Chroic Exertional Compartment Syndrome

by Jacob A. Brower, OMSII

Fascia is a form of connective tissue that surrounds and compartmentalizes muscles within the arms and legs. These anatomical compartments separate muscle from other tissues, such as bone and fat, and contain the blood and nerve supplies for their associated musculature. While these compartments are a normal structural component, there are some medical conditions associated with them. One of these conditions is an overuse injury termed chronic exertional compartment syndrome (CECS).
CECS is defined as reversible, insufficient blood supply to a fascial compartment’s contents. As an athlete performs repetitive movements, such as running, there is an increase in volume as muscles contract and blood is redirected to supply oxygen and nutrients to those tissues. Patients with CECS have abnormally elevated pressures within specific fascial compartments, causing decreased blood flow to that area. This temporary loss of blood supply produces a feeling of tightness in the affected muscles and a burning sensation around the associated compartments. While it is not clearly understood what causes the pressure difference in this disorder, experts believe that there are multiple contributing factors, including inelastic fascia.

CECS can occur in one or both arms or legs. While most commonly found in the lower legs of endurance athletes and marching military members, it is also seen in the arms of rowers and professional motorcyclists. The hallmark finding of patients with this syndrome is exercise-induced pain that diminishes with rest. The pain is typically in a reproducible area, related to the associated compartments, and fascial hernias, where tissue presses through a weak spot in the fascia, are sometimes present. Other associated symptoms include numbness, tingling, and an impaired ability to raise the foot during the normal walking cycle, termed foot drop.

There are many diagnoses that a physician must consider when a patient presents with arm or leg pain. These include, but are not limited to, shin splits, stress fractures, infection, and inappropriate blood clotting. Along with patient-reported symptoms, there is a clinical test the physician can perform to assess whether their patient has CECS. The test involves using a pressure monitor to measure intra-compartmental pressures of the suspected compartments, with pressure readings taken at rest, one minute post-exercise, and five minutes post-exercise. The Pedowitz criteria provides a list of pressures that, if exceeded upon examination, indicate the presence of this syndrome. Having at least one pressure reading being above the criteria, along with symptoms, is the basis for diagnosing CECS.

Treatment of the syndrome includes conservative and surgical methods, beginning with conservative therapy. This includes altering or completely ceasing activities that reproduce symptoms, medications that reduce pain and inflammation (i.e. non-steroidal anti-inflammatory medications), and physical therapy. If these options fail, the pain is substantial, and the patient is unwilling to cease aggravating activities, then surgery is indicated. The procedure performed by the orthopedic surgeon is a fasciotomy, where an incision is made through fascia of the implicated compartments. This procedure creates additional space for muscle expansion and more adequate blood supply to the appropriate tissues.

Chronic exertional compartment syndrome is a condition that can significantly impact an individual’s athletic ability and lifestyle. If you have pain or other symptoms related to CECS, it is best to consult an orthopedic surgeon. These doctors specialize in treating the muscles, bones,
and other associated connective tissues that support the body (i.e. the musculoskeletal system), and are well suited to treat it.

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