Concurrent Chronic Exertional Compartment Syndrome and Popliteal Artery Entrapment Syndrome.

Exertional leg pain occurs with notable frequency among athletes and poses diagnostic challenges to clinicians due to overlapping symptomatology. In this case report, we delineate the clinical presentation of a young collegiate soccer player who endured two years of progressive bilateral exertional calf pain and ankle weakness during athletic activity. The initial assessment yielded a diagnosis of chronic exertional compartment syndrome (CECS), predicated on the results of compartment testing. However, her clinical presentation was suspicious for concurrent type VI popliteal artery entrapment syndrome (PAES), prompting further radiographic testing of magnetic resonance angiography (MRA). MRA revealed severe arterial spasm with plantarflexion bilaterally, corroborating the additional diagnosis of PEAS. Given the worsening symptoms, the patient underwent open popliteal entrapment release of the right leg. Although CECS and PAES are both known phenomena that are observed in collegiate athletes, their co-occurrence is uncommon owing to their different pathophysiological underpinnings. This case underscores the importance for clinicians to be aware that the successful diagnosis of one condition does not exclude the possibility of a secondary, unrelated pathology. This case also highlights the importance of dynamic imaging modalities, including point-of-care ultrasound, dynamic MRA, and dynamic angiogram.

Ultrasound-guided fasciotomy in forearm chronic exertional compartment syndrome: Preliminary results in 12 cases.

INTRODUCTION: Forearm chronic exertional compartment syndrome is a rare condition in athletes and musicians who perform repeated prolonged forced gripping movements. It mainly affects young men, and presents with cramp-like pain, beginning on the anteromedial side of the forearm and progressively extending to the entire circumference, and may be associated with muscle weakness and neurologic symptoms. The objective of this study was to report preliminary results of ultrasound-guided fasciotomy in the treatment of forearm chronic exertional compartment syndrome. MATERIAL AND METHODS: A single-center retrospective observational study was conducted. Forearm chronic exertional compartment syndrome was diagnosed on clinical presentation and pathological intramuscular pressure measurement, defined as >30 mmHg at 1 min after effort. The series comprised 7 men, with bilateral involvement. Mean age was 30 years. All patients were motorcyclists. The mean preoperative intramuscular pressure at 1 min after effort was 60.75 mmHg (range: 30-81 mmHg). The main study endpoint was change in pain on visual analogic scale. Secondary endpoints comprised patient satisfaction, change in competitive sports level, and time to return to sport. Complications were noted. RESULTS: Six patients (12 forearms) were evaluated. Mean follow-up was 22.5 months (range: 3-48 months). Mean pain rating was 7.3/10 (range: 6-9) preoperatively, and 0/10 postoperatively. All patients were satisfied with the procedure. Mean time to return to sports was 25.5 days (range: 21-30 days). No patients decreased their competitive sports level after the procedure. One patient presented a postoperative hematoma, not requiring surgery. CONCLUSION: Ultrasound-guided fasciotomy in the treatment of Forearm chronic exertional compartment syndrome is an innovative technique with promising preliminary results. LEVEL OF EVIDENCE: IV; retrospective cohort.

Female patients have greater improvement in pain symptoms and physical activity after fasciotomy for treatment of chronic exertional compartment syndrome of the lower leg.

PURPOSE: The purpose of this study was to identify sex differences in postoperative outcomes and return-to-sport rates after fasciotomy for treatment of chronic exertional compartment syndrome (CECS) of the lower leg. It was hypothesised that male CECS patients would have a higher rate of return to sport than female CECS patients. METHODS: A retrospective cohort study was conducted involving patients who underwent primary fasciotomy of one to four leg compartments for treatment of CECS at a single centre from 2010 to 2020. Each affected leg was treated as a separate subject. Postoperative outcomes included CECS pain frequency and severity, return to sport and Tegner activity level. Multivariable regression was used to determine if sex was an independent predictor of outcomes after adjusting for demographic and clinical covariates. p < 0.05 were considered significant. RESULTS: Eighty-one legs (44 M, 37 F) of 47 unique patients (34 of whom had bilateral symptoms) were included with a mean follow-up time of 51.5 ± 31.4 months. Male subjects were older (p < 0.001) and had higher body mass index (p < 0.001) compared to female subjects. Most subjects (84.0%) underwent two- or four-compartment fasciotomies. Female sex was found to be predictive of lower overall postoperative pain severity (p = 0.007), higher odds of return to sport (p = 0.04) and higher postoperative Tegner score (p = 0.005). However, female sex was not predictive of postoperative pain frequency, odds of reoperation or odds of return to sport to at least the presymptomatic level (all p < 0.05). CONCLUSION: Female sex is independently predictive of reduced overall pain severity, higher odds of return to sport and higher postoperative improvement in Tegner score following fasciotomy for treatment of lower-limb CECS. LEVEL OF EVIDENCE: III.

