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Shankar DS, Vasavada KD, Gillinov LA, Kirschner N, Mojica ES, Blaeser AM, Borowski LE, Jazrawi LM, Cardone DA. Female patients have greater improvement in pain symptoms and physical activity after fasciotomy for treatment of chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38690978 DOI: 10.1002/ksa.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE The purpose of this study was to identify sex differences in postoperative outcomes and return-to-sport rates after fasciotomy for treatment of chronic exertional compartment syndrome (CECS) of the lower leg. It was hypothesised that male CECS patients would have a higher rate of return to sport than female CECS patients. METHODS A retrospective cohort study was conducted involving patients who underwent primary fasciotomy of one to four leg compartments for treatment of CECS at a single centre from 2010 to 2020. Each affected leg was treated as a separate subject. Postoperative outcomes included CECS pain frequency and severity, return to sport and Tegner activity level. Multivariable regression was used to determine if sex was an independent predictor of outcomes after adjusting for demographic and clinical covariates. p < 0.05 were considered significant. RESULTS Eighty-one legs (44 M, 37 F) of 47 unique patients (34 of whom had bilateral symptoms) were included with a mean follow-up time of 51.5 ± 31.4 months. Male subjects were older (p < 0.001) and had higher body mass index (p < 0.001) compared to female subjects. Most subjects (84.0%) underwent two- or four-compartment fasciotomies. Female sex was found to be predictive of lower overall postoperative pain severity (p = 0.007), higher odds of return to sport (p = 0.04) and higher postoperative Tegner score (p = 0.005). However, female sex was not predictive of postoperative pain frequency, odds of reoperation or odds of return to sport to at least the presymptomatic level (all p < 0.05). CONCLUSION Female sex is independently predictive of reduced overall pain severity, higher odds of return to sport and higher postoperative improvement in Tegner score following fasciotomy for treatment of lower-limb CECS. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dhruv S Shankar
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Kinjal D Vasavada
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Lauren A Gillinov
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Noah Kirschner
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Edward S Mojica
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Anna M Blaeser
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Lauren E Borowski
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Dennis A Cardone
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
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Gawel RJ, Kemler BR, Coladonato C, Freedman KB. Rehabilitation and return to activity criteria after operative management of chronic exertional compartment syndrome of the leg: a systematic review. PHYSICIAN SPORTSMED 2024; 52:125-133. [PMID: 37191583 DOI: 10.1080/00913847.2023.2214192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Endurance athletes with chronic exertional compartment syndrome (CECS) frequently require fasciotomy to return to activity, but there are no existing comprehensive evidence-based rehabilitation guidelines. We aimed to summarize rehabilitation protocols and return to activity criteria after CECS surgery. METHODS Through a systematic literature review, we identified 27 articles that explicitly defined physician-imposed restrictions or guidelines for patients to resume athletic activities following CECS surgery. RESULTS Common rehabilitation parameters included running restrictions (51.9%), postoperative leg compression (48.1%), immediate postoperative ambulation (44.4%), and early range of motion exercises (37.0%). Most studies (70.4%) reported return to activity timelines, but few (11.1%) utilized subjective criteria for guiding return to activity. No studies utilized objective functional criteria. CONCLUSIONS Rehabilitation and return to activity guidelines after CECS surgery remain poorly defined, and further investigation is needed to develop such guidelines that will enable endurance athletes to safely return to activities and minimize recurrence.
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Affiliation(s)
- Richard J Gawel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Bryson R Kemler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Dean RS, Farley KX, Waterman BR, Guettler J, Bicos J. Chronic exertional compartment syndrome is frequently diagnosed through static compartment pressure measurements and managed with fasciotomy: A systematic review. J ISAKOS 2024; 9:71-78. [PMID: 37778507 DOI: 10.1016/j.jisako.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/30/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Chronic exertional compartment syndrome (CECS) can be diagnosed either clinically or with intra-compartmental pressure monitor measurements and can be treated surgically or conservatively. METHODS A systematic review was performed on diagnostic and treatment modalities for CECS. Included studies were those that reported both their specific diagnostic modality and treatment regimens. Both surgical and conservative treatment strategies were considered. Demographic variables, diagnostic modalities, patient satisfaction and return to sport, the number of surgical incisions used for the anterior compartment fasciotomy, and the specific conservative treatment regimens were also recorded. Diagnostic modalities were grouped into one of three groups: 1) static compartment pressure monitor, 2) dynamic pressure monitoring, and 3) strictly clinical diagnosis. RESULTS The literature search identified 373 studies, of which 29 were included for final analysis. In total, there were 1270 total patients. Twenty-four studies used static compartment pressure monitors, 5 studies used dynamic pressure monitors and 2 studies used a strictly clinical diagnosis. Surgical management with fasciotomy was performed in 25 studies with a total of 1018 patients, while conservative management was used in 252 patients in 9 studies (5 studies included surgical and conservative treatments). Among surgical studies, 15 used a single-incision technique for anterior compartment fasciotomy, while 6 used a 2-incision technique. The reported satisfaction after fasciotomy was 42-94% while the return to sport was 26-100%. The reported return to sport in conservative management studies was 25-35%. CONCLUSION This systematic review found that the majority of clinical reports utilize static compartment pressure measurements to diagnose CECS, with fewer studies using dynamic intra-compartment pressure monitors. Additionally, surgical fasciotomy using a single-incision technique was the most common treatment strategy for anterior compartment CECC, with some studies reporting success with the two-incision technique. STUDY DESIGN Systematic review, level 4.
