Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Chronic Exertional Compartment Syndrome Workup

  • Author: Gregory A Rowdon, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Oct 08, 2015
 

Approach Considerations

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.

Next

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)
Previous
Next

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.[18]

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.[23] 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.[23] However, larger studies need to be conducted to prove the efficacy of this imaging modality in CECS.

Previous
Next

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.

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

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.[24] 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.

Previous
Next

Electromyography

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.

Previous
 
 
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, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

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 Association for Physician Leadership, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, Arthroscopy Association of North America, Chicago Medical Society, Illinois State Medical Society

Disclosure: Received consulting fee from Depuy for speaking and teaching; Received honoraria from Pegasus for board membership.

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, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Stephen Wallace, MD Chief of Emergency Medicine, Sublette County Rural Health Care District

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

Disclosure: Nothing to disclose.

Stuart B Goodman, MD, PhD, FRCSC, 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, FRCSC, FACS 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, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Orthopedic Surgery, Podiatry, Rheumatology, Sports Medicine, and Pain Management, Dreyer Medical Clinic; Chairman, Department of Surgery, Provena Mercy Medical Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, 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, American Medical Society for Sports Medicine

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, 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, 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 Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

References
  1. Claes T, Van der Beek D, Claes S, Verfaillie S, Bataillie F. Chronic exertional compartment syndrome of the forearm in motocross racers. Presented at: The European Sports Medicine Congress; Hasselt, Belgium; May 14-16, 2003.

  2. Goubier JN, Saillant G. Chronic compartment syndrome of the forearm in competitive motor cyclists: a report of two cases. Br J Sports Med. 2003. 37(5):452-3; discussion 453-4. [Medline]. [Full Text].

  3. Piasecki DP, Meyer D, Bach BR Jr. Exertional compartment syndrome of the forearm in an elite flatwater sprint kayaker. Am J Sports Med. 2008 Nov. 36(11):2222-5. [Medline].

  4. Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. 2000 Mar. 32(3 suppl):S4-10. [Medline].

  5. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975 Nov-Dec. 43-51. [Medline].

  6. Whitesides TE Jr, Haney TC, Harada H, Holmes HE, Morimoto K. A simple method for tissue pressure determination. Arch Surg. 1975 Nov. 110(11):1311-3. [Medline].

  7. Roberts A, Franklyn-Miller A. The validity of the diagnostic criteria used in chronic exertional compartment syndrome: a systematic review. Scand J Med Sci Sports. 2012 Oct. 22 (5):585-95. [Medline].

  8. Tiidus PM. Is intramuscular pressure a valid diagnostic criterion for chronic exertional compartment syndrome?. Clin J Sport Med. 2014 Jan. 24 (1):87-8. [Medline].

  9. Roscoe D, Roberts AJ, Hulse D. Intramuscular compartment pressure measurement in chronic exertional compartment syndrome: new and improved diagnostic criteria. Am J Sports Med. 2015 Feb. 43 (2):392-8. [Medline].

  10. Wittstein J, Moorman CT 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome. J Surg Orthop Adv. 2008 Summer. 17(2):119-21. [Medline].

  11. Reneman RS. The anterior and the lateral compartmental syndrome of the leg due to intensive use of muscles. Clin Orthop Relat Res. 1975 Nov-Dec. 69-80. [Medline].

  12. Clayton JM, Hayes AC, Barnes RW. Tissue pressure and perfusion in the compartment syndrome. J Surg Res. 1977 Apr. 22(4):333-9. [Medline].

  13. Shrier I, Magder S. Pressure-flow relationships in in vitro model of compartment syndrome. J Appl Physiol. 1995 Jul. 79(1):214-21. [Medline].

  14. Beraldo S, Dodds SR. Lower limb acute compartment syndrome after colorectal surgery in prolonged lithotomy position. Dis Colon Rectum. 2006 Nov. 49(11):1772-80. [Medline].

  15. Wassenaar EB, van den Brand JG, van der Werken C. Compartment syndrome of the lower leg after surgery in the modified lithotomy position: report of seven cases. Dis Colon Rectum. 2006 Sep. 49(9):1449-53. [Medline].

