Surgical treatment for chronic lower-leg compartment syndrome in young female athletes

Lower Leg Lateral Chronic Exertional Compartment Syndrome: Prospective Surgical Treatment Outcomes for Isolated or Combined Lateral Fasciotomy

BACKGROUND

Chronic exertional compartment syndrome involving the lower leg lateral compartment (lat-CECS) seldom occurs isolated but is usually combined with CECS of the anterior (ant-CECS) or deep posterior compartment (dp-CECS). Patient characteristics in lat-CECS and outcome after surgery are largely unknown. The aim of this prospective case series was to describe patient characteristics and symptoms and to report on outcome following a fasciotomy.

METHODS

All patients diagnosed with lat-CECS based on exertional lateral lower leg symptoms and elevated intracompartmental pressure (ICP) measurements according to the Pedowitz criteria (ICP ≥ 15 mm Hg at rest, and/or ≥30 mm Hg after 1 minute, and/or ≥20 mm Hg 5 minutes after exercise) were eligible for this study. A standard intake questionnaire scoring symptom patterns was completed by all patients. Patients who were operated for lat-CECS were asked to complete a 3-month and 12-month postoperative questionnaire scoring symptoms and surgical outcome. Patients with a history of CECS surgery, recent lower leg trauma, or peripheral neurovascular disease were excluded.

RESULTS

A total of 881 patients with possible lower leg CECS completed an intake questionnaire and 88 (10%) were diagnosed with lat-CECS according to the Pedowitz criteria (isolated lat-CECS n = 10; lat/ant CECS n = 54, lat/ant/dp CECS n = 19, lat/dp CECS n = 5). Severe pain during exercise and moderate tightness during rest were frequently reported. A group of 28 patients (49 legs; isolated lat-CECS n = 2; lat/ant CECS n = 22, lat/ant/dp CECS n = 3, lat/dp CECS n = 1) was analyzed after fasciotomy. Complications were minor (wound infection requiring antibiotics, n = 3; temporary complex regional pain syndrome with spontaneous recovery, n = 1). Superficial peroneal nerve damage was not observed. One year after surgery, 64% rated outcome as excellent or good, whereas 71% had resumed sports activities.

CONCLUSION

One in 10 patients with anterolateral exertional lower leg pain evaluated in a tertiary referral center met diagnostic criteria for lat-CECS. Pain and tightness were present during exertion and were often reported occurring during rest and at night. In this series, we found fasciotomy-either an isolated (lateral) or a multiple (combined with anterior and/or deep posterior) compartment fasciotomy-is safe and beneficial in most patients.

LEVEL OF EVIDENCE

Level IV, case series.

Intramuscular Pressure and Patient-Reported Outcomes in Patients Surgically Treated for Anterior Chronic Exertional Compartment Syndrome

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.

Muscle herniae: Conservative and surgical management. Systematic review

BACKGROUND

Muscle herniae are often unrecognized. The primary objective of this systematic review is to evaluate the outcomes of conservative and surgical management for muscle herniae. The secondary objective is to define the most appropriate management for muscle herniae depending on aetiology and size of the fascial defect.

METHODS

The PRISMA guidelines were used to organize this systematic review to assess the different management modalities and identify possible criteria useful to guide the management of muscle herniae. An electronic search of PubMed and Scopus databases was performed.

RESULTS

A total of 132 patients were identified. Conservative management was carried out in 22 (16.7%) patients, and 110 (83.3%) patients underwent surgical procedures. Pain was reported in 3/22 (13.6%) patients managed conservatively. Post-surgical pain was reported in 0/5 (0%) patients treated with autologous graft repair, 1/15 (6.7%) patient with mesh repair, 2/13 (15.4%) patients with direct repair and 11/77 (14.3%) patients with fasciotomy. Return to normal activity was possible in 16/22 (72.7%) patients treated conservatively, 5/5 (100%) patients undergoing autologous graft repair, 13/15 (86.7%) with mesh repair, 62/77 (80.52%) with fasciotomy and 4/12 (33.3%) with direct repair.

CONCLUSION

In congenital muscle herniae, fasciotomy should be considered the surgical choice to prevent complications. In post-traumatic muscle hernia, a small fascial defect can be treated with the direct suture repair, while mesh repair and autologous graft repair should be considered the most appropriate procedures to avoid severe complications such as compartment syndrome.

Single incision, minimally invasive fasciotomy of the anterior and lateral leg compartments with decompression of the superficial peroneal nerve

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.

Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg

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.

Chronic Exertional Compartment Syndrome of the Leg Management Is Changing: Where Are We and Where Are We Going?

