Chronic Exertional Compartment Syndrome

I enjoyed reading the article “Chronic Exertional Compartment Syndrome in a Collegiate Soccer Player: A Case Report and Literature Review” by Drs. Farr and Selesnick (Am J Orthop. 2008;37[7]:374-377). However, I do take some exceptions to the authors’ comments.

First, I think the history (supplemented by the usual almost total absence of findings on the exam) is sufficient to justify compartment manometrics without obtaining more costly magnetic resonance imaging (MRI), electromyography/nerve conduction studies (EMG/NCS), and nuclear medicine studies beforehand.

Second, I recommend using an exercise challenge that conforms to what the patient says causes his/her symptoms rather than a “standard” treadmill protocol. For example, I had a patient with the nephrotic syndrome who developed chronic exertional compartment syndrome (CECS) symptoms after walking 75 feet. A fasciotomy resolved her CECS symptoms. A 15-minute run on a treadmill would have likely precipitated a cardiac event. Conversely, I have had college track runners who required 45 minutes of “hard” running before their CECS symptoms were manifested.

Third, I think CECS examiners are remiss in their responsibilities if they do not pair the patient’s subjective perception of pain (using a [0 = no pain] to [10 = excruciating pain] scale) with compartment pressure measurements. This has saved my patients multiple “sticks” with the 19-gauge vented Stryker needles (Stryker Corporation, Kalamazoo, Mich). For example, a recent (markedly obese) patient judged the pain to be 5 (interfered with activities) in the anterior and posterior compartments of both legs after walking for 20 to 30 minutes. At the time of compartment pressure measurements, the symptoms were rated 2 (ie, the patient had to think about them to notice the pain). Resting pressures in the
two compartments were more than twice the upper limits of normal. From this information, I felt comfortable in recommending staged bilateral four-compartment leg fasciotomies while minimizing the needlesticks to two.

I have co-authored an article (with one of my patients, who is now an anesthesiologist and has resumed her half marathon runs after bilateral anterior compartment fasciotomies) which explains how I use perceived pain with manometrics to maximize the decision-making process and minimize the number of “sticks” the patient must experience. (Strauss MB, Wakim N. Patient perception pinpoints exertional leg pain. BioMechanics. 2002;9[10]:63-77.)