Conditions and procedures

Chronic exertional compartment syndrome in the leg

  • What are the different compartments of the leg and what is Chronic Exertional Compartment Syndrome (CECS)?
    The muscles in the leg are separated by facial layers, thereby grouping them into compartments. The leg muscles are divided into four fascial compartments which are shown in the picture.

    The pressure in these muscles can get raised in acute trauma or chronically with activity. The raised pressure in the leg leads to several symptoms and is called compartment syndrome. In athletes and exercising population, the increased pressure in the leg can be associated with prolonged and repetitive exercise. This is called chronic exertional compartment syndrome.
  • Can CECS only occur in legs?
    No CECS associated with activity can be seen to occur in the foot, thigh, forearm and hand. This is related to different sports disciplines and varying activities in those disciplines.
  • How common is CECS?

    CECS occurs in runners and sports that involve a lot of running. It can really be seen in the cyclists as well. It is not uncommon to have symptoms in both legs at one point of time. Males tend to have it more commonly than females. However, such difference is decreasing with increased participation of women in active sports.

    27-33% of the athletes have chronic lower leg pain.

  • What are the risk factors for CECS?
    The common risk factors associated with CECS are:

    - Rapid increase in activity
    - Large, muscular legs
    - High risk sport activities
    - Association with food supplements such as creatine
  • What are the common symptoms of CECS?
    Generally, patients do not have any pain at rest. On increasing the activity they can have cramping or burning pain being felt in the lower leg. The pain tends to increase over a period of time which necessitates the termination of the exercise. After stopping the exercise the pain settles gradually over a period of time. The pain tends to come sooner than the first episode if the activity is repeated quickly after stopping. Associated numbness/tingling or developing muscular dysfunction such as foot drop or inability to move the ankle is seen in progressive or late stages.
  • What do we see on clinical examination?

    The commonest examination finding associated with pain is tightness of the muscles. Firm or bulging muscles can be felt and seen in the leg/calf. Muscle hernias can be seen in 40 to 50% of the patients. There is increased pain on passive stretching of the muscles in the respective compartments. Also, there is weakness along with a pain on strength testing of the muscles, which recovers once the pain settles and the activity has been stopped for a period of time. Pain and weakness in the muscles can persist for long periods of time in later stages of CECS.

    The diagnosis is further confirmed by measuring the intracompartmental pressure and using the modified Pedowitz criteria to indicate a positive test.

    Criteria for positive test

    Pressure more than 15 mm of Hg at rest, more than 30 mm of Hg at 1 min and more than 20 mm of Hg at 5 min after stopping the exercise.

    Other diagnostic modalities as MRI, Infrared spectroscopy, Electromyography- Nerve conduction study, Ankle brachial index can be done to rule out the differential diagnosis.

  • What is the differential diagnosis of leg pain associated with physical activity?

    The common causes of leg pain associated with physical activity:

    -Stress fractures of the bones of the leg
    -Shin splints
    -Vascular and neural entrapments
    -Vascular claudication
    -Referred pain from the back
  • How is CECS treated?

    Acute compartment syndrome is a surgical emergency.

    For the CECS, the treatment usually starts with relative rest and activity modification. Modification in volume and intensity of training, footwear and running mechanics have been seen to help with the symptoms. Physical therapy in the form of soft tissue release and massage along with addressing the biomechanical factors have been used. In chronic cases however the non-surgical methods are usually not effective for the long-term, especially in competitive athletes. In confirmed cases of chronic exertional compartment syndrome, surgery provides a definitive treatment.

  • What is involved in the surgery?

    Surgery usually involves cutting of the tight fascia (Fasciotomy) to remove the constricting effect on the exercising muscles

    81-100% of the patients report good results in surgery for anterior chronic exertional compartment syndrome. 6-10% recurrent rates are reported, although this can be high if multiple compartments are involved.

  • When can the player return to activity after surgery?
    Although this depends on the number of compartments released by surgery but in general light, jogging can start in 3 to 4 weeks and full return to sports in 6 to 12 weeks of time.
  • How can Dr Khullar help me if I have leg pain related to activity?

    Dr Khullar has vast experience in working with elite and recreational athletes of different sporting teams. The assessment will first aim at ruling out the different causes of the leg pain. Dr Khullar can advise and interpret different imaging modalities. He can request rebated MRI scans which are included under the Medicare schedule.

    Dr Khullar can also perform compartment pressure testing in a clean outpatient clinic setting for the diagnosis of CECS.

    If surgical intervention is required, then he can refer you to the surgeon's for appropriate surgical management. He will then follow you up for your return to play program.

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