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Chronic Compartment Syndrome

Contributed by Richard Bouché, D.P.M., Past President AAPSM

What is Chronic Compartment Syndrome?

Definition: Compartment syndrome is a clinical condition in which increased pressure within a closed anatomical space compromises the circulation and function of the tissues within that space. This compromise in circulation may result in temporary or permanent damage to muscles and nerves. Compartment syndrome may be acute or chronic.

Acute compartment syndrome (ACS) is usually caused by trauma, i.e., closed leg fracture or contusion, although the trauma may be relatively minor. Intense exercise can also caused an ACS as well but this would be uncommon. ACS is a medical emergency requiring prompt diagnosis and treatment. Absolute pressure measurement and symptom duration, combined with clinical assessment are factors in determining the need for fasciotomy.

Chronic compartment syndrome (CCS) is an exercise-induced condition characterized by recurrent pain and disability. Symptoms subside when the offending activity (usually running) is stopped but return when the activity is resumed. CCS may be considered an uncommon though important cause of exercise-induced leg and/or foot pain.

History:

CCS of the leg was first described in1956 by Mavor. Up until 1975 only nine case reports were published on CCS of the leg. CCS of the foot was first described in 1991 by Bouché with only five cases reported since in the world literature. Over the past few years CCS has received considerable attention because of the continued growth of endurance sports, on going research on exercise-induced leg pain and refined testing procedures.

Etiology:

All theories concerning the cause of CCS propose that an increase in tissue pressure to a critical level results in a compromise in tissue perfusion. Increased tissue pressure may result from limited or decreased compartment volume (tight thickened fascia), increased compartment content (muscle swelling and hypertrophy) or externally applied pressure (taping or casts).

Clinical Presentation:

Four requisites are needed to make a diagnosis of CCS: 1) specific anatomic location (one of the four compartments of the leg or one of the multiple compartments of the foot), 2) evidence of increased tissue pressure (patient will relate severe pain & tightness of the involved compartment and exam will reveal hardness of the compartment to touch), 3) compromised circulation (pain on passive stretch of the involved compartment), 4) dysfunction of the nerves and muscles within the affected compartment (weakness on muscle testing, numbness of affected nerves on nerve evaluation and gait abnormality).

Diangostic Testing:

Intracompartment Pressure Testing before and after exercise is considered the gold standard for confirmation of CCS.

Treatment:

Patients who have diagnosed CCS of the leg and /or foot may decide to live with their problem or opt for conservative or surgical treatment. Living with their problem would involve eliminating or limiting the offending activity and becoming educated about CCS and risks involved, i.e., increased chance of developing ACS. Conservative treatment is limited for those who wish to continue vigorous exercise but treatment options may involve prolonged rest, modifying offending activities, altering training regimens and consideration of deep massage. Surgical treatment involving decompressive fasciotomy of the involved compartment(s) is definitive and curative in most cases. Although fasciotomy techniques vary, their purpose is to relieve pain and increase exercise tolerance.

Summary:

CCS is an uncommon though important cause of exercise-induced leg pain. It must be differentiated from the many other common and uncommon causes of leg pain associated with exercise. If CCS is suspected, intracompartment pressure testing should be considered. Once the diagnosis is established treatment options can be considered though surgical fasciotomy is definitive and curative for those individuals who wish to continue with vigorous exercise.

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