Chronic exertional compartment syndrome (CECS) is one of the wide range of causes of exercise-related leg pain in athletes. It is defined as a transient increase in compartment pressures during activity, which causes pain, because of the inability of the fascial compartments to accommodate and is usually relieved by cessation of exercise. Exercise-induced leg pain in the athletic population is a common complaint, with reports of up to 15% of all runners arriving to initial evaluation with this presentation. Often, this lower-extremity exertional pain is grouped into the common term of "shin splints" by athletes, which is a nondiagnostic term that implies no specific pathology. It may, however, encompass much of the differential for CECS, including medial tibial stress syndrome, muscle strain, and stress fracture. Improving diagnostic techniques, as well as treatments, will continue to help athletes and patients with leg pain in the future.

Outcome following mini-open lower limb fasciotomy for chronic exertional compartment syndrome

Purpose

The aim of this study was to report outcomes following mini-open lower limb fasciotomy (MLLF) in active adults with chronic exertional compartment syndrome (CECS).

Methods

From 2013–2018, 38 consecutive patients (mean age 31 years [16–60], 71% [n = 27/38] male) underwent MLLF. There were 21 unilateral procedures, 10 simultaneous bilateral and 7 staged bilateral. There were 22 anterior fasciotomies, five posterior and 11 four-compartment. Early complications were determined from medical records of 37/38 patients (97%) at a mean of four months (1–19). Patient-reported outcomes (including EuroQol scores [EQ-5D/EQ-VAS], return to sport and satisfaction) were obtained via postal survey from 27/38 respondents (71%) at a mean of 3.7 years (0.3–6.4).

Results

Complications occurred in 16% (n = 6/37): superficial infection (11%, n = 4/37), deep infection (3%, n = 1/37) and wound dehiscence (3%, n = 1/37). Eight per cent (n = 3/37) required revision fasciotomy for recurrent leg pain. At longer-term follow-up, 30% (n = 8/27) were asymptomatic and another 56% (n = 15/27) reported improved symptoms. The mean pain score improved from 6.1 to 2.5 during normal activity and 9.1 to 4.7 during sport (both p < 0.001). The mean EQ-5D was 0.781 (0.130–1) and EQ-VAS 77 (33–95). Of 25 patients playing sport preoperatively, 64% (n = 16/25) returned, 75% (n = 12/16) reporting improved exercise tolerance. Seventy-four per cent (n = 20/27) were satisfied and 81% (n = 22/27) would recommend the procedure.

Conclusion

MLLF is safe and effective for active adults with CECS. The revision rate is low, and although recurrent symptoms are common most achieve symptomatic improvement, with reduced activity-related leg pain and good health-related quality of life. The majority return to sport and are satisfied with their outcome.

Chronic Exertional Compartment Syndrome in the Leg: Comparing Surgery to Conservative Therapy

The aim of this nonrandomized cohort study was to compare the clinical effectiveness of an elective fasciotomy with conservative treatment for chronic exertional compartment syndrome of the leg. Patients diagnosed with chronic exertional compartment syndrome who opted for surgery (n=188) completed a preoperative questionnaire and a 12-month postoperative questionnaire. Patients who continued conservative treatments (n=23) served as controls. Gender, age, sports activity or affected compartments were comparable, but intensity of pain was higher in the surgical group (at rest: 2.5±0.1 vs. 2.0±0.2, during exercise: 4.2±0.1 vs. 3.8±0.2; both p<0.05). Following treatment, surgical patients demonstrated a larger drop in intensity levels of pain (surgery 1.6±0.1, conservative 0.9±0.2, p=0.01) and tightness (surgery 1.4±0.1, conservative 0.4±0.3, p=0.00) during exercise. Success (good or excellent treatment effect) was attained in 42% of the surgical group compared to only 17% in the conservatively treated group (p=0.02). However, previous activity level was achieved in a mere 26% in the surgical treatment group and 35% in the conservative treatment group (p=0.33). A fasciotomy for chronic exertional compartment syndrome in the leg results in significantly decreased levels of pain and tightness and better satisfaction compared to patients who continued a conservative treatment regimen.

Release of the Tibialis Posterior Muscle Osseofascial Sheath Improves Results of Deep Exertional Compartment Syndrome Surgery: A Comparative Analysis and Long-term Results

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.

Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg

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.

Return to sports after chronic anterior exertional compartment syndrome of the leg: Conservative treatment versus surgery

AIM

To evaluate whether surgical treatment for anterior chronic exertional compartment syndrome (CECS) of the lower leg will lead to full athletic activity recovery compared to conservative treatment.

METHODS

Patients diagnosed with anterior CECS of the leg were offered surgical treatment, as surgery considered today to be the mainstay of treatment. Patients unwilling to be treated surgically were treated conservatively. They were followed up, assessing both groups for pain, functional status, and the Tegner sports activity score with comparisons at diagnosis and following treatment.