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Affiliation(s)
| | | | - Brian R Waterman
- Wake Forest University School of Medicine, Winston-Salem, NC, 27103 USA
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Armando C, Sherbondy P, Simoni E, Cole S. Type III Popliteal Artery Entrapment Syndrome with Concurrent Chronic Exertional Compartment Syndrome: A Case Report. JBJS Case Connect 2024; 14:01709767-202403000-00035. [PMID: 38422191 DOI: 10.2106/jbjs.cc.23.00602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
CASE The patient, a 21-year-old female Division I track and field athlete, presents with bilateral calf pain, tightness, numbness, and swelling during activity. Initially diagnosed with chronic exertional compartment syndrome (CECS), she underwent bilateral four-compartment fasciotomies. After 4 months, she experienced persistence of some of her prefasciotomy symptoms and was referred to vascular surgery. A fibrous band was compressing the popliteal artery, making the diagnosis of popliteal artery entrapment syndrome (PAES). She underwent bilateral popliteal artery decompressions. She had a successful recovery with no recurrence of numbness, weakness, or pain. CONCLUSION Recognize that structural PAES may coexist with CECS.
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Affiliation(s)
- Chenée Armando
- Penn State College of Medicine, University Park, Pennsylvania
| | - Paul Sherbondy
- Department of Orthopedic Surgery, Penn State College of Medicine, University Park, Pennsylvania
| | - Eugene Simoni
- Division of Vascular Surgery, Penn State College of Medicine, University Park, Pennsylvania
| | - Sandra Cole
- Vascular Surgery, Muskegon Surgical Associates, Muskegon, Michigan
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Bosnina F, Padhiar N, Miller S, Girotra K, Massoura C, Morrissey D. Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review. J Foot Ankle Res 2023; 16:82. [PMID: 37990284 PMCID: PMC10662794 DOI: 10.1186/s13047-023-00680-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Numerous conditions are grouped under the generic term exercise-induced leg pain (EILP), yet clear diagnostic guidelines are lacking. This scoping review was conducted to clarify the definition and diagnostic criteria of nine commonly occurring EILP conditions. METHODS Three online databases were searched from inception to April 2022 for any English language original manuscripts identifying, describing, or assessing the clinical presentation and diagnostic criteria of the nine most common conditions that cause EILP. We included manuscripts considering all adults with any reported diagnostic criteria for EILP in any setting. Methodological quality was assessed using the Mixed Method Appraisal tool. Condition definitions were identified and categorised during data charting. Twenty-five potential elements of the history, 24 symptoms, 41 physical signs, 21 investigative tools, and 26 overarching diagnostic criteria, were identified and coded as counts of recommendation per condition, alongside qualitative analysis of the clinical reasoning. Condition definitions were constructed with 11 standardised elements based on recent consensus exercises for other conditions. RESULTS One hundred nineteen retained manuscripts, of which 18 studied multiple conditions, had a median quality of 2/5. A combination of the history, pain location, symptoms, physical findings, and investigative modalities were fundamental to identify each sub-diagnosis alongside excluding differentials. The details differed markedly for each sub-diagnosis. Fifty-nine manuscripts included data on chronic exertional compartment syndrome (CECS) revealing exertional pain (83% history), dull aching pain (76% symptoms), absence of physical signs (78% physical findings) and elevated intercompartment pressure (93% investigative modality). Twenty-one manuscripts included data on medial tibial stress syndrome (MTSS), revealing persistent pain upon discontinuation of activity (81% history), diffuse medial tibial pain (100% pain location), dull ache (86% symptoms), diffuse tenderness (95% physical findings) and MRI for exclusion of differentials (62% investigative modality). Similar analyses were performed for stress fractures (SF, n = 31), popliteal artery entrapment syndrome (PAES, n = 22), superficial peroneal nerve entrapment syndrome (SPNES, n = 15), lumbar radiculopathy (n = 7), accessory/low-lying soleus muscle syndrome (ALLSMS, n = 5), myofascial tears (n = 3), and McArdle's syndrome (n = 2). CONCLUSION Initial diagnostic frameworks and definitions have been developed for each condition of the nine most common conditions that cause EILP, suitable for clinical consideration and consensus confirmation.
