Exertional Compartment Syndrome

What is Exertional Compartment Syndrome?

Exertional compartment syndrome (ECS) is a type of compartment syndrome. Compartment syndrome occurs when the pressure in the muscles builds up to high and causes disturbances in blood flow to the muscles and nerves. Another type of compartment syndrome is acute compartment, which is most often caused by injury ^[1].

Causes

Relevant anatomy

Muscles, nerves and blood vessels in arms and legs are divided in groupings or compartments. These tissues are covered with thick membrane called fascia. Fascia is one of the structures that helps all the anatomical structures to stay in their place therefore it does not stretch or expand easily ^[1].

Etiology

Exertional Compartment Syndrome is a chronic condition that mostly affects athletes. It is caused by repetitive and exertional activities. This syndrome is usually observed in long distance runners, basketball players, soccer players and skiers.

Exertion causes microtrauma to the muscle cells and sets a process in action that is similar to acute compartment syndrome ^[2]. If you are interested in other conditions that can affect athletes, read about rotator cuff syndrome and patellofemoral pain syndrome.

Pathophysiology

The main problem in Exertional Compartment Syndrome is increased pressure in the muscles at rest. Normally repetitive muscle contractions cause increasing of the intramuscular pressure. This pressure usually normalizes within 5 minutes after stopping activity.

But in Exertional Compartment Syndrome the pressure in the muscles remains high and causes symptoms. With increased pressure the blood flow decreases and it can cause cramping. In patients with ECS intramuscular pressure can remain elevated for more than 30 minutes ^[2].

Symptoms

The typical signs of Exertional Compartment Syndrome are:

• Usually present in the lower leg
• Aching, burning sensation
• Cramping
• Numbness
• Tingling
• Weakness of the affected limb, foot drops in severe cases
• Often the symptoms present in the same compartment of both legs
• If muscles herniate, there might be swelling or bulging

These symptoms usually occur after a certain time of exercising. If the patient continues to exercise, the symptoms get worse. The symptoms usually go away after resting for a while, usually within 10 to 20 minutes, but they can also last for more than 30 minutes. Usually, the necessary recovery time increases over time ^[3].

Diagnosis

Physical examination

Patient history and clinical examination is one of the most important parts of diagnosing Exertional Compartment Syndrome. Proper physical examination can exclude other causes for leg pain, like iliotibial band syndrome. Patient history usually includes high-intensity physical activity and various symptoms (listed before).

Palpation of the affected limb is usually painful. The affected compartment is usually firm. When passively stretching the leg, pain usually increases. In around 40-60% of cases herniation through the fascia can be observed. Arterial pulse is usually intact, since this syndrome affects the venous blood flow.

Neurological examination may show neural involvement that presents with weakness and numbness. By assessing the movements of the foot, the affected compartment can be found:

• Anterior compartment- weakness when trying to flex the foot upwards
• Lateral compartment- weakness of eversion of the foot
• Posterior compartment- weakness when trying to move the foot downwards ^[4]

Laboratory studies

There are not many specific signs that can prove the diagnosis of Exertional Compartment Syndrome, but the following tests should be performed:

• Serum levels of creatine kinase and myoglobin- indictors for muscle cell death
• Urine analysis and urine myoglobin- also indicate cell death
• Metabolic panel- can show acidosis, hypercalcemia, hyperkaliemia and other metabolic derangements

Several blood and urine tests should be performed to rule out other conditions that might cause similar symptoms:

• D-dimer levels- high in case of deep venous thrombosis
• Complete blood count- can show signs of infection
• Thyroid-stimulating hormone- excluding thyroid myopathy
• Erythrocyte sedimentation rate- can suggest rheumatoid condition and infection ^[2]

Dynamic intracompartmental pressure

Dynamic intracompartmental pressure measurement is the gold standard for diagnosing Exertional Compartment Syndrome. The measurement is done by inserting a catheter in the compartment and reading the pressure measurement. The test is simple, cheap and easy to perform, but it is usually only done if signs and symptoms strongly suggest Exertional Compartment Syndrome ^[4].

Imaging studies

A sensitive method for diagnosing Exertional Compartment Syndrome is a thallous chloride scintigraphy with single photon emission computed tomography. With this imaging study, areas of reversible ischemia in the affected compartment as well as increased pressure in other compartments.

X-ray imaging and CT scans of the lower back are usually performed to rule out fractures, tumors and osteomyelitis. Ultrasonography can also be performed to evaluate blood flow and exclude deep venous thrombosis.

Also, X-ray imaging of the spine should be performed to rule out spinal fractures (also see caudal regression syndrome); CT scanning can be helpful in finding bulging intervertebral disk or fracture that can mimic the symptoms ^[2,4].

Differential diagnosis

Differential diagnosis of ECS includes:

• Deep venous thrombosis
• Hypothyroid myopathy
• Lumbosacral radiculopathy
• Myopathy
• Nerve entrapment
• Spinal stenosis
• Tumors, including spinal tumor^[2]

Treatment

Surgical

Fasciotomy is usually performed in order to treat Exertional Compartment Syndrome. A long incision is made in the involved compartment. When the fascia is slit, muscles have more space to expand therefore the pressure in the limb is lowered. In most cases this procedure relieves the symptoms ^[5].

In some cases, removal of the fascia (fasciectomy) is also performed to prevent the reoccurrence of symptoms ^[3]. Also read about using fascial flaps for management of Parry-Romberg syndrome.

Non-surgical

Non-surgical treatment can sometimes be successful, but in most cases symptoms of ECS come back once the patient starts to exercise again. Non-surgical treatment consists of physical therapy, proper stretching of the muscles and non-steroid anti-inflammatory drugs ^[2,3].

Prognosis

ECS, unlike acute compartment syndrome is usually not life threatening condition but it can cause severe nerve damage and impairment. If diagnosed correctly, the patient usually regains all function after treatment.

Usually surgical treatment is used, because in most cases symptoms come back once the patient starts physical activity. Surgical management also has a few risks like nerve damage and infection.

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References

1. General information for patients: http://orthoinfo.aaos.org/topic.cfm?topic=a00204
2. Detailed information about ECS for patients and health care specialists: http://emedicine.medscape.com/article/88014-clinical#b1
3. Symptoms: http://www.mayoclinic.org/diseases-conditions/chronic-exertional-compartment-syndrome/symptoms-causes/dxc-20182613
4. Diagnosis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941579/
5. Surgical treatment: http://journals.lww.com/cjsportsmed/Abstract/2006/05000/Diagnosis_and_Management_of_Chronic_Exertional.4.aspx
6. Prognosis: http://journals.lww.com/cjsportsmed/Abstract/2000/07000/Evaluation_of_Outcomes_in_Patients_Following.5.aspx