RESULTS

Forty-three patients were treated for CECS (31; 72.1% with surgery and 12; 27.9% conservatively) with a mean follow-up of 28.15 (4.16-54.09) months. Reported pain improved at follow-up by 1.59 (0-6) points and by 4.27 ± (0-10) points in the conservatively and the surgically treated patient groups, respectively ( p = 0.014) with a mean change in the Tegner score of 0.09 (-5 to 5) and 3.22 (-4 to 7), respectively ( p = 0.009). Three patients in the conservatively treated group (25% of 12) and 24 patients in the operated group (77.4% of 31) reported full resumption of their pre-diagnosis activity level ( p = 0.001).

CONCLUSION

This study supports surgery as the treatment of choice for anterior CECS of the leg with differential benefit for fasciotomy in terms of pain and return to pre-diagnosis athletic activity.

Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners

BACKGROUND

Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running.

HYPOTHESIS

Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy.

RESULTS

A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively.

CONCLUSION

Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery.

CLINICAL RELEVANCE

Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Isolated Lateral Chronic Exertional Compartment Syndrome of the Leg: A New Entity?

Background:

Chronic exertional compartment syndrome (CECS) mostly occurs in the anterior or deep posterior compartments (ant-CECS and dp-CECS, respectively) of the leg. It is generally accepted that CECS of the third or lateral compartment (lat-CECS) always occurs together with ant-CECS. However, whether exertional leg pain (ELP) can be caused by an isolated form of lat-CECS is unknown.

Purpose:

To determine the existence of isolated lat-CECS and study whether history taking and a physical examination aid in discriminating between different subtypes of CECS.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients were eligible for this single-center study, conducted between January 2013 and February 2018, if they reported anterolateral ELP and completed a questionnaire scoring the frequency and intensity of pain, tightness, cramps, muscle weakness, and paresthesia during rest and exercise. They were asked to mark areas of altered foot skin sensation, if present, on a drawing. All patients underwent a dynamic intracompartmental pressure (ICP) measurement of the anterior and lateral compartments simultaneously. The diagnosis of CECS was confirmed by elevated ICP (Pedowitz criteria). There were 3 patient groups: (1) isolated ant-CECS with elevated ICP in the anterior compartment and normal ICP in the lateral compartment, (2) isolated lat-CECS with elevated ICP in the lateral compartment but normal ICP in the anterior compartment, and (3) ant-/lat-CECS with elevated ICP in both the anterior and lateral compartments.

Results:

A total of 73 patients with anterolateral ELP fulfilled study criteria (isolated ant-CECS: n = 26; isolated lat-CECS: n = 5; ant-/lat-CECS: n = 42). Group differences were not observed regarding age (isolated ant-CECS: median, 26 years [range, 13-68 years]; isolated lat-CECS: median, 20 years [range, 17-63 years]; ant-/lat-CECS: median, 28 years [range, 17-57 years]; χ² (2) = 0.466; P = .79), sex (isolated ant-CECS: 50% male; isolated lat-CECS: 40% male; ant-/lat-CECS: 62% male; P = .49), or bilateral symptoms (isolated ant-CECS: 54%; isolated lat-CECS: 80%; ant-/lat-CECS: 69%; P = .40). However, cramps at rest were present in a portion of the patients with isolated ant-CECS (38%) and ant-/lat-CECS (57%) but not in those with isolated lat-CECS (P = .032). Patient drawings of altered foot skin sensation did not contribute to the diagnosis (P = .92). ICP values after provocation were all lower in patients with isolated ant-CECS and isolated lat-CECS compared with those with ant-/lat-CECS (P < .05).

Conclusion:

Seven percent of patients with CECS and anterolateral ELP who had symptoms due to isolated lat-CECS in the presence of normal muscle pressure in the anterior compartment.

[Chronic exertional compartment syndrome as a cause of anterolateral leg pain-German version]

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.

Chronic exertional compartment syndrome: current management strategies

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.

Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study

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.

Running mechanics of females with bilateral compartment syndrome

[Purpose] Primary purpose was to compare running mechanics between healthy runners and runners with chronic exertional compartment syndrome (CECS) including overstride angles, ankle dorsiflexion (DF) angles, and foot strike patterns. The secondary purpose was to analyze the association between the overstride angles and ankle DF angles. [Participants and Methods] Running images of 7 female runners with bilateral CECS patients were captured at a time of the medical examination. Their running images were compared with gender, age, and body mass index matched 31 healthy control runners. [Results] The bilateral CECS female runners have a propensity of running with significantly greater overstride and ankle DF angles than the healthy female runners. There were no foot strike differences between the two cohorts. There were a non-significant, poor relationship between overstride and ankle DF angles in the healthy female runners while a significant, strong association was found between overstride and ankle DF angles in the bilateral CECS female runners. [Conclusion] Compared to healthy female runners, bilateral CECS female runners demonstrated different running mechanics including greater overstride and ankle DF angles. The two variables were strongly associated with each other in bilateral CECS female runners, but not in healthy female runners. This may potentially contribute to the mechanism of CECS development.