Ultrasound guided compressibility of the lower leg anterior tibial muscle compartment: a feasibility study.

OBJECTIVES: Some young individuals participating in sports activities may encounter lower leg muscle pain and tightness, potentially indicating chronic exertional compartment syndrome (CECS). While muscle pressure measurement is typically recommended for diagnosis, it is invasive and associated with low sensitivity and specificity. Thus, there is a need for novel diagnostic approaches. METHODS: This feasibility study aims to assess whether an ultrasound-guided technique can effectively measure the compressibility of the anterior tibial muscle compartment, focusing on optimal leg positioning and identifying reliable external and internal anatomical landmarks. The compressibility of the anterior tibial muscle compartment was evaluated using ultrasound images obtained at 10 mmHg and 80 mmHg external pressure, with the drop in compartment thickness used to calculate the compressibility ratio. Measurements were conducted in various leg positions and utilizing different external and internal landmarks. RESULTS: Studies in healthy volunteers showed that knee and heel support positioning, measuring at the leg's widest circumference, and using the interosseous membrane as an internal landmark yielded the lowest measurement variability with an intra class correlation of .977 (.764-1.000; 95%-confidence interval). CONCLUSION: These findings suggest that ultrasound-guided techniques can feasibly determine the compressibility ratio of the anterior tibial muscle compartment, providing valuable insights for standardized protocols in future studies on suspected cases of chronic exertional compartment syndrome.

Return to Sport After Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm: A Systematic Review.

BACKGROUND: Forearm chronic exertional compartment syndrome (CECS) can represent considerable functional impairment in certain active populations, particularly motorcycle racers. Patients with forearm CECS frequently require fasciotomy to relieve symptoms and return to sport (RTS). PURPOSE: To evaluate the rate at which athletes RTS after fasciotomy for forearm CECS and to compare RTS outcomes between fasciotomy techniques. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the PubMed, Scopus, and Cochrane databases was performed from database inception to December 2022 to identify all published reports of forearm CECS managed with fasciotomy. Included studies were analyzed for demographic information, surgical approaches, rehabilitation parameters, RTS rates, time from surgery at which athletes resumed sport, complications, and recurrence. RESULTS: A total of 38 studies (15 level 4 case series, 23 case reports) accounting for 500 patients (831 forearms) who underwent open fasciotomy (112 patients), minimally invasive fasciotomy (166 patients), and endoscopically assisted fasciotomy (222 patients) satisfied inclusion criteria. Most patients (88.0%) were motorcycle racers. The overall RTS rate at any level (RTS-A) was 94.2% (97.3%, 92.2%, and 98.5% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .010), and the overall RTS at preinjury level or higher was 86.8% (95.9%, 85.6%, and 95.2% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .132). There was a significant difference in RTS-A between the minimally invasive fasciotomy and endoscopically assisted fasciotomy groups (P = .004). The overall RTS time was 5.1 ± 2.3 weeks, patient satisfaction was 85.1%, and the recurrence rate was 2.4%, and there were no significant differences between fasciotomy approach groups (P = .456, P = .886, and P = .487, respectively). CONCLUSION: Patients who underwent fasciotomy for forearm CECS had high rates of RTS, quick RTS time, high levels of satisfaction, and low rates of recurrence. Outcomes were largely similar between the 3 fasciotomy approaches.

Contemporary outcomes of surgical decompression for functional popliteal entrapment syndrome.

