Question regarding Chronic Exertional Compartment Syndrome
A question was sent in to me by a DC colleague of mine…..thought warranted a quick review/overview of the topic of Chronic Exertional Compartment Syndrome:
“Hey doc…43 year old male amateur kickboxer, seeing him for a few years for a large (Large) variety of different issues with great success. He recently came in with a new complaint of left shin pain that stemmed from checking several leg kicks in training, plus 500 bag kicks. Felt achy and tight, no neurovasc issues. Dx of compartment syndrome?? typical tx, felt better, but not perfect. Saw him the other day, and he hasn’t been stressing it at all lately, but still doesn’t feel right – just achy pain with a deep pressure sensation, some numb/tingle if gets a kick at random. Still no neurovasc, sensation WNL, static TA contraction for 45 sec was fine, as was 15 res dorsiflex. I’m still thinking the same Dx, maybe a bit of insertional tendonopathy, but of course upon throwing out compartment syndrome. What is involved with compartment pressure testing with MD, or would he even order it for him? Am i missing something common with MMA fighters?”
The leg is divided into four compartments that are divided by bony and fascial elements. Some authors believe that the encasement of the tibialis posterior muscle may be considered a fifth compartment. Any of these compartments can develop a compartment syndrome from elevated intercompartmental pressure. With exercise, muscular volume can increase up to 20%. In compartment syndrome, the dividing fascial layers cannot accommodate the additional volume resulting in the collapse of venous return and neuro-compression (in advanced cases). This leads to the onset of ischemia and soft tissue damage. As more soft tissue injury occurs, there is further pressure elevation within the compartment, and this viscious cycle propagates.
Acute compartment syndrome is a medical emergency that occurs when compartmental pressures exceed 70 mmHg. Immediate referral is necessary in these cases for surgical release of intercompartmental compression. Complications from lack of care in these cases may yield permanent neurologic and/or muscular necrosis, or rhabdomyolysis (the rapid breakdown of skeletal muscle dure to injury) with acute renal failure.
The classical presentation of an athlete with acute compartment syndrome includes:
- Pain out of proportion to the injury
- Swelling and tightness of the affected limb
- ****Pain exacerbated by passive stretching of the compartment
- Although there are many signs of diminished perfusion, decreased pulses and capillary refill is a late finding with significant intracompartmental damage occurring prior to this.
- Motor and sensory changes are also a late finding
More common, and more clinically challenging is the presence of chronic compartment syndrome, or Chronic Exertional Compartment Syndrome (CECS). This condition typically affects younger individuals (13-30 years of age) who are engaged in endurance sports or intensive training regimens. Another cause as is suggested with the patient above is repetitive trauma to a muscle group/compartment.
CECS pain is thought to derive from the same pathologic processes that cause pain with the acute type, that being compromise of the vascular supply which leads to myoneural ischemia. As for the cause, despite various explanations for the cause of this CECS (muscular hypertrophy, fascial inflexibility, muscle damage (leading to an increased osmotic pressure and decreased blood flow), no single theory has been overwhelmingly accepted. For our patient it would be expected that muscle damage would be the likely cause
- Achy pain, or tightness, cramping, burning, or aching over the affected compartment
- A feeling of ‘fullness’ in the compartment that typically has a gradual onset and usually worsens with activity (vs. tendon problems which tend to feel better with activity)
- Pain is constant, and related to exertion
- Pain begins at a predictable time after exercise onset
- Pain diminished with rest
- Sensation of weakness or loss of control of the affected extremity
- Subjective paresthesia
- Patient usually denies edema, temperature, or colour changes.
- Patient may note bumps or herniations over the affected compartment
Although some physical findings may be apparent upon examination, a referral for confirmation using a slit catheter to read intra-compartmental pressures is warranted. One or more of the following intramuscular pressures would be considered diagnostic:
- A pre-exercise pressure > 10-15 mmHg
- A one minute postexercise pressure >20-30 mmHg
- A 5 minute postexercise pressure greater than 20 mmHg
**Capillary pressure in skeletal muscle is between 20-30 mmHg; thus pressures exceeding this will compromise oxygen delivery and CO2 removal.
For the patient we are discussing, I would expect that his physical findings would be minimal. Most likely one would palpate an increased ‘tonus’ in the affected area, which increases with exercise. The presence of objective neurological or vascular findings would most likely not be present as was noted by the practitioner. Based on his symptoms, I believe the referral for diagnostic testing is appropriate. This is actually a common occurrence that I have found with treating MMA athletes due to either overtraining, and/or chronic repetitive trauma stemming from pad or heavy bag work.