move towards the appropriate consideration and adjustment of kinematics should be welcomed and should merit further study. The author would stress that any attempts to transition from rearfoot to forefoot striking needs to be done gradually, like any other training programme.
1. Aweid O, Del Buono A, Malliaras P, Iqbal H, Morrissey D, Maffulli N, et al. Systematic Review and Recommendations for Intracompartmental Pressure Monitoring in Diagnosing Chronic Exertional Compartment Syndrome of the Leg. Clin. J Sports Med. 2012;22(4):356–70.
2. Kirby RL, McDermott AG. Anterior tibial compartment pressures during running with rearfoot and forefoot landing styles. Arch Phys Med Rehabil. 1983;64: 296-299.
3. Lieberman DE, Venkadesan M, Werbel WA, Daoud AI, D’Andrea S, Davis IS et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010;463(7280):531-535.
4. Daoud AI, Geissler GJ, Wang F, Saretsky J, Daoud YA, Lieberman DE. Foot strike and injury rates in endurance runners: a retrospective study. Med Sci Sports Exerc. 2012;44(7):1325–34.
5. Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40(5):1060–7.
6. Franklyn-Miller A, Roberts A, Hulse D, Foster J. Biomechanical overload syndrome: defining a new diagnosis. Br J Sports Med. 2012;0:1-3.
7. Tweed JL, Barnes MR. Is eccentric muscle contraction a significant factor in the development of chronic anterior compartment syndrome? A review of the literature. The Foot. 2008;18(3):165–70.
Competing interests: No competing interests
This is a very useful article but it would have been even better if the four anatomical compartments of the lower leg had been defined. In the figure in the article, the anterior contains the tibialis anterior, ext hallucis longus and ext dig longus, and the lateral peroneus longus and brevis. The superficial posterior compartment contains the gastrocnemius and soleus and the deep posterior compartment, tibialis posterior, and flexors hallucis longus and digitorum longus.
As the article states, the lateral and anterior compartment syndromes are the commonest in clinical practice.
While the clinical example in the article referred to a 'runner', this syndrome can occur on the exertion of walking in non-diabetics and I have recently seen a case remain undiagnosed after the opinion of an orthopaedic surgeon, a neurologist, a vascular surgeon and a rheumatologist. The diagnosis was missed, I think, because of over-reliance of MRI-T2 imaging to exclude the diagnosis.
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I believe the article of Paik et al. to be somewhat outdated regarding Chronic Exertional Compartment Syndrome (CECS). Recent work by Aweid et al. (Clin J Sports Med, 2012) corroborates current feeling in the field that intracompartmental pressure (ICP) monitoring may offer inconsistent diagnosis at best, and Ringler et al (Skeletal Radiol, 2013) demonstrated that MRI may offer at least equal sensitivity and specificity. Furthermore Deibal et al (Am J Sports Med 2012) demonstrated significant improvement of symptoms and avoidance of surgery at one year in 100% of a small (10 patient) group of CECS patients treated with forefoot running education. This mirrors my own (former) practice at Headley Court Rehabilitation Centre, Surrey, UK, where the majority of CECS sufferers no longer undergo ICP monitoring and primary therapy with "running re-education" is effective in the majority. To the specialist, history alone gives a high index of suspicion of CECS and appropriate management must be given to avoid unnecessary interventions.
Competing interests: No competing interests
Dear Sir,
I read with great interest your article on CECS (Chronic Exertional Compartment Syndrome), which provided a concise overview of this condition. I would like to raise a few key points in a bit more detail particularly about the ambiguity of the diagnostic criteria.
The criteria for the diagnosis of CECS based on compartment pressure monitoring as described by Pedowitz et al [2] was established in 1990 and were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CECS. Based on these pressure measurements done in normal subjects the confidence intervals for diagnostic purposes were determined and thus the specificity of 5% was quoted. This so far has not been fully validated.
A recent systematic review by Aweid O et al [1], states that levels above 27.5 mm Hg at 1 min post exercise along with a good history should be regarded as highly suggestive of CECS. This suggestion is based on the fact that among all the 32 studies considered for the systematic review, only 1 minute post exercise pressure measurements showed no overlap when pressure measurement of CECS patients were compared with control subjects.