BACKGROUND: Functional popliteal entrapment syndrome (FPES) is an under-recognized source of leg pain caused by dynamic compression of the popliteal vessels by surrounding musculature in the absence of anatomic abnormality. Late recognition and difficulty capturing this entity across imaging modalities can lead to significant morbidity in an often young and active patient population. Surgical outcomes and optimal diagnostic strategies remain uncertain. METHODS: We performed a retrospective cohort study of all patients undergoing surgical decompression for FPES at an academic medical center between 2018 and 2022. Preoperative symptoms, patient characteristics, imaging, operative details, and follow-up were captured. The primary outcome was symptomatic improvement at last clinic visit. Secondary outcomes included symptomatic improvement at 6 months and postoperative complications. RESULTS: A total of 24 extremities (16 patients) were included. The mean ± standard deviation age was 23.3 ± 6.4 years and 75.0% of patients were female. The median symptom duration before decompression was 27 months (interquartile range, 10.7-74.6 months). Preoperative symptom severity in the affected extremity was as follows: 33.3% limited from peak exercise, 25% unable to exercise, and 41.7% with debilitating symptoms that affected activities of daily living. Preoperative imaging with provocative maneuvers included duplex ultrasound (87.5%), magnetic resonance angiography (100%), and digital subtraction angiography (100%). Using digital subtraction angiography as the gold standard, the sensitivity for detection of FPES was 85.7% for duplex examination and 58.3% for magnetic resonance angiography. The median follow-up was 451 days (interquartile range, 281-635 days). Most patients demonstrated durable improvement in the affected extremity, with 29.2% realizing complete resolution of symptoms and 37.5% reporting symptomatic improvement at last clinic visit for a total of 66.7%; 20.8% had initial improvement, but developed recurrent symptoms and were found to have elevated compartment pressures consistent with chronic exertional compartment syndrome and were treated with formal fasciotomy. Repeat decompression was required in one extremity (4.2%) owing to recurrent symptoms. Two patients (8.3%) had minimal or no improvement in their affected extremity and workup for the cause of continued discomfort was ongoing. CONCLUSIONS: Delays in diagnosis of FPES are common. Provocative maneuvers until replication of symptoms across multiple imaging modalities may be necessary to reliably identify the disease process. Surgical decompression improved or completely resolved symptoms in two-thirds of extremities. Treating physicians should maintain suspicion for comorbid chronic exertional compartment syndrome, especially if symptoms recur or persist after decompression.

Chronic exertional compartment syndrome is frequently diagnosed through static compartment pressure measurements and managed with fasciotomy: A systematic review.

OBJECTIVES: Chronic exertional compartment syndrome (CECS) can be diagnosed either clinically or with intra-compartmental pressure monitor measurements and can be treated surgically or conservatively. METHODS: A systematic review was performed on diagnostic and treatment modalities for CECS. Included studies were those that reported both their specific diagnostic modality and treatment regimens. Both surgical and conservative treatment strategies were considered. Demographic variables, diagnostic modalities, patient satisfaction and return to sport, the number of surgical incisions used for the anterior compartment fasciotomy, and the specific conservative treatment regimens were also recorded. Diagnostic modalities were grouped into one of three groups: 1) static compartment pressure monitor, 2) dynamic pressure monitoring, and 3) strictly clinical diagnosis. RESULTS: The literature search identified 373 studies, of which 29 were included for final analysis. In total, there were 1270 total patients. Twenty-four studies used static compartment pressure monitors, 5 studies used dynamic pressure monitors and 2 studies used a strictly clinical diagnosis. Surgical management with fasciotomy was performed in 25 studies with a total of 1018 patients, while conservative management was used in 252 patients in 9 studies (5 studies included surgical and conservative treatments). Among surgical studies, 15 used a single-incision technique for anterior compartment fasciotomy, while 6 used a 2-incision technique. The reported satisfaction after fasciotomy was 42-94% while the return to sport was 26-100%. The reported return to sport in conservative management studies was 25-35%. CONCLUSION: This systematic review found that the majority of clinical reports utilize static compartment pressure measurements to diagnose CECS, with fewer studies using dynamic intra-compartment pressure monitors. Additionally, surgical fasciotomy using a single-incision technique was the most common treatment strategy for anterior compartment CECC, with some studies reporting success with the two-incision technique. STUDY DESIGN: Systematic review, level 4.