  16. Rafiq I, Anderson DJ. Acute rhabdomyolysis following acute compartment syndrome of upper arm. J Coll Physicians Surg Pak. 2006 Nov. 16(11):734-5. [Medline].

  17. Walker JL, Smith GH, Gaston MS, Robinson CM. Spontaneous compartment syndrome in association with simvastatin-induced myositis. Emerg Med J. 2008 May. 25(5):305-6. [Medline].

  18. Amendola A, Rorabeck CH, Vellett D, et al. The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med. 1990 Jan-Feb. 18(1):29-34. [Medline].

  19. Kaper BP, Carr CF, Shirreffs TG. Compartment syndrome after arthroscopic surgery of knee. A report of two cases managed nonoperatively. Am J Sports Med. 1997 Jan-Feb. 25(1):123-5. [Medline].

  20. Awbrey BJ. Office diagnosis and intraoperative pressure-assisted fasciotomy for exercise-induced compartment syndrome. Paper (no. 395) presented at: Annual Meeting of the American Academy of Orthopaedic Surgeons; March 19-22, 1998; New Orleans, La.

  21. King TW, Lerman OZ, Carter JJ, Warren SM. Exertional compartment syndrome of the thigh: a rare diagnosis and literature review. J Emerg Med. 2010 Aug. 39(2):e93-9. [Medline].

  22. Rowdon GA, Richardson JK, Hoffmann P, Zaffer M, Barill E. Chronic anterior compartment syndrome and deep peroneal nerve function. Clin J Sport Med. 2001 Oct. 11(4):229-33. [Medline].

  23. Hayes AA, Bower GD, Pitstock KL. Chronic (exertional) compartment syndrome of the legs diagnosed with thallous chloride scintigraphy. J Nucl Med. 1995 Sep. 36(9):1618-24. [Medline]. [Full Text].

  24. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990 Jan-Feb. 18(1):35-40. [Medline].

  25. Edwards PH Jr, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med. 2005 Aug. 33(8):1241-9. [Medline].

  26. Black KP, Taylor DE. Current concepts in the treatment of common compartment syndromes in athletes. Sports Med. 1993 Jun. 15(6):408-18. [Medline].

  27. Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med. 1985 May-Jun. 13(3):162-70. [Medline].

  28. Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med. 1993 Nov-Dec. 21(6):811-7; discussion 817. [Medline].

  29. Mouhsine E, Garofalo R, Moretti B, Gremion G, Akiki A. Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc. 2006 Feb. 14(2):193-7. [Medline].

  30. Raikin SM, Rapuri VR, Vitanzo P. Bilateral simultaneous fasciotomy for chronic exertional compartment syndrome. Foot Ankle Int. 2005 Dec. 26(12):1007-11. [Medline].

  31. Styf JR, Körner LM. Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. J Bone Joint Surg Am. 1986 Dec. 68(9):1338-47. [Medline]. [Full Text].

  32. Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med. 1988 May-Jun. 16(3):224-7. [Medline].

  33. Fronek J, Mubarak SJ, Hargens AR, ET AL. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res. 1987 Jul. 220:217-27. [Medline].

  34. Sebik A, Dogan A. A technique for arthroscopic fasciotomy for the chronic exertional tibialis anterior compartment syndrome. Knee Surg Sports Traumatol Arthrosc. 2008 May. 16(5):531-4. [Medline].

  35. Schepsis AA, Gill SS, Foster TA. Fasciotomy for exertional anterior compartment syndrome: is lateral compartment release necessary?. Am J Sports Med. 1999 Jul-Aug. 27(4):430-5. [Medline].

  36. Hutchinson MR, Ireland ML. Common compartment syndromes in athletes. Treatment and rehabilitation. Sports Med. 1994 Mar. 17(3):200-8. [Medline].

  37. Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009 Jan. 102(1):3-11. [Medline].

 
Previous
Next
 
An illustration that depicts measurement of compartment pressures in the forearm.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.