Lower Leg Chronic Exertional Compartment Syndrome in Patients 50 Years of Age and Older

Background

Lower leg chronic exertional compartment syndrome (CECS) is usually diagnosed in young and athletic individuals. The presence of CECS in older patients has received little attention in the literature, and patient characteristics are unknown.

Purpose

To determine the prevalence of CECS in older patients (≥50 years) and to assess whether older patients with CECS differ clinically from younger patients with CECS.

Study Design

Cohort study; Level of evidence, 3.

Methods

All individuals with exercise-induced lower leg pain who visited a referral center for CECS between January 2001 and December 2013 were eligible for analysis. Patients were included if history, physical examination, and dynamic intracompartmental pressure measurement indicated CECS. Characteristics of patients 50 years of age or older were compared with characteristics of patients younger than 50.

Results

A total of 698 patients with CECS were included: 98 patients were aged 50 years or older and 600 patients were younger than 50 years. Older individuals more often reported a history of lower leg events or comorbidities (≥50 years, 45% vs <50 years, 25%; P < .01) and unilateral symptoms (≥50 years, 45% vs <50 years, 22%; P < .01). Most older patients (62%) did not participate in sport or only walked or hiked, whereas the same was true of only 7% of the younger population. Pain (≥50 years, 94%; <50 years, 96%) and tightness (≥50 years, 57%; <50 years, 62%) were the predominant symptoms of CECS in both groups. Type of CECS differed significantly (P < .01); the anterior muscle compartment was involved more frequently in older patients (≥50 years, 82% vs <50 years, 59%) and deep flexor muscle CECS was more often diagnosed in younger patients (≥50 years, 26% vs <50 years, 53%).

Conclusion

In the present population, 1 in 7 patients diagnosed with lower leg CECS was 50 years of age or older. These individuals were less active and had more comorbidities than patients younger than 50 years. Older individuals predominantly have anterior CECS. Clinicians should consider CECS in older individuals with exercise-induced lower leg pain, particularly if it is unilateral.

Prevalence of chronic compartment syndrome of the legs: Implications for clinical diagnostic criteria and therapy

INTRODUCTION

Poorly defined musculoskeletal disorders are a common clinical problem and have considerable psychosocial impact. Chronic compartment syndrome (CCS) of the legs has primarily been noted in young athletes and soldiers. The epidemiology of CCS in the general population has not been studied previously. The aim of this study was to establish the prevalence of CCS of the legs in the general population and to study its association with possible etiological factors.

METHODS

A two-stage population survey was performed, using a questionnaire followed by clinical examination. A sample of 3000 individuals aged 25-75 years was randomly selected from the general population. A clinical examination was offered to those answering "Yes" to the following question: "Do you wake up at nights due to leg pains or cramps, causing you to walk around?" Intracompartmental pressures in the leg were measured in 13 persons randomly selected from among those diagnosed with CCS after the clinical examination.

RESULTS

Of the 3000 persons contacted, 2308 (76.9%) responders were included in the study. Leg pain or cramps at night was reported by 24% of the respondents. Age, rheumatic disease, use of hormone medication, heart failure, leg oedema, and peripheral arterial disease were all significantly associated with leg pain or cramps (P<0.05). Among 286 persons with leg pain who underwent a subsequent clinical examination, 91 persons (31.9%) were classified as definite CCS. This suggests a CCS prevalence of 7.6% in the total sample ([24%×31.9%/100]). In 13 of the individuals with CCS intracompartmental pressure was measured before and after performance of the step test exercise. One individual had a post-exercise pressure >15mmHg. None had post-exercise pressure past the conventional threshold of >30mmHg.

CONCLUSION

Nocturnal leg pain or cramps is a common symptom. A significant part of the general population (7.6%) may have CCS of the legs, with symptoms ranging from very mild to severe.

IMPLICATIONS

Considering the high prevalence of CCS found in this study, it is likely that a large proportion of those presenting with muscular pain actually have CCS. These persons are usually advised to increase their physical training to achieve some degree of pain relief. However, CCS patients may instead experience both increased leg pain and a proximal myalgia, which is possibly a referred pain. A demanding "gold standard" test (requiring identification of elevated of intracompartmental pressures), unclear diagnostic criteria, poor long-term results from incomplete surgery, and an uncertain explanation for what may be termed referred pain seem to have delayed the acceptance of CCS as a common cause of leg pain/cramps and numbness. At the same time, the enormous costs to society and the reduced quality of life of patients require that such disease entities are correctly diagnosed as they can be effectively treated by simple, low-risk surgical procedures.