Rehabilitation and return to activity criteria after operative management of chronic exertional compartment syndrome of the leg: a systematic review.

OBJECTIVES: Endurance athletes with chronic exertional compartment syndrome (CECS) frequently require fasciotomy to return to activity, but there are no existing comprehensive evidence-based rehabilitation guidelines. We aimed to summarize rehabilitation protocols and return to activity criteria after CECS surgery. METHODS: Through a systematic literature review, we identified 27 articles that explicitly defined physician-imposed restrictions or guidelines for patients to resume athletic activities following CECS surgery. RESULTS: Common rehabilitation parameters included running restrictions (51.9%), postoperative leg compression (48.1%), immediate postoperative ambulation (44.4%), and early range of motion exercises (37.0%). Most studies (70.4%) reported return to activity timelines, but few (11.1%) utilized subjective criteria for guiding return to activity. No studies utilized objective functional criteria. CONCLUSIONS: Rehabilitation and return to activity guidelines after CECS surgery remain poorly defined, and further investigation is needed to develop such guidelines that will enable endurance athletes to safely return to activities and minimize recurrence.

Sex and gender differences in lower limb chronic exertional compartment syndrome: a systematic review.

OBJECTIVES: Chronic exertional compartment syndrome (CECS) is a cause of exertional leg pain and has been reported in varying frequencies in males and females. Currently, it is unclear whether there are significant sex and gender differences in lower-limb CECS. Delineating sex and gender differences is vital in determining the causes of CECS and best treatments. This systematic review aimed to determine the sex/gender distribution of CECS and to assess for sex and gender differences in CECS diagnosis and outcomes. METHODS: PubMed (Medline), Cochrane Library, and EMBASE databases were searched for studies that were published from January 2000-March 2022 and reported lower-limb CECS data in males and/or females. Data on CECS diagnosis (intracompartmental pressures) and outcomes (e.g. post-surgical return-to-sport, need for re-operation) with sex/gender breakdowns were extracted. The sex/gender distribution of CECS and prevalence of CECS by sex/gender were calculated. RESULTS: Forty-one studies were included in the systematic review; there were 27 retrospective reviews, 8 prospective studies, and 6 retrospective studies with prospective follow-ups. Thirty studies involved surgical populations. Sex/gender distribution of CECS was calculated using data from 24 studies; 51% were female. Prevalence of CECS was available in five studies and ranged widely for males (54%-73%) and females (43%-65%). Intracompartmental pressure data varied by sex/gender. Male athletes were more likely than female athletes to return to sport following surgery for CECS, but variations in all other post-surgical outcomes were observed between sexes and genders in the general population. CONCLUSION: Females represented 51% of the patients who were diagnosed with CECS among studies. Most CECS diagnosis and outcomes data varied by sex/gender, except for post-surgical outcomes data in athletes, which demonstrated that males had higher rates of return to sport than females. Future studies are needed to examine factors contributing to sex and gender differences in CECS diagnosis and outcomes.

Chronic Exertional Compartment Syndrome in Athletes: An Overview of the Current Literature.

Chronic exertional compartment syndrome is an incapacitating condition that primarily affects athletes and individuals with high activity levels. The exact etiology of the condition is unknown to date, but multiple factors play a role in its occurrence. The clinical presentation includes pain, tightness, muscle weakness, paresthesia, and cramps. Common tools utilized during the diagnostic approach include intramuscular compartment pressure measurement, advanced imaging to exclude other disorder entities, near-infrared spectrometry, and shear wave elastography, with the clinical diagnosis being the gold standard. Management includes both conservative and surgical options. Conservative treatment includes gait re-training and botulinum toxin injections. Further, the operative treatment has variable approaches and may be combined with conservative modalities. This article reviews the literature on chronic exertional compartment syndrome and elucidates future recommendations.

Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review.

