Chronic Exertional Compartment Syndrome Treatment & Management

  • Author: Gregory A Rowdon, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Aug 8, 2011
 

Approach Considerations

A trial of conservative treatment may be undertaken for chronic exertional compartment syndrome (CECS). However, symptoms generally recur when the patient returns to exercise. If conservative therapy is unsuccessful, the patient should be referred to an orthopedic surgeon for consideration of fasciotomy.[22, 23, 24, 25]

Fasciotomy of the anterior compartment has a better outcome than fasciotomy of the posterior compartment.[26, 27, 28, 29, 30] Furthermore, the rehabilitation phase is longer for patients who undergo deep posterior compartment fasciotomy than it is for those who undergo anterior compartment fasciotomy. The reasons for this difference in outcome remain unclear.

Multiple techniques have been described for fasciotomy of the lower leg. Newer techniques have been developed to minimize the skin incision and maximize the fascial release.[31] For example, Wittstein et al have suggested that "endoscopic assistance may minimize the intraoperative and postoperative complications associated with compartment release and offer improved cosmesis."[7] These investigators used a balloon dissector that was designed to address the shortcomings of open and semi-blind techniques.

In cases of fasciotomy for anterior CECS, lateral compartment fasciotomy may not be necessary. A study by Schepsis et al demonstrated similar outcomes in athletes with CECS who were treated either by single-compartment or dual-compartment release.[32]

Recurrence after fasciotomy is unusual. If fasciotomy fails, the diagnosis of CECS should be fully reevaluated. Repeat pressure measurements are usually required. For a true recurrence, a second decompression is performed via fasciectomy and is usually successful.

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Physical Therapy

Conservative therapy has been attempted for CECS, but it is generally unsuccessful; symptoms typically recur once the patient returns to exercise.[7] Discontinuing participation in sports is an option, but it is a choice that most athletes refuse.

Conservative therapy

Conservative treatment of CECS mainly involves a decrease in activity or load to the affected compartment. The activity level gradually is increased, depending on the patient’s symptoms. Aquatic exercises, such as running in water, can improve mobility and strength without unnecessarily loading the affected compartment. Massage and stretching exercises also have been shown to be effective, according to Hutchinson and Ireland.[33]

Presurgical therapy

Presurgical therapy in CECS includes reduction of activity, with encouragement of cross-training exercises (eg, swimming, bicycling, other low-impact activities) and muscle stretching before initiating exercise. This approach may also be helpful for primary prevention of CECS, although only limited information is available on this topic. Other preoperative measures are rest, shoe modification, and the use of nonsteroidal anti-inflammatory medications (NSAIDs) to reduce inflammation. It is recommended to avoid casting, splinting, or compression of the affected limb.

Postsurgical therapy

Postsurgical therapy for CECS includes assisted weight bearing with some variation, depending on surgical technique. Some physicians recommend immediate postsurgical range-of-motion activity that may include walking (unaided by 3-5 d). Early mobilization as soon as is feasible is recommended by many surgeons to minimize scarring, which can lead to adhesions and a recurrence of the syndrome.

Activity can be upgraded to stationary cycling and swimming after healing of the surgical wounds. Isokinetic muscle strengthening exercises can begin at 3-4 weeks. Running is integrated into the activity program at 3-6 weeks. Full activity is introduced at approximately 6-12 weeks, with a focus on speed and agility.

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Contributor Information and Disclosures
Author

Gregory A Rowdon, MD  Associate Clinical Professor, Department of Medicine, Division of Family Practice, Indiana University Medical Center; Team Physician, Purdue University

Gregory A Rowdon, MD is a member of the following medical societies: American College of Sports Medicine and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Samuel Agnew, MD, FACS  Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Stuart B Goodman, MD, PhD, FRCS(C), FACS, FBSE  Robert L and Mary Ellenburg Professor of Surgery, Professor, Department of Orthopedic Surgery, Fellowship Director, Orthopedic Adult Reconstruction, Affiliated Faculty, Department of Bioengineering, Affiliated Faculty, Stanford Center on Longevity, Stanford University School of Medicine, Stanford University Medical Center

Stuart B Goodman, MD, PhD, FRCS(C), FACS, FBSE is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, California Medical Association, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

Steven I Rabin, MD  Clinical Associate Professor, Loyola University Medical Center; Chair, Department of Orthopedic Surgery, Dreyer Medical Clinic

Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Fracture Association, AO Foundation, and Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Douglas G Smith, MD  Associate Professor, Department of Orthopedic Surgery, Harborview Medical Center, University of Washington School of Medicine

Disclosure: Nothing to disclose.

Jeffrey L Visotsky, MD  Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University, The Feinberg School of Medicine

Jeffrey L Visotsky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, Arthroscopy Association of North America, Chicago Medical Society, and Illinois State Medical Society

Disclosure: Depuy Consulting fee Speaking and teaching; Pegasus Honoraria Board membership

Stephen Wallace, MD  Staff Physician, Department of Emergency Medicine, Memorial Hospital of Sweetwater County

Stephen Wallace, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph P Garry, MD, FACSM, FAAFP  Associate Professor, Sports Medicine Faculty, Department of Family and Community Medicine, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, and North American Primary Care Research Group

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

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An illustration that depicts measurement of compartment pressures in the forearm.
 
 
 
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