Chronic Exertional Compartment Syndrome - Everything You Need To Know - Dr. Nabil Ebraheim

Educational video describing the condition of Chronic Exertional Compartment Syndrome (CECS).
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CECS is an exercise-induced neuromuscular condition that occurs when a compartment cannot accommodate the increase in muscle volume and pressure during exercise.
CECS of the lower leg occurs bilaterally in 80-90% of patients. Distribution by compartment:
•Anterior 40-60%
•Lateral 12-35%
•Deep posterior 32-60%
•Sup[erficial posterior 2-20%
In rare occasions, cases of CECs occur in the thigh, foot, forearm and the hand. Increased blood flow during exercise can cause up to 20% increase in muscle volume. In CECS patients, the osetofascial compartment cannot accommodate the expanding tissue volume which raises the intra-compartmental pressure. While elevated pressure may lead to ischemia and pain, it is not enough to cause irreversible damage to the tissues.
The high-pressure cause pain, tenderness, swelling, paresthesia, and weakness that usually affects the activity. symptoms may be due to relative ischemia, stimulation of the fascia or periosteal sensory nerves by increased compartment pressures in response to reduced blood flow.
Differential diagnosis
Medial tibial stress syndrome (shin splits)
•Often develops in distance runners.
•Pain is diffuse in the distal third of the anterior leg, usually over the medial border of the tibia.
Stress fracture
•Usually develops in those who sharply increase their training activity who perform high impact sports.
•Most stress fracture is located at the distal third of the tibia, but they may occur anywhere on the tibia or the fibula.
•A runner with pain in the leg may have a stress fracture and the x-ray may be negative. A bone scan or MRI may be needed for the diagnosis.
Deep vein thrombosis
•Caused by a blood clot, usually from trauma, surgery or prolonged immobilization.
•Includes diffuse pain, tenderness and swelling throughout the leg.
•Doppler may be necessary for the diagnosis.
Nerve entrapment
•Often involves the superficial peroneal nerve but the deep peroneal nerve or sural nerve can be entrapped.
•Pain and paresthesia begin with exertion in the distribution of the involved nerve.
•Tinel’s sign is usually positive.
Vascular disorders
•Popliteal artery entrapment syndrome is the most common.
•Claudication from atherosclerotic disease and venous insufficiency are possible.
Radiculopathy
•Radiating pain from the lumbosacral spine to the lower leg even when at rest.
•Pain sometimes accompanied by weakness and paresthesia.
Fascial defects
•Pain may occur over the distal, anterolateral leg where the superficial peroneal nerve exits the lateral compartment.
•Herniated muscle may be visible and tender to palpation.
•In CECS patients, the resting intra-compartmental pressure is usually greater than 15 mmHg.
Clinical presentation
•Pain begins within 20 minutes of exercise.
•Pain, swelling, claudication, and paresthesia after exercise.
•Pressure remains over 30 mmHg 1 minute after the end of the exercise.
•Pressure remains over 20 mmHg for longer than 5 minutes after the end of exercise.
•CECS presents bilaterally in 80-95% of patients.
•Anterior compartment most frequent
•Incidence is equal among male and female young athletes.
•Physical examination is often normal before exercise.
•The onset of pain I usually predictable and reproducible at a specific distance and/or intensity.
•If left untreated, symptoms will worsen or become constant.
Diagnosis is made by intra-compartmental pressure measurement.
Patients should be placed in a supine position with the knee in 10-30 degrees of flexion and the foot in 20 degrees plantar flexion.
One or more of the following is generally accepted as diagnostic:
•Pre-exercise pressure -15 mmHg.
•Post-exercise pressure at 1 minute - 30 mmHg
•Post-exercise pressure at 5 minutes - 20 mmHg
Diagnosis and treatment
•Conservative treatments include cessation of causative activity, rest, ice, physical therapy and deep massage. These treatment, however are generally unsuccessful.
•Fasciotomy is the only proven successful treatment of CECs and is recommended if symptoms worsen or continue for more than 3 months.
•Following physical therapy complete recovery and full return to activity are typical within 8 to 12 weeks.