BACKGROUND: Numerous conditions are grouped under the generic term exercise-induced leg pain (EILP), yet clear diagnostic guidelines are lacking. This scoping review was conducted to clarify the definition and diagnostic criteria of nine commonly occurring EILP conditions. METHODS: Three online databases were searched from inception to April 2022 for any English language original manuscripts identifying, describing, or assessing the clinical presentation and diagnostic criteria of the nine most common conditions that cause EILP. We included manuscripts considering all adults with any reported diagnostic criteria for EILP in any setting. Methodological quality was assessed using the Mixed Method Appraisal tool. Condition definitions were identified and categorised during data charting. Twenty-five potential elements of the history, 24 symptoms, 41 physical signs, 21 investigative tools, and 26 overarching diagnostic criteria, were identified and coded as counts of recommendation per condition, alongside qualitative analysis of the clinical reasoning. Condition definitions were constructed with 11 standardised elements based on recent consensus exercises for other conditions. RESULTS: One hundred nineteen retained manuscripts, of which 18 studied multiple conditions, had a median quality of 2/5. A combination of the history, pain location, symptoms, physical findings, and investigative modalities were fundamental to identify each sub-diagnosis alongside excluding differentials. The details differed markedly for each sub-diagnosis. Fifty-nine manuscripts included data on chronic exertional compartment syndrome (CECS) revealing exertional pain (83% history), dull aching pain (76% symptoms), absence of physical signs (78% physical findings) and elevated intercompartment pressure (93% investigative modality). Twenty-one manuscripts included data on medial tibial stress syndrome (MTSS), revealing persistent pain upon discontinuation of activity (81% history), diffuse medial tibial pain (100% pain location), dull ache (86% symptoms), diffuse tenderness (95% physical findings) and MRI for exclusion of differentials (62% investigative modality). Similar analyses were performed for stress fractures (SF, n = 31), popliteal artery entrapment syndrome (PAES, n = 22), superficial peroneal nerve entrapment syndrome (SPNES, n = 15), lumbar radiculopathy (n = 7), accessory/low-lying soleus muscle syndrome (ALLSMS, n = 5), myofascial tears (n = 3), and McArdle's syndrome (n = 2). CONCLUSION: Initial diagnostic frameworks and definitions have been developed for each condition of the nine most common conditions that cause EILP, suitable for clinical consideration and consensus confirmation.

Common Peroneal Nerve Palsy Due to Chronic Exertional Compartment Syndrome after Military Training: A Case Report.

Introduction: The common peroneal nerve (CPN) palsy in military personnel due to chronic exertional compartment syndrome (CECS) is uncommon. There are no previous reports of treatment of this condition with simultaneous CPN and superficial peroneal nerve (SPN) neurolysis and compartment release. Case Report: An 18-year-old military recruit presented with complete CPN palsy after sitting cross-legged for 2 h in training. After 3 months of failed non-operative treatment, a clinical diagnosis of CECS with CPN palsy was made and the patient was treated with simultaneous CPN and SPN neurolysis and release of the anterior and lateral leg compartments. The patient had full recovery at 6 months post-operative period and returned to sports at 1 year follow-up. Conclusion: This case report of a young military recruit with CPN palsy after prolonged cross-legged sitting in the setting of CECS demonstrates successful treatment with simultaneous CPN and SPN neurolysis and anterior and lateral compartment release. Future studies should explore the efficacy of this treatment option and prevention strategies of CPN palsy in military personnel.

Lower Leg Lateral Chronic Exertional Compartment Syndrome: Prospective Surgical Treatment Outcomes for Isolated or Combined Lateral Fasciotomy.