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Affiliation(s)
- Fatma Bosnina
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Nat Padhiar
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
- London Sportswise, London, UK.
| | - Stuart Miller
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Krishna Girotra
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Chrysovalanto Massoura
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Dylan Morrissey
- Sports & Exercise Medicine, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Health NHS Trust Physiotherapy Department, London, UK
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Lindorsson S, Zhang Q, Brisby H, Rennerfelt K. Intramuscular Pressure and Patient-Reported Outcomes in Patients Surgically Treated for Anterior Chronic Exertional Compartment Syndrome. Orthop J Sports Med 2023; 11:23259671221151088. [PMID: 36846814 PMCID: PMC9947687 DOI: 10.1177/23259671221151088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background Chronic exertional compartment syndrome (CECS) causes exercise-induced leg pain. The diagnosis is confirmed by intramuscular pressure (IMP) measurements. Fasciotomy has been demonstrated to be a successful treatment for CECS; however, few studies have examined postoperative IMP and long-term outcomes. Purpose To evaluate long-term outcomes and postoperative IMP in patients surgically treated for anterior CECS, and to identify possible preoperative or postoperative factors associated with overall satisfaction with treatment at follow-up. Study Design Case-control study; Level of evidence, 3. Methods A consecutive series of 209 patients who underwent fasciotomy of the anterior compartment for CECS between 2009 and 2019 and had at least 1 year of follow-up were approached for inclusion. A total of 144 patients (69%), with a follow-up time of 1 to 11.5 years, were ultimately included. All patients underwent preoperative and postoperative 1-minute postexercise IMP measurements of the anterior compartment and completed a questionnaire covering pain and activity parameters at both time points. The follow-up questionnaire included an additional question on overall satisfaction with treatment, and surgical details were collected from the patient's medical records. Results The median IMP was significantly lower at follow-up than at baseline (17 mm Hg [range, 5-91 mm Hg] vs 49 mm Hg [range, 25-130 mm Hg]; P < .001). The overall satisfaction rate was 77%, and 83% reported a decreased pain level. The group of patients who were satisfied with the treatment included more men and had a higher ΔIMP and a lower revision rate (P < .05). Among the 16 patients (11%) who had undergone revision fasciotomies before follow-up, the satisfaction rate was 56%, and 64% reported a decrease in pain level. Conclusion Fasciotomy significantly reduced 1-minute postexercise IMP in patients with CECS and resulted in satisfaction and decreased pain in more than three-quarters of the patients at long-term follow-up. The male sex and a significant decrease in IMP were both positively associated with treatment satisfaction. Patients who underwent revision surgery before the follow-up had lower satisfaction rates and less pain reduction than the overall group.
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Affiliation(s)
- Sophia Lindorsson
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sophia Lindorsson, MD, Sahlgrenska University Hospital,
Ortopedmottagningen Mölndal, 431 80 Mölndal, Sweden (
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| | - Qiuxia Zhang
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Brisby
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kajsa Rennerfelt
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Williams S, Chen S, Todd NW. Compartment Syndrome in the Foot and Leg. Clin Podiatr Med Surg 2023; 40:1-21. [PMID: 36368837 DOI: 10.1016/j.cpm.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronic exertional compartment syndrome is a common cause of exercise-related leg pain that can be debilitating to many athletes. Diagnosis of this syndrome is based on patient history and clinical examination in correlation with intracompartmental pressure measurement or other advanced diagnostic tests. Treatments include initial nonsurgical management, such as modification of causative activity and gait retraining with physical therapy. If symptoms persist, surgical fasciotomy may be warranted via an open or minimally invasive approach. In this article, we review the anatomy, pathophysiology, history and physical examination, diagnostic modalities, treatment, and complications of chronic exertional compartment syndrome in the athlete.
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Affiliation(s)
- Samantha Williams
- Palo Alto Medical Foundation, Palo Alto Foundation Medical Group, 701 East El Camino Real, Mountain View, CA 94040, USA.
| | - Shirley Chen
- Palo Alto Medical Foundation, Palo Alto Foundation Medical Group, 701 East El Camino Real, Mountain View, CA 94040, USA
| | - Nicholas W Todd
- Palo Alto Medical Foundation, Palo Alto Foundation Medical Group, 701 East El Camino Real, Mountain View, CA 94040, USA
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Chronic exertional compartment syndrome: a review of the literature. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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Symeonidis PD, Stavrou P. Single incision, minimally invasive fasciotomy of the anterior and lateral leg compartments with decompression of the superficial peroneal nerve. Foot Ankle Surg 2022; 28:30-36. [PMID: 33632658 DOI: 10.1016/j.fas.