Exertional Compartment Syndrome

ICD-9	Classification / Treatment
Etiology / Epidemiology / Natural History	Associated Injuries / Differential Diagnosis
Anatomy	Complications
Clinical Evaluation	Follow-up Care
Xray / Diagnositc Tests	Review References

synonyms: Chronic extertional compartment syndrome, CECS

CECS ICD-9

CECS Etiology / Epidemiology / Natural History

• An exercise-induced increase in muscle size can result in elevated intracompartmental pressures and progress to tissue ischemia. 

CECS Anatomy

• Leg Compartments: (1) Anterior, (2) Lateral, (3)Superficial Posterior, (4)Deep Posterior.
• Anterior Compartment (contains:Tibialis Anterior ,EHL, EDL, Peroneus tertius, Deep Peroneal nerve, and the anterior tibial vessesls)
• Lateral Compartment (contains:,Peroneus longus , Peroneus brevis, and the Superficial Peroneal nerve)
• Superficial Posterior Compartment (contains: Gastrocnemius, soleus, Plantaris, and the Sural nerve)
• Deep Posterior Compartment (contains:Popliteus, FHL, FDL, Tibialis Posterior, Tibial nerve and the posterior Tibial vessels)

CECS Clinical Evaluation

• pain after running a particular distance, may last for a few hours after finished running.  Pain is usually localized to a compartment and resolves with discontinuing activity
• anterior and lateral compartments most common.  Has been described in shoulder, arm, forearm, hand, thigh, foot.
• 39%-46%  of pts have fascial defects over the anterolateral lower leg compared with <5% in asymptomatic individuals.  Defects generally 1-2cm2 in size and near the intermuscular septum between anterior and lateral compartments, often at exit of superficial peroneal nerve.  Usually at junction of middle and distal thirds of leg.  At rest no palpable abnormality may be apparent, but with exercise, local tenderness and swelling occur.  Occasionally may have + Tinel’s sign.
• pain begins as dull ache with activity and progresses to point where activity must be stopped.  Pain typically in entire affected compartment.  May note transient numbness, parasthesias, weakness.  Pain relieved with rest.
• Most often bilateral
• Physical exam is normal at rest; may have tenderness, fascial defect/swelling immediately following exercise.

CECS Xray / Diagnositc Tests

CECS Classification / Treatment

• Non-op =  activity modification.  Only effective if pt gives up offending activity.
• Operative = fasciotomy. One incision technique, Two incision technique.
• Fasciotomy for posterior exertional compartment syndrome has lower success rate that fasciotomy for anterior compartment syndrome due high potential for inadequate release of the FDL. (Hislop M, AJSM 2003;31:770).

One Incision Fasciotomy Technique

• CPT: 27602(anterior and/or lateral and posterior compartments), 27600(fasciotomy leg anterior/lateral compartments only), 27601(posterior compartments only)
• Pre-op antibiotics.
• Anesthesia: General or regional.
• Postion: supine with bump under hip. Thigh tourniquet.
• Prep and drape in standard sterile fashion
• Incision over the fibula from 5cm distal to fibular head to 5cm proximal to the lateral malleolus.
• Identify the septum between the anterior and lateral compartments.
• Release the fascia 1cm anterior and 1cm posterior to the septum releasing the anterior and lateral compartments.
• Avoid injury to the superficial peroneal nerve distally.
• Elevate the lateral compartment musculature off the posterior intramuscular septum.
• Incise the possterior intramuscular septum releasing the lateral portion of the superficial posterior compartment.
• Elevate the superficial compartment posteriorly to access and release the deep posterior compartment. The posterior compartment can be found by following the interosseous membrane from the posterior aspect of the fibula.
• Ensure FDL has been adequately released. (Hislop M, AJSM 2003;31:770).
• Irrigate.
• Close the subcuteous tissue and skin.

Stress fx (tenderness over tibia)
Medial tibial stress syndrome
Chronic Regional Pain Syndrome
Gastrocnemious muscle tear
Peripheral nerve entrapment
DVT / Venous stasis
Radiculopathy
Arterial vascular disease
Popliteal artery syndrome

Incidence =4.5-13%
Recurrence=7-17%
Bleeding
Wound infection
Nerve entrapment / Nerve injury
Swelling
Arterial injury
Hematoma
Lymphocele
DVT

CECS Follow up  care

• ice/elevation 3-5 days
• immediate AROM
• crutches prn, encourage ambulation, WBAT
• full activities when tolerated usually 3-4 wks after sugery.  Light activity at 2-4 wks, full activity at 4-6 wks.
• Expect 81%-100% improvement.  Deep posterior compartment = 50-65% relief.