BACKGROUND: Chronic exertional compartment syndrome involving the lower leg lateral compartment (lat-CECS) seldom occurs isolated but is usually combined with CECS of the anterior (ant-CECS) or deep posterior compartment (dp-CECS). Patient characteristics in lat-CECS and outcome after surgery are largely unknown. The aim of this prospective case series was to describe patient characteristics and symptoms and to report on outcome following a fasciotomy. METHODS: All patients diagnosed with lat-CECS based on exertional lateral lower leg symptoms and elevated intracompartmental pressure (ICP) measurements according to the Pedowitz criteria (ICP ≥ 15 mm Hg at rest, and/or ≥30 mm Hg after 1 minute, and/or ≥20 mm Hg 5 minutes after exercise) were eligible for this study. A standard intake questionnaire scoring symptom patterns was completed by all patients. Patients who were operated for lat-CECS were asked to complete a 3-month and 12-month postoperative questionnaire scoring symptoms and surgical outcome. Patients with a history of CECS surgery, recent lower leg trauma, or peripheral neurovascular disease were excluded. RESULTS: A total of 881 patients with possible lower leg CECS completed an intake questionnaire and 88 (10%) were diagnosed with lat-CECS according to the Pedowitz criteria (isolated lat-CECS n = 10; lat/ant CECS n = 54, lat/ant/dp CECS n = 19, lat/dp CECS n = 5). Severe pain during exercise and moderate tightness during rest were frequently reported. A group of 28 patients (49 legs; isolated lat-CECS n = 2; lat/ant CECS n = 22, lat/ant/dp CECS n = 3, lat/dp CECS n = 1) was analyzed after fasciotomy. Complications were minor (wound infection requiring antibiotics, n = 3; temporary complex regional pain syndrome with spontaneous recovery, n = 1). Superficial peroneal nerve damage was not observed. One year after surgery, 64% rated outcome as excellent or good, whereas 71% had resumed sports activities. CONCLUSION: One in 10 patients with anterolateral exertional lower leg pain evaluated in a tertiary referral center met diagnostic criteria for lat-CECS. Pain and tightness were present during exertion and were often reported occurring during rest and at night. In this series, we found fasciotomy-either an isolated (lateral) or a multiple (combined with anterior and/or deep posterior) compartment fasciotomy-is safe and beneficial in most patients. LEVEL OF EVIDENCE: Level IV, case series.

Three-Month Complication Rate of Ultrasound-Guided Soft Tissue Surgical Procedures Across Six Sports Medicine Clinics.

OBJECTIVES: To 1) determine the types and frequency of complications within 3 months following ultrasound-guided surgical procedures, and 2) identify any patient demographics, co-morbidities, or procedural characteristics that were associated with an increased risk of complications. METHODS: A retrospective chart review was performed at six Sports Medicine clinics across the United States. The Clavien-Dindo classification was used to categorize procedural complications on a 5-point scale from 1, representing any deviation in post-procedure care without requiring pharmacological or invasive treatment to 5, representing death. Generalized Estimating Equations for binomial outcomes with a logit link were used to estimate the overall and procedure-specific 3-month complication rates. RESULTS: Among 1902 patients, 8.1% (n = 154) had diabetes and 6.3% (n = 119) were current smokers. The analysis included 2,369 procedures, which were performed in either the upper extremity (44.1%, n = 1045) or lower extremity (55.2%, n = 1308) regions. The most common procedure was ultrasound-guided tenotomy (69.9%, n = 1655). Additional procedures included, trigger finger release (13.1%, n = 310), tendon scraping (8.0%, n = 189), carpal tunnel release (5.4%, n = 128), soft tissue release (2.1%, n = 50), and compartment fasciotomy (1.6%, n = 37). Overall, there was a complication rate of 1.2% (n = 29 complications; 95% CI: 0.8-1.7%). Individual procedures had complication rates that ranged from 0 to 2.7%. There were 13 Grade I complications in 13 patients, 12 Grade II complications in 10 patients, 4 Grade III complications in 4 patients, and 0 Grade IV or V complications. No associations between complication risk and any patient demographics (age, sex, BMI), co-morbidities (diabetes, smoker), or procedure characteristics (type, region) were identified. CONCLUSION: This retrospective review provides an evidence-based estimate supporting the low level of risk associated with ultrasound-guided surgical procedures for patients from a variety of geographical settings who are seeking care at private and academic-affiliated clinics.

Muscle Strength, Oxygen Saturation and Physical Activity in Patients with Chronic Exertional Compartment Syndrome Compared to Asymptomatic Controls.