The general teaching that invasive compartment pressure monitoring is ‘GOLD STANDARD’ in diagnosing the CECS may not be totally true. Van den Brand et al conducted a Level 2 study of 50 patients with CECS and concluded that near-infrared spectroscopy is comparable to invasive intracompartmental pressure measurements. This study clearly shows high sensitivity of near infra red spectrometry (85%) vs. invasive pressure monitoring (77%), contrary to what previous literature was quoting based on low level evidence [4]. It is worth emphasizing that van den Brand et al did not used the Pedowitz criteria for compartment pressure monitoring rather used single threshold of 35 mm of Hg post-exercise pressure.
A survey done in UK, however, showed that most (83%) of the orthopaedic surgeons and sports medicine specialists still use compartment pressure monitoring for the diagnosis of CECS [3]. Of these, 42% use maximal ICP during exercise greater than 35 mmHg as a criterion for anterior CECS diagnosis and 35% use Pedowitz’s modified criteria.
REFERENCES
1. A Aweid O, Del Buono A, Malliaras P, Iqbal H, Morrissey D, Maffulli N, et al. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clin J Sport Med 2012;22:356-70.
2. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med1990;18:35-40
3. Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin J Sport Med 2006;16:209-13.
4. Van den Brand JG, Nelson T, Verleisdonk EJ, van der Werken C. The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients. Am J Sports Med 2005;33:699-704
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Where are the fascial layers in the cross-sectional anatomy picture?
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Re: Chronic exertional compartment syndrome
We read a well written article by Paik et al on CECS with interest and make the following comments:
1. CECS also occurs in the forearm1 (usually the superficial and deep flexor compartments) and the foot2 (usually the medial and central compartments).
2. As stated in the article, a good history taking is the most important as examination is often normal. One point worth mentioning and is an important consideration during history taking, is that, often patients will differentiate between tightness and cramp. Tightness is often one of the symptoms described by patients and, in some cases it is often followed by loss of function as the tibialis anterior muscle goes into a spasm.
3. Measurement of Intra-compartment pressure is a primary investigation to support the diagnosis of CECS. There is much debate about the methods used and, criteria applied in making the diagnosis3. In our view, ICP must have an accompanying tracing and should be interpreted in the same way as an ECG. The tracing can provide vital information regarding (a) correct placement of the catheter in the compartment under investigation, (b) patency of the catheter, (c) it can detect blocked tip of the catheter as the wave form changes, (d) it can detect whether the catheter has slipped out of the compartment and may be sitting under the skin, (e) it can detect if it is part or fully in a blood vessel (very rare) and, (f) it provides data to measure various aspects of ICP i.e. maximum, mean, relaxation and resting pressures.
The system used must also be versatile enough to allow measurement of ICP in patient’s specific exercise which provokes the symptoms as in some cases increase in ICP is exercise specific4. http://cjsmblog.com/tag/chronic-exertional-compartment-syndrome/
4. When considering differential diagnosis, the site of pain will dictate what other diagnosis to consider e.g. anterior compartment is the most common anatomical site to develop CECS, so Popliteal Artery Entrapment Syndrome (PAES) is less likely to be in the list of differential diagnosis.
Conditions that have not been mentioned in the article that mimic CECS should include Superficial Fibular (peroneal) Nerve Entrapment Syndrome which is more common than appreciated and usually has a unilateral distribution which differentiates it from CECS, which is usually bilateral. The other 2 conditions should include Myopathy (McArdle Syndrome) and Eosinophilic fasciitis (uncommon).
When the anatomical site is the superficial posterior compartment, Sural Nerve Entrapment and Radiculopathy should be included in the differential list along with PAES.
CECS affecting the deep posterior compartment is often associated with Medial Tibial Stress Syndrome.
REFERENCES
1. Brown JS, Wheeler PC, Boyd KT, Barnes MR, Allen MJ. Chronic exertional compartment syndrome of the forearm: a case series of 12 patients treated with fasciotomy. J Hand Surg Eur Vol. 2011 Jun;36(5):413-9.
2. Padhiar N, Allen M, King JB. Chronic exertional compartment syndrome of the foot. Sports Med Arthrosc; 2009 Sep;17(3):198-202.
3. Aweid O, Del Buono A, Malliaras P, Iqbal H, Morrissey D, Maffulli N, Padhiar N. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clin J Sport Med. 2012 Jul;22(4):356-70.
4. Padhiar N, King JB. Exercise induced leg pain-chronic compartment syndrome. Is the increase in intra-compartment pressure exercise specific? Br J Sports Med. 1996 Dec;30(4):360-2.
Competing interests: No competing interests