Slide 1

Chronic Exertional Compartment Syndrome Sathish Rajasekaran, MD, Clinical Assistant Professor, Division of PM&R, University of Alberta

Slide 2

None Disclosures

Slide 3

Introduction Anatomy Pathophysiology History and Physical Exam Diagnostic Evaluation Treatment Outline Have an approach to adding CECS to your differential diagnosis based on history and physical examination Outline an approach to ordering the appropriate tests for patients where CECS is on the differential diagnosis Outline conservative and surgical treatment options for CECS Outline return to play guidelines for CECS Objectives Choric Exertional Compartment Syndrome (CECS)

Slide 4

Clinical Case 24 year old female J.M. History: Classical symptoms? Physical Examination At rest vs. post-exertion Diagnostic Testing Compartment pressure testing vs. other imaging modalities Other studies to exclude other diagnoses Treatment options Conservative (rehabilitation) vs. interventional options vs. surgery

Slide 5

Slide 6

Epidemiology Incidence 2,3 General population (unknown) Undiagnosed leg pain (14-27%) Age 4-8 Potential bimodal distribution (20 [before 30] vs. 48 years) Association with sports 4,9 Involved in sports (87%) Running (69%) Diabetic patients with exertional leg pain and normal vascular studies (90%)

Slide 7

Location Can present in various regions of the body 10 Lower leg, thigh, foot, and forearm Lower leg most common region affected (95%) 10 Bilateral lower leg involvement (82%) 4

Slide 8

Anatomy 40-60% 4,5 32-60% 4,5 12-35% 4,5 2-20% 4,5 Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000.

Slide 9

Pathophysiology Compliance Compartment pressure?

Slide 10

Pathophysiology Reduced microcirculatory capacity Vascular congestion as a result of decreased venous return

Slide 11

Pathophysiology Abstract presented at AMSSM 2013 (Rajasekaran and Aly)

Slide 12

Pathophysiology

Slide 13

History and Physical Examination Pain with exertion Dull sharp pain Neurological symptoms Worsening over time Pain with passive stretching of muscles in involved compartment

Slide 14

Diagnostic Evaluation Pressure testing Pre-exercise (15 mm Hg), 1 min post-exercise (30 mm Hg), 5 min post-exercise (20 mm Hg)

Slide 15

Diagnostic Evaluation (Imaging)

Slide 16

Diagnostic Evaluation - Imaging Bresler M, Mar W, Toman J. Diagnostic imaging in the evaluation of leg pain in athletes. Clinics in sports medicine. Apr 2012;31(2):217-245. Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol. Skeletal radiology. Nov 2007;36(11):1067-1075.

Slide 17

Diagnostic Evaluation - Imaging Tib Fib TP ATMG Rajasekaran S, Beavis C, Aly AR, Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2013;23(4):305-311.

Slide 18

Treatment Conservative Interventional Surgery

Slide 19

Treatment Conservative

Slide 20

Treatment Interventional

Slide 21

Treatment - Interventional

Slide 22

Treatment Surgery Single incision (open) technique One or two incision (subcutaneous) technique with or without endoscopic assistance with the removal of a strip of fascia

Slide 23

Slide 24

Treatment - Surgery 24

Slide 25

Treatment - Surgery Complications (11-16%) 28,29 Infection Nerve or vascular injury Deep vein thrombosis Wound dehiscence Complex regional pain syndrome Scar hypersensitivity Seroma/hematoma formation

Slide 26

Treatment - Surgery POD 1-2 Gentle active and passive range-of-motion, weight bearing as tolerated, edema control measures, basic activities of daily living, protect the healing incision at all times POD 3-4 Achieve independence with activities of daily living, and begin unassisted ambulation Weeks 1-4 Add stair climbing and increase walking distance Weeks 4-6 Begin non-impact lower extremity aerobic exercise Weeks 6+ Initiate unrestricted impact lower extremity activities Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000.

Slide 27

Clinical Case 24 year old female J.M. Trialed forefoot running technique Symptoms resolved Repeat pressures were not done Patient continues to be asymptomatic (7 months)

Slide 28

Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000.