Surgical Treatment of Chronic Exertional Compartment Syndrome in Pediatric Patients

BACKGROUND

Chronic exertional compartment syndrome (CECS) is a cause of leg pain in running athletes and is treated with fasciotomy after failure of nonoperative management. CECS is being seen with increased frequency in younger patients. The demographics and outcomes of fasciotomy for CECS in pediatric patients, including risk factors for treatment failure, have not been described.

PURPOSE

To describe characteristics of pediatric patients with CECS and determine surgical outcomes of the condition in this population.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review was performed for patients 18 years and younger treated surgically for CECS with compartment release at a single institution from 1995 to 2014. Demographic and condition characteristics, operative procedure, postoperative course, and clinical outcomes were recorded for 286 legs of 155 patients. Compartment pressure testing using the Pedowitz criteria confirmed the diagnosis in all patients.

RESULTS

A total of 155 patients were included in the study (average patient age at presentation, 16.4 ± 1.38 years); 136 (88%) were female. All 155 patients presented with leg pain; of these patients, 8 (5%) also had neurologic symptoms, and 131 (85%) presented with bilateral symptoms requiring bilateral compartment release. Symptoms were chronic in nature, with duration over 1 year in 63% of patients. The primary sport was most commonly reported as running (25%), soccer (23%), or field hockey (12%); 50% of patients were multisport athletes. Of 286 legs, 138 (48%) had only anterior and/or lateral compartments released, while 84 (29.4%) had all 4 compartments released. Documented return to sport was seen in 79.5% of patients. Outcomes analysis was performed for 250 of 286 legs. Of these 250 legs, 47 (18.8%) had recurrent CECS requiring reoperation at a median of 1.3 years (interquartile range, 0.8-3.5) after initial compartment release. For each additional month between presentation and release, the odds of recurrence decreased by 12% (P = .04). Legs with only anterior and/or lateral compartment released had 3.4 times (95% CI, 1.29-9.14) the odds of reoperation compared with legs that had all 4 compartments released (P = .01). Twenty-eight of 250 legs (11.2%) had wound issues that resolved with nonoperative management. No wounds required repeat surgical management.

CONCLUSION

CECS in pediatric patients most commonly occurs in adolescent females participating in running sports. Fasciotomy results in a 79.5% return-to-sports rate. Recurrence occurs in 18.8% of patients, more commonly in patients undergoing anterior and lateral release only.

Surgical Management for Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature

PURPOSE

To review published literature to characterize the at-risk demographic, operative indications, surgical techniques, functional outcomes, and reoperation and complication rates after operative management of chronic exertional compartment syndrome (CECS) of the lower leg.

METHODS

We searched PubMed, Embase, Cochrane Database, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) through February 1, 2015, using the terms "chronic exertional" and/or "exercise induced compartment syndrome." The inclusion criteria were studies of Level I to IV evidence in English, published in 1970 or later, involving human subjects, reporting clinical outcomes of operative management of CECS of the lower leg, including at least 5 patients, and having follow-up of at least 80% and 6 months.

RESULTS

Among the 204 original articles, 24 primary studies with 1,596 patients met the inclusion criteria. The mean age was 26.6 years (standard deviation, 8.9 years), and the majority of patients were male patients (70%). The total study population mostly comprised military service members (54%) and athletes (29%). Of the athletes, 83% were recreational; 9% were college level; and 8% were either national, international, or professional. The most commonly involved compartment was the anterior compartment (51%; 95% confidence interval [CI], 48.6% to 52.3%), followed by lateral (33%; 95% CI, 31.4% to 34.9%), deep posterior (13%), and superficial posterior (3%). The cumulative posterior involvement rate was 16% (95% CI, 15.1% to 17.8%). Mean follow-up was 48.8 months (standard deviation, 22.1 months; 95% CI, 47.1 to 50.5 months). Six percent underwent revision surgery. The overall complication rate was 13% (due to postoperative neurologic dysfunction, infection, and so on).

CONCLUSIONS

Primary operative management of lower-extremity CECS was successful in approximately two-thirds of all young athletic patients, and 84% were satisfied with their surgical outcomes at short- to mid-term follow-up. Open fasciotomy remains the predominant surgical technique, although its comparative efficacy relative to newer endoscopic or other minimally invasive techniques is not currently known. These data may be used to guide the orthopaedic community on accurate preoperative counseling and benchmark patient outcomes for future quality-improvement initiatives.

LEVEL OF EVIDENCE

Level IV, systematic review (studies ranging from Level I to Level IV).

Isolated Chronic Exertional Compartment Syndrome of the Lateral Lower Leg: A Case Series

Background:

Exercise-induced lower leg pain may be caused by chronic exertional compartment syndrome (CECS). The anterior (ant-CECS) or deep posterior compartment (dp-CECS) is usually affected. Knowledge regarding CECS of the lateral compartment (lat-CECS) is limited.

