Chronic Exertional Compartment Syndrome Treatment & Management

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

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. [25, 26, 27, 28]

Fasciotomy of the anterior compartment has a better outcome than fasciotomy of the posterior compartment. [29, 30, 31, 32, 33] 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. [34] 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." [10] 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. [35]

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. [10] 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. [36]

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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