Background: One of the most common causes of exercise-induced pain in the lower leg is chronic exertional compartment syndrome (CECS). Research is limited on muscle strength, oxygen saturation and physical activity in patients with CECS. Purpose: To compare muscle strength, oxygen saturation, and daily physical activity between patients with CECS and matched asymptomatic controls. A secondary purpose was to investigate the association between oxygen saturation and lower leg pain in patients with CECS. Study Design: Case-control study. Method: Maximal isometric muscle strength of the ankle plantar and dorsiflexors was tested in patients with CECS and sex- and age-matched controls using an isokinetic dynamometer and oxygen saturation (StO2) during running was tested by near infrared spectroscopy. Perceived pain and exertion were measured during the test using the Numeric Rating Scale and Borg Rating of Perceived Exertion scale and the exercise-induced leg pain questionnaire. Physical activity was assessed by accelerometry. Results: Twenty-four patients with CECS and 24 controls were included. There were no differences in maximal isometric plantar or dorsiflexion muscle strength between patients and controls. Baseline StO2 was 4.5pp (95% CI: 0.7;8.3) lower for patients with CECS than for controls, whereas no difference existed when they experienced pain or reached exhaustion. No differences were found in daily physical activities, except that on average, patients with CECS spent less time cycling daily. During the StO2 measurement, patients experienced pain or reached exhaustion while running significantly earlier than the controls (p<0.001). StO2 was not associated with leg pain. Conclusion: Patients with CECS have similar leg muscle strength, oxygen saturation and physical activity levels as asymptomatic controls. However, patients with CECS experienced significantly higher levels of lower leg pain than the controls during running, daily activities and at rest. Oxygen saturation and lower leg pain were not associated. Level of Evidence: Level 3b.

Intramuscular Pressure and Patient-Reported Outcomes in Patients Surgically Treated for Anterior Chronic Exertional Compartment Syndrome.

Background: Chronic exertional compartment syndrome (CECS) causes exercise-induced leg pain. The diagnosis is confirmed by intramuscular pressure (IMP) measurements. Fasciotomy has been demonstrated to be a successful treatment for CECS; however, few studies have examined postoperative IMP and long-term outcomes. Purpose: To evaluate long-term outcomes and postoperative IMP in patients surgically treated for anterior CECS, and to identify possible preoperative or postoperative factors associated with overall satisfaction with treatment at follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: A consecutive series of 209 patients who underwent fasciotomy of the anterior compartment for CECS between 2009 and 2019 and had at least 1 year of follow-up were approached for inclusion. A total of 144 patients (69%), with a follow-up time of 1 to 11.5 years, were ultimately included. All patients underwent preoperative and postoperative 1-minute postexercise IMP measurements of the anterior compartment and completed a questionnaire covering pain and activity parameters at both time points. The follow-up questionnaire included an additional question on overall satisfaction with treatment, and surgical details were collected from the patient's medical records. Results: The median IMP was significantly lower at follow-up than at baseline (17 mm Hg [range, 5-91 mm Hg] vs 49 mm Hg [range, 25-130 mm Hg]; P < .001). The overall satisfaction rate was 77%, and 83% reported a decreased pain level. The group of patients who were satisfied with the treatment included more men and had a higher ΔIMP and a lower revision rate (P < .05). Among the 16 patients (11%) who had undergone revision fasciotomies before follow-up, the satisfaction rate was 56%, and 64% reported a decrease in pain level. Conclusion: Fasciotomy significantly reduced 1-minute postexercise IMP in patients with CECS and resulted in satisfaction and decreased pain in more than three-quarters of the patients at long-term follow-up. The male sex and a significant decrease in IMP were both positively associated with treatment satisfaction. Patients who underwent revision surgery before the follow-up had lower satisfaction rates and less pain reduction than the overall group.

Review of Reliable and Valid Noninvasive Tools for the Diagnosis of Chronic Exertional Compartment Syndrome.