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/28/2020] [Accepted: 01/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a considerable overlap of symptoms between chronic exertional compartment syndrome (CECS) of the anterior and lateral compartments of the lower leg and entrapment neuropathy of the superficial peroneal nerve (SPN). We describe a minimally invasive, single incision surgical technique for release of both the compartments and the SPN in the same setting. The operative technique involves a minimal anterolateral approach at the level where the SPN pierces the subcutaneous fascia. METHODS Nineteen patients were operated with the method and 24 anterolateral compartments (5 cases with bilateral CECS) were released. Anterior and lateral, proximal and distal fasciotomies were performed sequentially with the use of a specific instrument designed for carpal tunnel release (KnifeLight®, Stryker). This is a modification of a fasciotome with an intergrated light source which allows for transillumination of the subcutaneous tissues. The SPN and its main branches with their anatomical variations were explored and decompressed at the same setting. RESULTS Patients who met the inclusion criteria were reviewed at one year postoperatively with a Numeric Analog Pain Scale (NAS) and the Linkert satisfaction scale. There were 5 men and 10 women, aged 35.7 (21-60) years. The NAS scores improved by a mean 6 points (p<0.0001) postoperatively and 86.6% (13/15) of the patients were either satisfied or very satisfied with the operation. There were no intraoperative complications. There were two patients with SPN neuropathy symptoms postoperatively, one of whom required revision surgery. One patient had recurrence of less intense symptoms in the first postoperative year with no need for reoperation. CONCLUSIONS The simultaneous release of the anterolateral compartment of the leg and decompression of the SPN with the described technique was safe and effective. It combined the advantages of a single, minimally invasive approach with the subcutaneous transillumination, and had a high patient satisfaction and a low recurrence rate. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Affiliation(s)
| | - Peter Stavrou
- Private Practice, 215 Hutt Street, Adelaide, SA, Australia
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10
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de Bruijn JA, van Zantvoort APM, Hundscheid HPH, Hoogeveen AR, van Eerten P, Teijink JAW, Scheltinga MR. Comparison of 2 Fasciotomes for Treatment of Patients With Chronic Exertional Compartment Syndrome of the Anterior Leg. Orthop J Sports Med 2021; 9:23259671211051358. [PMID: 34888390 PMCID: PMC8649103 DOI: 10.1177/23259671211051358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Chronic exertional compartment syndrome (CECS) of the anterior leg compartment (ant-CECS) is frequently treated with a minimally invasive fasciotomy. Several operative techniques and operative devices exist, but none have been compared in a systematic and randomized manner. Purpose: To compare efficacy, safety, and postoperative pain of a novel operative device (FascioMax fasciotome) with a widely accepted device created by Due and Nordstrand (Due fasciotome) during a minimally invasive fasciotomy for ant-CECS. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients with bilateral isolated ant-CECS between October 2013 and April 2018 underwent a minimally invasive fasciotomy using the FascioMax fasciotome in 1 leg and the Due fasciotome in the contralateral leg in a single operative session. Symptom reduction at 3 to 6 months and >1 year, postoperative pain within the first 2 weeks, peri- and postoperative complications, and ability to regain sports were assessed using diaries, physical examination, and timed questionnaires. Results: Included in the study were 50 patients (66% female; median age, 22 years [range, 18-65 years]). No differences between the devices were found in terms of perioperative complications (both had none), minor postoperative complications including hematoma and superficial wound infection (overall complication rate: FascioMax, 8% vs Due, 6%), or reduction of CECS-associated symptoms at rest and during exercise. At long-term follow-up (>1 year), 82% of the patients were able to regain their desired type of sport, and 67% (33/49) were able to exercise at a level that was comparable with or higher than before their CECS-associated symptoms started. Conclusion: Both the FascioMax and the Due performed similarly in terms of efficacy, safety, and levels of pain within the first 2 weeks postoperatively. Registration: NL4274; Netherlands Trial Register.
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Affiliation(s)
- Johan A de Bruijn
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | | | | | - Adwin R Hoogeveen
- Department of Sports Medicine, Máxima Medical Center, Veldhoven, the Netherlands
| | - Percy van Eerten
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | - Joep A W Teijink
- Department of Surgery, Catherina Hospital, Eindhoven, the Netherlands.,Department of Epidemiology, CAPHRI Research School, Maastricht University, Maastricht, the Netherlands
| | - Marc R Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
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Kaplan S, Olivier B, Obiora OL. Effectiveness of surgical and non-surgical management strategies in patients with chronic exertional compartment syndrome of the anterior compartment of the leg: a systematic review protocol. JBI Evid Synth 2021; 19:3198-3205. [PMID: 34132238 DOI: 10.11124/jbies-20-00324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this review is to evaluate the effectiveness of surgical management versus non-surgical management on pain, range of motion, intracompartmental pressure values, patient satisfaction, recurrence of symptoms, return to activity, function, strength, and sensation in patients diagnosed with chronic exertional compartment syndrome of the anterior compartment of the leg. INTRODUCTION Chronic exertional compartment syndrome is the most prevalent cause of exercise-induced leg pain in athletes. Current evidence suggests that the best methods for management include activity modification or cessation, injection of botulinum toxin into the affected compartment, or surgical intervention. Due to the limited number and quality of studies available, the evidence needs to be synthesized to pool findings from current research and to identify gaps in the literature. INCLUSION CRITERIA This review will consider studies that include people with chronic exertional compartment syndrome of the anterior compartment of the leg diagnosed through a combination of elevated intracompartmental pressure values and patient history. Studies that include patient-reported outcome measures will be included. METHODS MEDLINE, SPORTDiscus, Physiotherapy Evidence Database, MasterFILE Premier, CINAHL Complete, ProQuest Health and Medical Complete, Scopus, and Science Direct will be searched from 1956 to date. Gray literature databases will also be searched. Two reviewers will independently retrieve and screen full-text studies, critically appraise included studies, and extract data. Meta-analyses will be performed where possible. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020189661.