Slide 29

Introduction Anatomy and Pathophysiology History and Physical Exam Diagnostic Evaluation Treatment Return-to-Play Guidelines Outline Have an approach to adding CECS to your differential diagnosis based on history and physical examination Outline an approach to ordering the appropriate tests for patients where CECS is on the differential diagnosis Outline conservative and surgical treatment options for CECS Outline return to play guidelines for CECS Objectives Choric Exertional Compartment Syndrome (CECS)

Slide 30

References 1.Horn C. Acute ischaemia of the anterior tibial muscle and the long extensor muscles of the toes. J Bone Joint Surg Am. 1945;27(4):615-622. 2.Qvarfordt P, Christenson JT, Eklof B, Ohlin P, Saltin B. Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clinical orthopaedics and related research. Oct 1983(179):284-290. 3.Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. The American journal of sports medicine. Mar-Apr 1988;16(2):165-169. 4.Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. The American journal of sports medicine. May-Jun 1985;13(3):162-170. 5.Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. The American journal of sports medicine. Jan-Feb 1990;18(1):35-40.

Slide 31

References 6.Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. The Journal of bone and joint surgery. American volume. Dec 1983;65(9):1245-1251. 7.Wallensten R. Results of fasciotomy in patients with medial tibial syndrome or chronic anterior-compartment syndrome. The Journal of bone and joint surgery. American volume. Dec 1983;65(9):1252-1255. 8.Styf JR, Korner LM. Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. The Journal of bone and joint surgery. American volume. Dec 1986;68(9):1338-1347. 9.Edmundsson D, Toolanen G. Chronic exertional compartment syndrome in diabetes mellitus. Diabetic medicine : a journal of the British Diabetic Association. Jan 2011;28(1):81-85. 10.Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med. Mar 1997;31(1):21-27.

Slide 32

References 11.Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R : the journal of injury, function, and rehabilitation. Dec 2012;4(12):985-1000. 12.Hurschler C, Vanderby R, Jr., Martinez DA, Vailas AC, Turnipseed WD. Mechanical and biochemical analyses of tibial compartment fascia in chronic compartment syndrome. Annals of biomedical engineering. May-Jun 1994;22(3):272-279. 13.Dahl M, Hansen P, Stal P, Edmundsson D, Magnusson SP. Stiffness and Thickness of Fascia Do Not Explain Chronic Exertional Compartment Syndrome. Clinical orthopaedics and related research. Sep 24 2011. 14.Edmundsson D, Toolanen G, Thornell LE, Stal P. Evidence for low muscle capillary supply as a pathogenic factor in chronic compartment syndrome. Scandinavian journal of medicine & science in sports. Dec 2010;20(6):805-813. 15.Birtles DB, Rayson MP, Casey A, Jones DA, Newham DJ. Venous obstruction in healthy limbs: a model for chronic compartment syndrome? Medicine and science in sports and exercise. Oct 2003;35(10):1638-1644.

Slide 33

References 16.Aweid O, Del Buono A, Malliaras P, et al. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2012;22(4):356-370. 17.Roberts A, Franklyn-Miller A. The validity of the diagnostic criteria used in chronic exertional compartment syndrome: A systematic review. Scandinavian journal of medicine & science in sports. Sep 13 2011. 18.McDonald S, Bearcroft P. Compartment syndromes. Seminars in musculoskeletal radiology. Jun 2010;14(2):236-244. 19.Bresler M, Mar W, Toman J. Diagnostic imaging in the evaluation of leg pain in athletes. Clinics in sports medicine. Apr 2012;31(2):217-245. 20.Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol. Skeletal radiology. Nov 2007;36(11):1067-1075.

Slide 34

References 21.Rajasekaran S, Beavis C, Aly AR, Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2013;23(4):305-311. 22.Kirby RL, McDermott AG. Anterior tibial compartment pressures during running with rearfoot and forefoot landing styles. Archives of physical medicine and rehabilitation. Jul 1983;64(7):296-299. 23.Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. International journal of sports physical therapy. Dec 2011;6(4):312-321. 24.Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome. The American journal of sports medicine. Mar 16 2012. 25.Isner-Horobeti ME, Dufour SP, Blaes C, Lecocq J. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study. The American journal of sports medicine. Nov 2013;41(11):2558-2566.

Slide 35

References 26.Wittstein J, Moorman CT, 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. The American journal of sports medicine. Aug 2010;38(8):1661-1666. 27.Packer JD, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. The American journal of sports medicine. Feb 2013;41(2):430-436. 28.Waterman BR, Laughlin M, Kilcoyne K, Cameron KL, Owens BD. Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. The Journal of bone and joint surgery. American volume. Apr 3 2013;95(7):592-596. 29.Brennan FH, Jr., Kane SF. Diagnosis, treatment options, and rehabilitation of chronic lower leg exertional compartment syndrome. Current sports medicine reports. Oct 2003;2(5):247-250.

Slide 36

Acknowledgments Dr. Jonathan Finnoff