Chronic Exertional Compartment SyndromeWritten by Jonathan Hunyadi with Dr. Nabil Ebraheim
Chronic exertional compartment syndrome (CECS) a pathology in runners usually involving the anterior compartment of the leg. It is believed to result from swelling and hypoperfusion of muscle and nerve during physical activity. Patients typically present with anterior burning leg pain that is exacerbated by exercise and is greatly reduced or completely subsides 15 to 30 minutes after exercise.
The condition can be diagnosed by measuring the pressure of the affected compartment one and five minutes after exercise. A pressure of 30 mmHg one minute and a pressure of 20 mmHg five minutes after exercise is considered diagnostic. Patients with CECS usually have a resting intra-compartment pressure greater than 15 mmHg which greatly increases during running. This typically produces a burning, cramping or aching pain after about 10 minutes of running resulting in cessation of exercise. Additionally, patients sometimes report tingling over the dorsal aspect of the foot while running.
Patients often present following stretching and strengthening therapy without relief. On physical exam, the patient will present with diffuse, nonspecific tenderness over the anterolateral leg without focal tenderness over bone. Pulses and x-ray will be normal and bone scan or MRI will be negative for stress fractures. Classic findings of acute compartment syndrome such as pain with passive toe dorsiflexion and sensory loss in the first web space, are typically absent.
Following diagnosis, treatment consists of the surgical release of affected compartments. During lateral compartment release, the superficial peroneal nerve, which pierces the fascia 10cm to 12cm proximal to the tip of the lateral malleolus, must be avoided. Surgical fasciotomy is usually successful but with a relatively high recurrence rate of approximately 20%. Recurrence typically occurs around two years following the initial procedure and is due to fibrosis within the compartment, causing return of symptoms and potential nerve entrapment. Additional causes of recurrences are inadequate release, failure to recognize and release all compartments, and misdiagnosis.
The differential diagnosis for CECS is large with overlap of symptoms. A common example is medial tibial stress syndrome. With this condition, bony tenderness along the posteromedial tibia will be present. Popliteal artery entrapment, a dynamic exercise related vascular phenomenon, is another condition in the differential. CECS can be distinguished by its predictable exercise related onset, relief of symptoms at rest and by being present for a long time.
