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Compartment Syndromes: Differential Diagnoses & Workup

Author: Gregory A Rowdon, MD, Associate Clinical Professor, Department of Medicine, Division of Family Practice, Indiana University Medical Center; Team Physician, Purdue University
Coauthor(s): Basim Abdelkarim, MD, Staff Physician, Department of Internal Medicine, University of California at Irvine Medical Center; Federico E Vaca, MD, FACEP, Team Physician, Department of Emergency Medicine, University of California Irvine; Clinical Assistant Professor, University of California at Irvine School of Medicine
Contributor Information and Disclosures

Updated: Oct 29, 2008

Differential Diagnoses

Other Problems to Be Considered

Deep venous thrombosis
Infection
Lumbosacral radiculopathies
Medial tibial stress syndrome
Myopathy (to include thyroid myopathy)
Neurogenic claudication
Neurologic entrapment syndromes
Periostitis
Stress fracture of the tibia or fibula
Tenosynovitis
Tumor
Vascular entrapment syndromes
Vascular claudication

Workup

Laboratory Studies

Laboratory studies are generally not helpful in the case of a true chronic exertional compartment syndrome (CECS), and these tests are not usually ordered. However, some laboratory studies may be ordered to help rule out other causes of lower leg pain on an individual case-by-case basis. The diagnosis of chronic exertional compartment syndrome (CECS) may be one of exclusion, based on the clinical history, the physical examination findings, and the exclusion of various differential diagnoses (see Other Problems to Be Considered).

• Serum creatine kinase (CK) and myoglobin level (myopathy or rhabdomyolysis)
• Urinalysis (UA) and urine myoglobin (rhabdomyolysis)
• D-dimer level (deep venous thrombosis)
• Complete blood cell (CBC) count with differential (infection, osteomyelitis)
• Complete metabolic panel (metabolic derangements, acidosis, hypercalcemia, hyperkalemia)
• Thyroid-stimulating hormone (thyroid myopathy)
• Erythrocyte sedimentation rate (ESR) (infection, rheumatologic conditions)

Imaging Studies

• Generally, imaging studies are not helpful in the diagnosis of chronic exertional compartment syndrome (CECS), but, similar to the physical examination, they may help rule out related disorders.
  • Radiography of the extremity: Anteroposterior, lateral, and oblique views may help rule out stress fractures. In addition, radiographs of the spine may help identify spinal stenosis or disc degeneration that may be the source of lower extremity pain.
  • Bone scanning: This study helps exclude stress fracture, periostitis, and malignancy of the lower extremity.
  • Ultrasonography: This can be performed to visualize blood flow (ie, to rule out hematoma, deep venous thrombosis, or vascular entrapment).
  • Computed tomography (CT) scanning and MRI: Findings can help rule other significant causes of chronic lower leg pain.
• MRI may be helpful in the diagnosis of chronic exertional compartment syndrome (CECS), although its exact role is unclear.²
• Thallous chloride scintigraphy with single-photon emission CT (SPECT) scanning has  been studied in the diagnosis of chronic exertional compartment syndrome (CECS). One study showed that thallous chloride scintigraphy with SPECT scanning was a sensitive method of diagnosis.⁴ The study was able to show (1) reversible areas of ischemia in the affected compartment during exercise testing and (2) multiple compartments with elevated pressures.⁴ However, larger studies need to be conducted to prove the efficacy of this imaging modality in chronic exertional compartment syndrome (CECS).

Other Tests

• Compartment pressure readings with and without exercise are the gold standard for the diagnosis of chronic exertional compartment syndrome (CECS). Pain reproduced during exercise in combination with elevated compartment pressures can confirm the diagnosis of chronic exertional compartment syndrome (CECS). If symptoms are not reproduced with exertion, the diagnosis is less certain.
• Nerve conduction studies may be helpful for detecting neurologic involvement of affected compartments. However, their role is questionable in aiding the diagnosis of chronic exertional compartment syndrome (CECS). Such studies may be helpful for excluding other related disorders such as peripheral nerve entrapment. In fact, a study by the  authors of this article only demonstrated a loss of the postexercise amplitude potentiation in patients with chronic exertional compartment syndrome (CECS) compared controls when pre- and postexercise electromyography studies (EMGs) were completed.

Related eMedicine topics:
EMG Evaluation of the Motor Unit: The Electrophysiologic Biopsy
Motor Unit Recruitment in EMG
Single-Fiber EMG

Related Medscape topics:
Specialty Site Exercise and Sports Medicine
Specialty Site Neurology & Neurosurgery

Procedures

• Compartment pressure testing is considered the criterion standard for diagnosing chronic exertional compartment syndrome (CECS). A large-bore needle or a wick catheter is inserted into the affected muscular compartment and is then connected to a solid-state pressure monitor.
  • Compartment pressure testing must be performed under sterile conditions. The needle tip location, the depth of penetration, and the knee and ankle position are controlled to obtain reliable measurements. The anterior, lateral, and superficial posterior compartments are relatively easy to test; testing the deep posterior compartment is more difficult. The generally accepted method of testing is to measure the resting compartment pressure, exercise the patient until a symptomatic level is reached, and then measure again, noting pressure readings at 1 minute and 5 minutes postexercise.
  • Not all sports medicine centers have facilities to perform this test, but most centers do have this capability. Occasionally, the clinician may have to rely on history and physical examination findings. However, history and examination findings alone are not usually sufficient to confirm the diagnosis of chronic exertional compartment syndrome (CECS).
• Pedowitz et al defined the criteria for the diagnosis of chronic exertional compartment syndrome (CECS) in the leg, which are the following⁵ : 
  • A preexercise/rest pressure of greater than 15 mm Hg
  • A 1-minute postexercise pressure of greater than 30 mm Hg,
  • A 5-minute postexercise pressure of greater than 20 mm Hg
  • Although the diagnosis of chronic exertional compartment syndrome (CECS) can be made if just 1 of the above criteria is met, the greater the number of criteria that are satisfied, the greater the confidence level of the diagnosis.

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