Purpose:

To describe demographic characteristics and symptoms in a consecutive series of patients with isolated CECS of the lateral compartment of the leg.

Study Design:

Case series; Level of evidence, 4.

Methods:

Since 2001, patients undergoing dynamic intracompartmental pressure (ICP) measurements for suspected CECS in a single institution were prospectively monitored. Individuals with a history possibly associated with lat-CECS and elevated ICP measurements (Pedowitz criteria) were identified. Exclusion criteria were concomitant ipsilateral ant-CECS/dp-CECS, acute compartment syndrome, recent significant trauma, peroneal nerve entrapment, or vascular claudication.

Results:

During an 11-year time period, a total of 26 patients with isolated lat-CECS fulfilled study criteria (15 females; median age, 21 years; range, 14-48 years). Frequently identified provocative sports were running (n = 4), walking (n = 4), field hockey (n = 3), soccer (n = 3), and volleyball (n = 2). Exercise-induced lateral lower leg pain (92%) and tightness (42%) were often reported. The syndrome was bilateral in almost two-thirds (62%, n = 16). Delay in diagnosis averaged 24 months (range, 2 months to 10 years).

Conclusion:

Young patients with exercise-induced pain in the lateral portions of the lower leg may suffer from isolated CECS of the lateral compartment. ICP measurements in the lateral compartment in these patients are recommended.

Feasibility and Safety of an Operative Tool for Anterior Chronic Exertional Compartment Syndrome Treatment

BACKGROUND

Operative management of chronic exertional compartment syndrome of the tibialis anterior muscle compartment (ant-CECS) usually involves the use of a fasciotome. Collateral tissue damage such as hematoma and nerve damage may occur during the procedure. The current report assessed the feasibility and safety of an alternative tool for the operative management of ant-CECS.

METHODS

The system had a speculum-like hollow tube that was inserted via a 2-cm skin incision and allowed for the protected advancement of a fasciotome. The device was tested in patients with bilateral ant-CECS. Symptoms were prospectively scored before and after surgery using a 5-category verbal rating scale (VRS). Fourteen patients (age 26 ± 10 years) were analyzed. Complications and operative efficacy were determined using physical examination and questionnaires after 21 (range = 16-25) months.

RESULTS

Technical operative success rate was 100% (28/28 legs). Operation time was 10 ± 2 minutes per leg (range = 6-14). Perioperative complications were not observed. One superficial wound infection was treated nonoperatively. Significant reductions in pain (-2.2 ± 1.1 on 5-point VRS, P < .001), tightness (-1.9 ± 1.6, P = .01), cramps (-1.4 ± 1.6, P = .009), muscle weakness (-1.6 ± 1.2, P < .001), and altered sensibility (-1.3 ± 1.4, P = .005) were registered 21 months postoperatively.

CONCLUSION

This fasciotome was simple to use and allowed for a safe fasciotomy in patients with leg ant-CECS. A randomized controlled trial comparing the present device with a widely used fasciotome was under way at the time of writing of this study.

Endoscopic Thermal Fasciotomy for Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome is an activity-induced condition that occurs when intracompartmental pressures within an osteofascial envelope increase during exercise, leading to reversible ischemic symptoms such as pain, cramping, numbness, or weakness. Nonoperative treatment options for this condition have shown limited success and are often undesirable for the patient given the requirement for activity modification. Traditional surgical treatment options involving open or subcutaneous fasciotomies have more favorable results, but these techniques are associated with significant morbidity. Endoscopically assisted fasciotomy techniques afford the advantages of being minimally invasive, providing excellent visualization, and allowing accelerated rehabilitation. The purpose of this article is to describe a technique for performing endoscopically assisted fasciotomies for chronic exertional compartment syndrome of the lower leg using an entirely endoscopic thermal ablating device. The endoscopic thermal fasciotomy technique is associated with minimal morbidity, ensures excellent hemostasis, and affords an early return to sports.

The natural course of chronic exertional compartment syndrome of the lower leg

PURPOSE

The aim of this study was to investigate the natural course of chronic exertional compartment syndrome (CECS) in the lower leg.

METHODS

Twelve military men [mean age 30 (SD 4)] diagnosed with CECS after intracompartmental pressure (ICP) measurements immediately post-exercise in 21 legs, who did not undergo a fasciotomy, were reviewed and participated in a repeat pressure measurement after a mean time of 50 months (SD 15).

RESULTS

Sixteen of 21 legs still showed an ICP of 35 mm Hg or more (the cut-off point) at the second visit. All twelve patients still had typical complaints. Mean ICP at index measurement was 58 (SD 15) mm Hg. At the second visit, it was 51 (SD 15) mm Hg. Six patients chose to undergo a subcutaneous fasciotomy, and these six patients all benefited in the short term.

CONCLUSION

The natural course of CECS seems to be persistent symptoms over time.