Background: Currently, invasive dynamic intracompartmental pressure (ICP) measurements are considered the gold standard for diagnosis of chronic exertional compartment syndrome (CECS). During recent years, different noninvasive imaging modalities have been presented as a possible replacement for ICP measurement. Purpose: To provide an overview of the current state of evidence and possibilities regarding noninvasive diagnostic methods for CECS. Study Design: Scoping review; Level of evidence, 4. Methods: The PubMed (MEDLINE) and Embase databases were searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Full-text articles were included if they reported on noninvasive diagnostic methods for CECS, included ≥5 patients with CECS, and were published between 1994 and 2022. Articles not written in English were excluded. Systematic reviews, letters to the editor, and case reports were not eligible for inclusion. Out of 961 articles identified in the initial search, 25 studies (N = 1257 participants) were included. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-Comparative (QUADAS-C) tool for comparative studies and the QUADAS-2 tool for noncomparative studies. Narrative synthesis was used to present results. Results: The level of evidence for the 25 studies ranged from 2 to 4. Four studies were classified as having a low risk of bias, 21 studies were classified as being at risk of bias. The following noninvasive diagnostic tools for CECS were reported: magnetic resonance imaging/diffusion tensor imaging (n = 8), near-infrared spectroscopy (n = 6), electromyography (n = 4), single-photon emission computed tomography (n = 5), ultrasound (n = 2), myotonometry (n=1) and predictive clinical model (n = 1). There was insufficient evidence in the literature to support the use of any of these noninvasive diagnostic tools as a gold standard for CECS. Conclusion: Despite the need to replace the controversial use of ICP for the diagnosis of CECS, our review indicated a lack of validity on all discussed noninvasive diagnostic tools as a replacement.

Compartment Syndrome in the Foot and Leg.

Chronic exertional compartment syndrome is a common cause of exercise-related leg pain that can be debilitating to many athletes. Diagnosis of this syndrome is based on patient history and clinical examination in correlation with intracompartmental pressure measurement or other advanced diagnostic tests. Treatments include initial nonsurgical management, such as modification of causative activity and gait retraining with physical therapy. If symptoms persist, surgical fasciotomy may be warranted via an open or minimally invasive approach. In this article, we review the anatomy, pathophysiology, history and physical examination, diagnostic modalities, treatment, and complications of chronic exertional compartment syndrome in the athlete.

Association Between Intracompartmental Pressures in the Deep Posterior Compartment of the Leg and Conservative Treatment Outcome for Exercise-Related Leg Pain in Military Service Members.

Objective: To evaluate the relationship between intracompartmental pressure (ICP) values of the deep posterior compartment and the outcomes of a comprehensive conservative outpatient treatment program in service members with chronic exercise-related leg pain. Design: Historic cohort study. Setting: Department of sports medicine at a military secondary care facility. Participants: During the 5-year study period, 266 military patients completed a treatment program for chronic exercise-related leg pain. Eighty-three service members with 145 affected legs met all inclusion criteria (N=83; 59 men, 24 women; median age, 22 years). Main Outcome Measures: The primary outcome measure was return to active duty. The secondary outcome measure was development of acute on chronic compartment syndrome. A generalized linear mixed model was used to identify predictor variables associated with return to active duty, including ICP values of the deep posterior compartment and Single Assessment Numeric Evaluation (SANE) score. Results: Sixty service members (72%) successfully returned to active duty. No association between ICP values of the deep posterior compartment and treatment outcome was found (odds ratio, 1.02; 95% confidence interval, 0.97-1.07; P=.50). A low SANE score (ie, more severe symptoms at baseline) was negatively associated with primary outcome (odds ratio, 0.95; 95% confidence interval, 0.90-0.99; P=.01). None of the patients developed acute on chronic compartment syndrome during the treatment program. Conclusions: There was no association between a single postexercise ICP value of the deep posterior compartment of both legs in military service members and return to active duty after a comprehensive conservative outpatient treatment program. None of the patients developed acute on chronic compartment syndrome. In this population, ICP measurement of the deep posterior compartment can be safely postponed until conservative treatment fails and surgical treatment is considered.

Intrafasciomembranal Fluid Pressure: A Novel Approach to the Etiology of Myalgias.

Fascia is a continuous membrane (fasciomembrane) that enables differentiation of fluid pressure on either side. Fascia membrane also enables an internal increased fluid pressure at all muscle levels (fibers, fiber bundles, skeletal muscles, compartments), and the author introduces a new unifying term for these pressures, regardless of the anatomical level - the intrafasciomembranal fluid pressure (IFMFP). Swelling, pain, and loss of tissue function are identified as common cardinal symptoms in trigger point (TrP), chronic exertional compartment syndrome (CECS), overtraining syndrome (OTS), and delayed onset muscle soreness (DOMS). Existing literature and an overall assessment indicate that intramuscular conditions related to fluid flow and pressure play a central role in different conditions, providing a common biomechanical explanation of the etiology and influence, supporting the article's theory that an increased IFMFP plays a key role in these conditions.