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Affiliation(s)
- Sean Kaplan
- The Wits-JBI Centre for Evidence-Based Practice: A JBI Affiliated Group, Johannesburg, South Africa.,Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Benita Olivier
- The Wits-JBI Centre for Evidence-Based Practice: A JBI Affiliated Group, Johannesburg, South Africa.,Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Oluchukwu Loveth Obiora
- The Wits-JBI Centre for Evidence-Based Practice: A JBI Affiliated Group, Johannesburg, South Africa.,Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Vogels S, VAN Ark W, Janssen L, Scheltinga MRM. Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg. Med Sci Sports Exerc 2021; 53:1549-1554. [PMID: 33731658 DOI: 10.1249/mss.0000000000002631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial. METHODS Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result. RESULTS Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14-37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2-65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity. CONCLUSION An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.
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Affiliation(s)
| | - Wendela VAN Ark
- Department of Surgery, Máxima MC, Veldhoven, THE NETHERLANDS
| | - Loes Janssen
- Department of Surgery, Máxima MC, Veldhoven, THE NETHERLANDS
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13
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Ding A, Machin M, Onida S, Davies AH. A systematic review of fasciotomy in chronic exertional compartment syndrome. J Vasc Surg 2020; 72:1802-1812. [DOI: 10.1016/j.jvs.2020.05.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/14/2020] [Indexed: 11/25/2022]
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14
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Dual-incision minimally invasive fasciotomy of the anterior and peroneal compartments for chronic exertional compartment syndrome of the lower leg. Sci Rep 2020; 10:18113. [PMID: 33093617 PMCID: PMC7582176 DOI: 10.1038/s41598-020-75268-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/13/2020] [Indexed: 11/08/2022] Open
Abstract
To evaluate the risk of iatrogenic injury when using a dual-incision minimally invasive technique to decompress the anterior and peroneal compartments of the lower leg. Forty lower extremities from 20 adult cadavers, embalmed with Thiel’s method, were subject to fasciotomy of the anterior and peroneal compartment using a dual-incision minimally invasive fasciotomy. The first incision was made 12 cm proximal to the lateral malleolus to identify and protect the superficial peroneal nerve (SPN). The second incision was made at the mid-point of the Fibula (half-way between the fibular head and the lateral malleolus). Release of the anterior and peroneal compartments was successful in all specimens. Two nerve injuries of the superficial peroneal nerve were reported. More precisely, in these cases the medial dorsal cutaneous nerve got injured during the fascial opening of the extensor compartment. Two incision minimally invasive fasciotomy to decompress the anterior and peroneal compartments of the lower leg appears to be safe with regard to the results of this study.
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Grechenig P, Valsamis EM, Müller T, Gänsslen A, Hohenberger G. Minimally Invasive Lower Leg Fasciotomy for Chronic Exertional Compartment Syndrome-How Safe Is It? A Cadaveric Study. Orthop J Sports Med 2020; 8:2325967120956924. [PMID: 33062761 PMCID: PMC7536378 DOI: 10.1177/2325967120956924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Chronic exertional compartment syndrome (CECS) is a recognized
clinical diagnosis in running athletes and military recruits.
Minimally invasive fasciotomy techniques have become
increasingly popular, but with varied results and small case
numbers. Although decompression of the anterior and peroneal
compartments has demonstrated a low rate of iatrogenic injury,
little is known about the safety of decompressing the deep
posterior compartment. Purpose: To evaluate the risk of iatrogenic injury when using minimally
invasive techniques to decompress the anterior, peroneal, and
deep posterior compartments of the lower leg. Study Design: Descriptive laboratory study. Methods: A total of 60 lower extremities from 30 adult cadavers were subject
to fasciotomy of the anterior, peroneal, and deep posterior
compartments using a minimally invasive technique. Two common
variations in surgical technique were employed to decompress
each compartment. Anatomical dissection was subsequently carried
out to identify incomplete division of the fascia, muscle
injury, neurovascular injury, and the anatomical relationship of
key neurovascular structures to the incisions. Results: Release of the anterior and peroneal compartments was successful in
all but 2 specimens. There was no injury to the superficial
peroneal nerve or any vessel in any specimen. A transverse
incision crossing the anterior intermuscular septum resulted in
muscle injury in 20% of the cases. Release of the deep posterior
compartment was successful in all but 1 specimen when a
longitudinal skin incision was used, without injury to
neurovascular structures. Compared with a longitudinal incision,
a transverse skin incision resulted in fewer complete releases
of the deep posterior compartment and a significantly higher
rate of injury to the saphenous nerve (16.7%; P
= .052) and long saphenous vein (23.3%; P =
.011). Conclusion: Minimally invasive fasciotomy of the anterior, peroneal, and deep
posterior compartments using longitudinal incisions had a low
rate of iatrogenic injury in a cadaveric model. Complete
compartment release was achieved in 97% to 100% of specimens
when employing this technique. Clinical Relevance: Minimally invasive fasciotomy techniques for CECS have become
increasingly popular with purported low recurrence rates,
improved cosmesis, and faster return to sport. It is important
to determine whether this technique is safe, particularly given
the variable rates of neurovascular injury reported in the
literature.
