Chronic Exertional Compartment Syndrome Workup
- Author: Gregory A Rowdon, MD; Chief Editor: Craig C Young, MD more...
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. Compartment pressure readings with and without exercise are the gold standard for the diagnosis of CECS.[7, 8, 9]
Laboratory studies are generally not helpful, but specific tests may be ordered to help rule out other causes of lower leg pain on an individual case-by-case basis. Similarly, imaging studies are not helpful in the diagnosis of CECS but may help rule out related disorders.
Blood and Urine Studies
The following studies may be useful for excluding other diagnoses in patients with suspected CECS:
Serum creatine kinase (CK) and myoglobin level (identifies myopathy or rhabdomyolysis)
Urinalysis (UA) and urine myoglobin (rhabdomyolysis)
D-dimer level (deep venous thrombosis)
Complete blood cell 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)
Lower-Extremity Imaging Studies
Imaging studies may help exclude related disorders in patients with suspected CECS. 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 helps exclude stress fracture, periostitis, and malignancy of the lower extremity. Ultrasonography can be performed to visualize blood flow (ie, to rule out hematoma, deep venous thrombosis, or vascular entrapment).
Computed tomography (CT) scanning and magnetic resonance imaging (MRI) can help rule other significant causes of chronic lower leg pain. MRI may be helpful in the diagnosis of CECS, although its exact role is unclear.
A study of thallous chloride scintigraphy with single-photon emission CT (SPECT) scanning showed that thallous chloride scintigraphy with SPECT scanning was a sensitive method of diagnosis. 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. However, larger studies need to be conducted to prove the efficacy of this imaging modality in CECS.
Compartment Pressure Testing
Compartment pressure readings with and without exercise are the gold standard for the diagnosis of CECS. Pain reproduced during exercise in combination with elevated compartment pressures can confirm the diagnosis. If symptoms are not reproduced with exertion, the diagnosis is less certain.[7, 8, 9]
Most, but not all, sports medicine centers have the facilities to perform compartment pressure testing. Occasionally, the clinician may have to rely on history and physical examination findings. History and examination findings alone are not usually sufficient to confirm the diagnosis of CECS; however, some authors do not advocate measurement of compartment pressures when the findings of the history and clinical examination are clear and the patient is selected for surgery.
For this procedure, 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. See the image below.
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.
Pedowitz et al defined the criteria for the diagnosis of CECS in the leg. One or more of the following is required:
A preexercise/rest pressure of 15 mm Hg or higher
A 1-minute postexercise pressure of 30 mm Hg or higher
A 5-minute postexercise pressure of 20 mm Hg or higher
Although the diagnosis of 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.
Nerve conduction studies may be helpful for detecting neurologic involvement of affected compartments. However, their role in the diagnosis of CECS is questionable. Such studies may be helpful for excluding other related disorders such as peripheral nerve entrapment. One study of pre- and postexercise electromyography demonstrated only a loss of the postexercise amplitude potentiation in patients with CECS compared with controls.
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