Under pressure!

A leg cramp is maddening but repeated leg pain on exertion halts an athlete's progress and performance. Such is the case with chronic exertional compartment syndrome (CECS), the topic of today's feature article. Physiotherapist Chris Mallac highlights this frustrating syndrome, including the theories about why it happens in the first place. Although several theories of etiology exist, CECS occurs when the pressure within a muscular compartment is greater than the systemic blood pressure. The heart, therefore, is not able to pump blood into the muscles within the compartment, and tissue death (ischemia) follows.

Chronic exertional compartment syndrome causes up to one-third of all cases of leg pain in athletes (1). Any athlete who participates in a running sport is susceptible to CECS. It can effect both the anterior and posterior compartments of the leg. Athletes who grip, such as rowers or motorcycle racers, may also experience CECS in the compartments of their lower arm. Both male and female athletes suffer from CECS equally.

Athletes describe the pain of compartment syndrome as deep and burning. When affecting the anterior compartment of the leg, they may demonstrate foot drop and weakness on dorsiflexion. Soccer players are particularly susceptible to anterior CECS after lengthy shooting drills.

Mallac describes the gold standard of CECS diagnosis, measurement of intra-compartmental pressure using a needle manometer (see figure 1). Because CECS can present as an acute medical emergency, all cases should be referred to a physician. Except in the most severe cases, they usually recommend conservative treatment as the first course of action. This requires the athlete to modify his activity anywhere from six to 12 weeks, use NSAIDS, and receive physical therapy.

Figure 1: Stryker catheter used to measure intra-compartmental pressure.

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Severe or emergent cases require a fasciotomy to relive the compartment pressure. Assuming no permanent damage to the muscle and an uncomplicated recovery without infection, athletes return to sport when the wound is healed. Treatment with fasciotomy remains highly successful in up to 90% of cases (1). Progressive rehabilitation focuses on regaining strength in the compromised muscles and moves from gait training to sport specific drills.

References

1. Kiel J, Kaiser K. Tibia, Anterior Compartment Syndrome. [Updated 2018 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.