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Affiliation(s)
- Peter Grechenig
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria
| | | | - Tom Müller
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria
| | - Axel Gänsslen
- Trauma Department, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Gloria Hohenberger
- Department of Orthopaedics and Trauma Surgery, Medical University of Graz, Graz, Austria
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Bellamy JT, Boissonneault AR, Melquist ME, Labib SA. Release of the Tibialis Posterior Muscle Osseofascial Sheath Improves Results of Deep Exertional Compartment Syndrome Surgery: A Comparative Analysis and Long-term Results. Orthop J Sports Med 2020; 8:2325967120942752. [PMID: 32851105 PMCID: PMC7427151 DOI: 10.1177/2325967120942752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/20/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present. Purpose: Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS. Study Design: Cohort study; Level of evidence, 3. Methods: Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction. Results: Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release. Conclusion: The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.
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Affiliation(s)
- J Taylor Bellamy
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Adam R Boissonneault
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Morgan E Melquist
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sameh A Labib
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Vogels S, Ritchie ED, van Dongen TTCF, Scheltinga MRM, Zimmermann WO, Hoencamp R. Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg. Scand J Med Sci Sports 2020; 30:1827-1845. [PMID: 32526086 PMCID: PMC7540008 DOI: 10.1111/sms.13747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022]
Abstract
Objective Surgery is the gold standard in the management of chronic exertional compartment syndrome (CECS) of the lower extremity, although recent studies also reported success following gait retraining. Outcome parameters are diverse, and reporting is not standardized. The aim of this systematic review was to analyze the current evidence regarding treatment outcome of CECS in the lower leg. Material and Methods A literature search and systematic analysis were performed according to the PRISMA criteria. Studies reporting on outcome following treatment of lower leg CECS were included. Results A total of 68 reports fulfilled study criteria (n =; 3783; age range 12‐70 year; 7:4 male‐to‐female ratio). Conservative interventions such as gait retraining (n =; 2) and botulinum injection (n =; 1) decreased ICP (x- =; 68 mm Hg tox- =; 32 mm Hg) and resulted in a 47% (±42%) rate of satisfaction and a 50% (±45%) rate of return to physical activity. Fasciotomy significantly decreased ICP (x- =; 76 mm Hg to x- =; 24 mm Hg) and was associated with an 85% (±13%) rate of satisfaction and an 80% (±17%) rate of return to activity. Return to activity was significantly more often achieved (P < .01) in surgically treated patients, except in one study favoring gait retraining in army personnel. Conclusion Surgical treatment of CECS in the lower leg results in higher rates of satisfaction and return to activity, compared to conservative treatment. However, the number of studies is limited and the level of evidence is low. Randomized controlled trials with multiple treatment arms and standardized outcome parameters are needed.
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Affiliation(s)
- Sanne Vogels
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewan D Ritchie
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thijs T C F van Dongen
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
| | | | - Wes O Zimmermann
- Department of Sports Medicine, Royal Netherlands Army, Utrecht, The Netherlands.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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18
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Maksymiak R, Ritchie E, Zimmermann W, Maliko N, van der Werve M, Verschure M, Hoencamp R. Historic cohort: outcome of chronic exertional compartment syndrome-suspected patients. BMJ Mil Health 2020; 167:387-392. [PMID: 32019808 DOI: 10.1136/jramc-2019-001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/17/2019] [Accepted: 10/25/2019] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Exercise-related leg pain (ERLP) may be caused by chronic exertional compartment syndrome (CECS), occurring mainly in athletes and military recruits. In military populations, the effectiveness of surgical treatment in CECS is debated. The purpose of this study is to assess the outcome of surgical treatment for CECS in Alrijne Hospital (the Netherlands), a civilian hospital with supraregional referral function. METHODS A historic cohort study was performed on patients with ERLP who were suspected for CECS and were referred for intracompartmental pressure measurement (ICPM) from 2013 to 2017 (n=160). Patient demographics, ICPM and survey response were analysed. RESULTS The mean delay before visitation was 29.0±30.3 months. When comparing surgical-treated patients with CECS with conservative-treated patients with ERLP, surgical-treated patients were more satisfied, reported better recovery towards former level of performance (2.8±2.0 vs 3.9±1.7 and 2.5±1.6 vs 3.2±1.4 on a 7-point Likert scale, respectively) and better subjective injury status (79.3±22.6 vs 63.5±27.4 using the Single Assessment Numeric Evaluation score). Treatment satisfaction was 75.0% in surgical-treated CECS versus 51.4% in conservative-treated ERLP. CONCLUSION Civilian patients report improved functional outcomes after fasciotomy for CECS. Future research should focus on non-invasive diagnostic options and methods to determine which treatment is the most appropriate for each individual patient.