LEVEL OF EVIDENCE

Case series with no comparative group, Level IV.

Diagnosis and management of symptomatic muscle herniation of the extremities: a retrospective review

BACKGROUND

There is a paucity of published literature on diagnosis and surgical management of muscle herniation of the extremities, with most reported cases involving military personnel and men aged 18 to 40 years. Hypothesis/

PURPOSE

The purpose of this study is to describe the presentation, diagnosis, and results of fasciotomy for symptomatic muscle herniation in young athletes. We hypothesize that fasciotomy can be a safe and effective treatment option that allows the majority of athletes to return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From 2001 to 2011, 26 athletes (19 women; 11 runners) with a mean age 19.0 ± 4.0 years (range, 14.2-28.4 years) underwent fasciotomy for symptomatic muscle herniation at the authors' institution. Retrospective chart review recorded pertinent patient data and clinical course. Questionnaires were sent to all patients to assess satisfaction with surgery, ability to return to sports, and residual symptoms.

RESULTS

Muscle hernias were classified as primary (n = 8, 31%), postsurgical (n = 8, 31%), and associated with underlying untreated chronic exertional compartment syndrome (n = 10, 38%). The tibialis anterior muscle (n = 12, 46%) was most commonly involved. The mean time from onset of symptoms to surgery was 15.1 ± 8.6 months (range, 3-38 months). Dynamic ultrasound (5/6 patients, 83%) was more accurate than magnetic resonance imaging (3/18, 17%) at identifying the hernia. At median follow-up of 28 months (range, 12-127 months), 17 patients (65%) had returned to sports. Seventeen patients (65%) completed the postoperative questionnaire; 14 reported being satisfied with their results (82%). Mild residual symptoms were common (9 of 17 respondents, 53%), especially in runners (5 of 7, 71%), all of whom were satisfied with surgery. Patients with a postsurgical muscle herniation took the longest to return to sports and were the least likely to return to sports, had the highest rate of dissatisfaction with surgery, and were most likely to have persistent symptoms not improved by surgery.

CONCLUSION

Fasciotomy is a safe surgical option for symptomatic muscle herniation in young athletes. Many patients are able to return to sports and most are satisfied with surgery. Residual symptoms are common, especially in runners. Patients with postsurgical muscle herniations may have the worst clinical outcome.

Endoscopic compartment release for chronic exertional compartment syndrome

Exertional compartment syndrome of the leg is a condition that can cause chronic debilitating pain in active persons during a variety of aerobic activities. Nonoperative treatments using stretching protocols and activity modifications are often unsuccessful, and thus several operative strategies have been used to treat this condition. A novel technique for endoscopically assisted fasciotomy for chronic exertional compartment syndrome is described. By use of a small laterally based incision and an arthroscope, polydioxanone sutures are passed percutaneously along the anterior and lateral compartments with the Spectrum suture-shuttling device (ConMed Linvatec, Largo, FL). These sutures are used to retract the skin and subcutaneous tissues over the respective compartments. This method allows excellent visualization of the intercompartmental septum, the superficial peroneal nerve, and all perforating vessels. The anterior and lateral compartments can be safely and completely released with this minimally invasive approach. The patient is allowed to return to full activity at 6 weeks postoperatively, because of the decreased soft-tissue disruption.

Compartment pressure curves predict surgical outcome in chronic deep posterior compartment syndrome

BACKGROUND

Results of surgery for chronic exertional compartment syndrome (CECS) of the lower leg deep posterior compartment are inferior compared with other types of CECS. Factors predicting success after surgery are unknown.

PURPOSE

To study the prognostic value of preoperative compartmental pressure curves in patients receiving surgery for deep posterior compartment CECS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Intracompartmental pressures (ICPs) of patients with deep posterior lower leg CECS were obtained at 4 time points (ie, before, immediately after, and 1 and 5 minutes after a standard exercise challenge test). Area under the 4-point pressure curve was calculated. Patients received a questionnaire investigating residual symptoms after surgery.

RESULTS

A complete data set was available for 52 patients (men, n = 23; age, 33 ± 14 years). They rated their 3-month postoperative clinical outcome as excellent (14%), good (38%), fair (35%), or poor (13%). Outcome at 3 months was related to the area under the preoperative 4-point pressure curve (excellent, 127 ± 28; good, 113 ± 25; fair, 100 ± 22; and poor, 88 ± 15; P = .005; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.08). At the long-term follow-up (39 ± 24 months), all 5 cardinal symptoms (pain, tight feeling, cramps, weakness, and diminished sensibility) were greatly attenuated (P < .001) in the successfully operated group. Long-term success was 48%. Delay in diagnosis was related to poor outcome (P = .04). Correlations between pressures/area under the 4-point pressure curve and long-term outcome were not significant, however.

