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Compartment Syndrome, Anterior



Ovid: 5-Minute Sports Medicine Consult, The


Compartment Syndrome, Anterior
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]
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


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