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Affiliation(s)
- Roy Maksymiak
- Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands
| | - E Ritchie
- Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands
| | - W Zimmermann
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Department of Military Sports Medicine, Royal Dutch Army, Utrecht, The Netherlands
| | - N Maliko
- Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands
| | | | - M Verschure
- Alrijne Ziekenhuis Leiden, Leiden, The Netherlands
| | - R Hoencamp
- Alrijne Zorggroep, Leiderdorp, The Netherlands.,Defense Healthcare Organization, Ministry of Defence, Utrecht, The Netherlands.,Trauma Research Unit Department of Surgery, University Medical Center Rotterdam, Erasmus MC, Rotterdam, Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
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19
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de Bruijn J, Winkes M, van Eerten P, Scheltinga M. [Chronic exertional compartment syndrome as a cause of anterolateral leg pain-German version]. Unfallchirurg 2019; 122:840-847. [PMID: 31628498 DOI: 10.1007/s00113-019-0642-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Exercise-induced leg pain (ELP) and tightness may be caused by a chronic exertional compartment syndrome (CECS). Although CECS can develop in any muscle compartment, most individuals suffer from an anterior tibial muscle CECS (ant-CECS). Typically, a patient with ant-CECS experiences discomfort toward the end of sports activity or in the hours thereafter. Physical examination may reveal tenderness upon palpation of the anterior tibial muscle belly. The gold standard diagnostic tool is a dynamic intracompartmental pressure (ICP) measurement demonstrating elevated muscle tissue pressures. Duplex analysis and imaging may be indicated for exclusion of concomitant entities such as entrapment of the popliteal artery or nerves. Conservative treatments including modification of the patient's running technique can be successful. A fasciotomy must be considered in recalcitrant cases. Residual or recurrent disease may necessitate partial removal of the fascia. The aim of this overview is to discuss the management of CECS in the anterolateral portion of the leg.
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Affiliation(s)
- Johan de Bruijn
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande
| | - Michiel Winkes
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande
| | - Percy van Eerten
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande
| | - Marc Scheltinga
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, Niederlande.
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20
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Buerba RA, Fretes NF, Devana SK, Beck JJ. Chronic exertional compartment syndrome: current management strategies. Open Access J Sports Med 2019; 10:71-79. [PMID: 31213933 PMCID: PMC6537460 DOI: 10.2147/oajsm.s168368] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/23/2019] [Indexed: 11/23/2022] Open
Abstract
Chronic exertional compartment syndrome (CECS) is an underdiagnosed condition that causes lower and upper extremity pain in certain at-risk populations. Lower-extremity CECS is most often observed in running athletes and marching military members. Upper-extremity CECS is most commonly seen in rowers and professional motorcyclists. Although early outcome research on CECS has been based mostly on adult male patients, there has been an increase in the number of studies in pediatric and adolescent patient populations, particularly in females. Evaluation of CECS must include a thorough history and physical exam to rule out other causes of exertional leg pain, but differential diagnosis must remain high on the list. Needle manometry can be used to confirm diagnosis of CECS by measuring intracompartmental pressure. Operative treatment of CECS with fasciotomy has been shown to be effective in resolution of CECS, and new surgical techniques are being developed. In the pediatric population, endoscopy-assisted compartment release has provided high success rates with low complication rates. Nonoperative management of CECS is more commonly described in the literature, and consists of cessation of activities, altering foot-strike pattern, physical therapy, taping, and injections of botulinum toxin A. Nonetheless, larger samples and a more diverse population are needed to better understand the outcomes of nonoperative management. There have been fewer studies on upper-extremity CECS, given its rarity. Success has been found in the treatment of upper-extremity CECS with open fasciotomy, but more studies are needed to understand the efficacy of minimally invasive techniques in the upper extremity. Further research also needs to be done to understand why a large portion (approximately 20%) of the patient population does not experience full resolution of symptoms after fasciotomy.
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Affiliation(s)
- Rafael A Buerba
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nickolas F Fretes
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sai K Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer J Beck
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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21
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de Bruijn J, Winkes M, van Eerten P, Scheltinga M. Chronic exertional compartment syndrome as a cause of anterolateral leg pain. Unfallchirurg 2019; 123:8-14. [DOI: 10.1007/s00113-019-0641-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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de Bruijn JA, van Zantvoort APM, Hundscheid HPH, Hoogeveen AR, Teijink JAW, Scheltinga MR. Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study. Foot Ankle Int 2019; 40:343-351. [PMID: 30466306 DOI: 10.1177/1071100718811632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Up to 8% of patients who underwent a fasciotomy for leg anterior chronic exertional compartment syndrome (ant-CECS) report sensory deficits suggestive of iatrogenic superficial peroneal nerve (SPN) injury. In the current study we aimed to thoroughly assess the risk of SPN injury during a semiblind fasciotomy of the anterior compartment using 2 separate approaches. METHODS: A modified semiblind fasciotomy of the anterior compartment was performed via a longitudinal 2-cm skin incision 2 cm lateral of the anterior tibial crest halfway along the line fibular head-lateral malleolus both in cadaver legs and in patients with ant-CECS. In the cadaver legs, the skin was removed after the procedure and possible SPN injuries and spatial relationships between the SPN and the opened fascia were studied. Between January 2013 and December 2016, 64 ant-CECS patients who underwent a fasciotomy of the anterior compartment were prospectively followed. Iatrogenic SPN injuries were assessed using questionnaires and physical examinations. RESULTS: Macroscopic SPN nerve injury was not observed in any of the 9 cadaver legs. In 8 specimens, the SPN was located at least 5 mm posterolateral to the opened fascia. In 1 specimen, an undamaged SPN branch crossed the operative field in a ventral plane. De novo sensory deficits suggestive for iatrogenic SPN injury were not observed in any of the 64 patients (120 legs; 36 females; median age, 22 years) who underwent a fasciotomy of the anterior compartment. CONCLUSION: The proposed semiblind fasciotomy for treatment of ant-CECS was not associated with SPN injury in either the cadaveric study or our clinical series. LEVEL OF EVIDENCE: Level IV, case series.
