Compartment Syndrome, Anterior

By admin Last updated Nov 21, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Andrew Getzin

Jake Veigel

Basics

Description

Compartment syndrome is a condition caused by an increase in interstitial pressure in a closed fascial compartment that leads to microvascular compromise and ischemic pain over the anterior lower leg and possibly associated numbness and muscular dysfunction.
It can come on acutely owing to a rapid increase in training.
It can present as chronic activity-related pain owing to repetitive activity over months.
The anterior compartment consists of the tibialis anterior, extensor hallicis longus, extensor digitorum longus, peroneus tertius, and deep peroneal nerve. It is bounded by the tibia, fibula, and a thick inelastic fibrous septum.

Epidemiology

Incidence

Occurs in runners and in sports that involve a lot of running. It is not seen in cyclists because there is no eccentric contraction of the muscle in the anterior compartment in cycling.
Bilaterality is common.
Predominant gender: Male = Female

Prevalence

Present in 27–33% of athletes with chronic lower leg pain (1)

Risk Factors

Rapid increase in activity
Large, muscular lower legs
Use of creatine supplements (2)
Participation in high-risk sport activities

Etiology

It is caused by an increase in interstitial pressure in a closed fascial compartment that leads to microvascular compromise and ischemic pain.

Diagnosis

History

Signs and symptoms include (1)[C]:
- Asymptomatic at rest
- Cramping, burning, or pain felt over anterior lower leg with exercise
- Symptoms in a crescendo–decrescendo pattern, increasing until usually necessitating termination of activity, followed by gradual recovery
- Muscle hernias seen in 40–50% of patients
- Athletes may develop paresthesias distally and may develop motor problems (eg, foot drop) as a late finding.
History:
- Patients usually don't report a one-time injury.
- Pain is usually progressive with continued exercise or increased intensity and begins to occur sooner into the activity as time progresses.

Physical Exam

Exam is usually normal at rest. The key to the exam at rest is to help exclude other potential causes of lower leg pain (1)[C].
Examination immediately after exercise can be helpful. Compartments can be very rigid, or there may be fascial defects (1)[C].
- Tender anterior compartment on direct palpation
- Tender with passive stretching
- Tender with resisted strength testing
Muscle hernias may be present (1)[C].

Diagnostic Tests & Interpretation

Imaging

Radiographs and MRI images are helpful to exclude stress fractures.

Diagnostic Procedures/Surgery

Intracompartmental pressure measurements before, during, and after exercise provide helpful information and are considered the gold standard. Most clinicians use the modified Pedowitz criteria to indicate a positive test: ≥15 mm Hg at rest, ≥30 mm Hg immediately after exercise (1 min), and ≥20 mm Hg 5 min after exercise (3)[C].
However, there is considerable testing variability between clinicians (4). Compartment pressure measurement should be used only to validate the clinical diagnosis.
For atypical presentations, consider MRI/MRA of the knee with attention to the popliteal fossa with the foot in neutral, plantarflexion, and dorsiflexion or arteriogram to rule out popliteal artery entrapment syndrome. Electromyography (EMG) with attention to the superficial peroneal nerve should be considered to rule out superficial peroneal nerve entrapment.
MRI has been looked at and does not appear to be as useful as the gold standard compartment pressure measurement. Near-infrared spectroscopy, a noninvasive means of measuring IM oxygen content, holds promise as a future possibility for diagnosing compartment syndrome.
Consider performing duplex US of the lower extremities and ABIs with the foot in neutral, dorsiflexion, and plantarflexion and MRI/MRA of the popliteal fossa to exclude popliteal artery entrapment syndrome. EMG of the lower extremities is useful to exclude superficial peroneal nerve entrapment syndrome.

Differential Diagnosis

Tibia or fibula stress fracture
Periostitis
Popliteal artery entrapment syndrome
Superficial peroneal nerve entrapment (1)[C]

Treatment

Rest and activity modification (volume and intensity of training, training activity, practice surface, footwear) (1)[C]
Elevation when not exercising
Physical therapy to address any biomechanical predisposition; orthosis may help to address biomechanical issues.
Nonsurgical treatment is usually not effective for competitive athletes.
Special considerations:
- Acute compartment syndrome is a different entity from exercise-induced compartment syndrome. It usually follows acute lower leg trauma, such as a crush injury, but can occur after sudden, extreme exertion.
- Acute compartment syndrome is a surgical emergency that must be treated with emergent fasciotomy to avoid muscle necrosis.

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Medication

There is no consensus as to the role Tylenol or NSAIDs prior to exercise for pain control.

Additional Treatment

Additional Therapies

After surgery, the athlete is encouraged to walk as tolerated to decrease risk of the release fascia closing.
Full return to participation is gradual over 6–12 wks.

Surgery/Other Procedures

Surgery is the definitive treatment (5)[C].
Surgery consists of a fasciotomy of the affected anterior compartment (4,5,6,7)[C].
81–100% of patients report good to excellent long-term results (6,7)[C].
6% recurrence rate (8)

Ongoing Care

Postoperative care:

Initial weight bearing as tolerated and early range of motion to prevent postoperative scarring
Light jogging at 2–4 wks
Full participation in 6–12 wks

References

1. Edwards PH, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med. 2005;33:1241–1249.

2. Schroeder C, Potteiger J, Randall J, et al. The effects of creatine dietary supplementation on anterior compartment pressure in the lower leg during rest and following exercise. Clin J Sport Med. 2001;11:87–95.

3. Pedowitz RA, Hargens AR, Mubarak SJ, et al. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35–40.

4. Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin J Sport Med. 2006;16:209–213.

5. Detmer DE, Sharpe K, Sufit RL, et al. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med. 1985;13:162–170.

6. Schepsis AA, Fitzgerald M, Nicoletta R. Revision surgery for exertional anterior compartment syndrome of the lower leg: technique, findings, and results. Am J Sports Med. 2005;33:1040–1047.

7. Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med. 1993;21:811–817; discussion 817.

8. Turnipseed WD. Diagnosis and management of chronic compartment syndrome. Surgery. 2002;132:613–617; discussion 617–619.

Additional Reading

Eisele SA, Sammarco GJ. Chronic exertional compartment syndrome. In: Instructional course lectures. Rosemont, IL: American Academy of Orthopedic Surgeons, 1993:213–217.

Codes

ICD9

729.72 Nontraumatic compartment syndrome of lower extremity
958.92 Traumatic compartment syndrome of lower extremity

Clinical Pearls

Activity-related lower leg pain that escalates during a workout but usually resolves shortly afterward
There are no long-term sequelae, but the phenomenon is progressive and usually inhibits successful participation in running sports.
Condition is not usually responsive to conservative measure but instead requires surgical compartment release.
Treatment success rate is high, with ∼90% of athletes returning to full sports participation.
There is no evidence that long-term tissue damage occurs with repetitive bouts of exercise-associated pain from compartment syndrome. However, runners usually are unable to compete successfully once the problem has progressed. Athletes who play stop-and-go sports are usually able to complete their season but have to limit their training so that the compartment stays calm.
Surgical compartment release can be done open or endoscopically using 1 or 2 incisions. They seem to provide the same degree of symptom release with only a minimal difference in postoperative scarring.
There is overlap with medial tibial stress syndrome, tibial stress fractures, and compartment syndrome. The same inappropriate rate of increase in forces placed on the lower legs can result in more than one problem occurring at the same time.