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Affiliation(s)
- Johan A de Bruijn
- 1 Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | | | | | - Adwin R Hoogeveen
- 2 Department of Sports Medicine, Máxima Medical Center, Veldhoven, the Netherlands
| | - Joep A W Teijink
- 3 Department of Surgery, Catherina Hospital, Eindhoven, the Netherlands.,4 Department of Epidemiology, CAPHRI Research School, Maastricht University, Maastricht, the Netherlands
| | - Marc R Scheltinga
- 1 Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
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Dyer KT, Hogrefe CP. Don't Just Blame it on the Veins: An Update on Vascular Exertional Limb Pain. Curr Sports Med Rep 2018; 17:347-353. [PMID: 30300197 DOI: 10.1249/jsr.0000000000000527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Exertional limb pain is a common problem encountered in recreational and competitive athletes. Affecting both the upper and lower extremities, this broad entity can be musculoskeletal, vascular, neurologic, oncologic, or infectious in origin. This article focuses on the vascular causes of exercise-related extremity pain, which encompass a cadre of elusive diagnoses. Specifically, we examine arterial endofibrosis, popliteal artery entrapment syndrome, and chronic exertional compartment syndrome of both the upper and lower extremities. For each of these conditions, we offer updates regarding the respective epidemiology, common signs and symptoms, worthwhile diagnostic modalities, and pertinent treatment options, all based on evidence and reports published over the past year.
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Affiliation(s)
- Kevin T Dyer
- Department of Emergency Medicine, Northwestern Medicine, Chicago, IL
| | - Christopher P Hogrefe
- Department of Emergency Medicine, Northwestern Medicine, Chicago, IL.,Department of Medicine-Sports Medicine, Northwestern Medicine, Chicago, IL.,Department of Orthopaedic Surgery-Sports Medicine, Northwestern Medicine, Chicago, IL
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Dai AZ, Zacchilli M, Jejurikar N, Pham H, Jazrawi L. Open 4-Compartment Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg. Arthrosc Tech 2017; 6:e2191-e2201. [PMID: 29349018 PMCID: PMC5766428 DOI: 10.1016/j.eats.2017.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/07/2017] [Indexed: 02/03/2023] Open
Abstract
Chronic exertional compartment syndrome (CECS) is a significant source of lower extremity pain and morbidity in the athletic population. Although endoscopic techniques have been introduced, open fasciotomy remains the mainstay of surgical treatment because of the paucity of evidence in support of an endoscopic approach. The literature on surgical management of CECS is mixed, and overall success rates are modest at best. Optimizing surgical technique, including prevention of neurovascular injury and wound complications, can make a significant impact on the clinical outcome. Here we present our surgical technique, including pearls and pitfalls, for open 4-compartment fasciotomy for treatment of chronic exertional compartment syndrome.
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Affiliation(s)
- Amos Z. Dai
- Address correspondence to Amos Z. Dai, B.S., NYU Hospital for Joint Diseases, 301 E 17th Street, Suite 1500, New York, NY 10003, U.S.A.NYU Hospital for Joint Diseases301 E 17th Street, Suite 1500New YorkNY10003U.S.A.
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Vajapey S, Miller TL. Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature. PHYSICIAN SPORTSMED 2017; 45:391-398. [PMID: 28952402 DOI: 10.1080/00913847.2017.1384289] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chronic exertional compartment syndrome (CECS) is a rare condition that usually affects distance runners and other running athletes. It is characterized by pain and pressure in one or multiple muscle compartments with repetitive physical activity. Reduction in pain typically occurs with cessation of activity. Evaluation of CECS consists of a thorough history of patient symptoms and ruling out of other causes of symptoms. Post-exercise pressure measurements can help confirm the diagnosis when symptoms are consistent and imaging evaluation negative for other causes. Non-operative treatment is a viable option for hindfoot runners and patients with anterior compartment syndrome of the leg. Limited-incision fasciotomy has been shown to be the most effective treatment and remains the gold standard for treatment. Minimal-incision open fasciotomy and endoscopic fasciotomy have surgical outcomes similar to wide-open fasciotomy. Military patients treated with fasciotomy have higher failure rates compared to civilians. Pediatric patients have similar outcomes compared to adults.
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Affiliation(s)
- Sravya Vajapey
- a Wexner Medical Center, Orthopaedics , Ohio State University , Columbus , OH , USA
| | - Timothy L Miller
- a Wexner Medical Center, Orthopaedics , Ohio State University , Columbus , OH , USA
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