CONCLUSION

Preoperative measured intracompartmental pressures obtained in rest and after a standard exercise test may predict success of surgery for deep posterior compartment CECS of the lower limb. Further standardizing of preoperative pressure protocols may confirm that compartmental pressure analysis has diagnostic as well as predictive properties.

Compartment syndrome: a review of the literature

Compartment syndrome is a rare but severe complication of lower extremity trauma. This article provides an extensive review of the literature, including incidence, physical examination findings, pathophysiology, compartment pressure evaluation, and surgical decompression techniques. Most of the recent compartment syndrome literature shows case reports of atypical causes of this limb-threatening disorder. Although the emphasis of this article is traumatic compartment syndrome, recent literature on chronic lower extremity compartment syndrome, secondary to exercise or activity, is also discussed.

Accuracy of palpation-guided and ultrasound-guided needle tip placement into the deep and superficial posterior leg compartments

BACKGROUND

Invasive leg compartment testing may be performed to diagnose chronic exertional compartment syndrome. No prior study has assessed the accuracy of leg compartment needle tip access.

PURPOSE

This study was undertaken to describe and determine the accuracy of palpation-guided and ultrasound-guided techniques for needle tip placement into the deep and superficial posterior leg compartments by a less experienced clinician and a more experienced clinician using a cadaveric model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty unembalmed adult lower limb cadaveric specimens were used for the study. Two investigators, a sports medicine fellow with 10 months of musculoskeletal ultrasound experience and a staff physiatrist with 3 years of musculoskeletal ultrasound experience, each performed 1 palpation-guided and 1 ultrasound-guided colored latex dye injection into the deep and superficial posterior leg compartments of each cadaveric specimen. A blinded investigator dissected the specimens and graded them for accuracy.

RESULTS

The accuracy rates of palpation-guided (accuracy rate, 90%; 95% confidence interval [CI], 76%-97%) and ultrasound-guided (accuracy rate, 88%; 95% CI, 73%-95%) deep posterior compartment injections were statistically equivalent (P = 1.000). All 80 injections performed into the superficial posterior compartment were accurate (accuracy rate, 100%; 95% CI, 89%-100%). The accuracy of the less experienced investigator (total injection accuracy rate, 88%; 95% CI, 73%-95%) and the more experienced investigator (total injection accuracy rate, 90%; 95% CI, 76%-97%) were not significantly different (P = 1.000).

CONCLUSION

Needle tip placement into the deep and superficial posterior leg compartments is relatively accurate with palpation guidance regardless of level of experience, and does not improve with the use of ultrasound guidance.

CLINICAL RELEVANCE

Ultrasound guidance does not appear to be indicated for routine deep or superficial posterior leg compartment pressure testing. However, this does not preclude the need for ultrasound guidance in selected clinical scenarios.

Associations between disordered eating, menstrual dysfunction, and musculoskeletal injury among high school athletes

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine the prevalence of, and association between, disordered eating (DE), menstrual dysfunction (MD), and musculoskeletal injury (MI) among high school female athletes.

BACKGROUND

Female athlete triad (Triad) syndrome is the interrelatedness of DE, MD, and low bone mass. Few studies have examined 2 or more Triad components simultaneously, or their relationship to injury, among female high school athletes.

METHODS

The subject sample consisted of 311 female high school athletes competing on 33 interscholastic high school teams during the 2006-2007 school year. Athletes completed the Eating Disorder Examination Questionnaire (EDE-Q) and Healthy Wisconsin High School Female Athletes Survey (HWHSFAS). Athletes were classified by sport type as aesthetic (AES), endurance (END), or team/anaerobic (T/A).

RESULTS

Of those surveyed, 35.4% reported DE, 18.8% reported MD, and 65.6% reported sustaining a sports-related musculoskeletal injury during the current sports season. Athletes reporting DE were twice as likely to be injured compared to those reporting normal eating behaviors (odds ratio [OR], 2.3; 95% confidence interval [CI]: 1.4, 4.0). Multivariate logistic regression analyses revealed that athletes who reported a history of DE (OR, 2.1; 95% CI: 1.1, 3.9) or prior injury (OR, 5.1; 95% CI: 2.9, 8.9) were more likely to be injured during the sports season.

CONCLUSION

A high prevalence of DE and MD exists among high school female athletes. Additionally, athletes with DE were over 2 times more likely to sustain a sports-related injury during a sports season. Screening and intervention programs designed to identify and decrease the prevalence of DE should be implemented with high school females.

LEVEL OF EVIDENCE

Prognosis, level 2b.

Revision surgery for exertional anterior compartment syndrome of the lower leg: technique, findings, and results

BACKGROUND

Recurrent symptoms or failure after fasciotomy for exertional anterior compartment syndrome is not uncommon.

HYPOTHESIS

Symptoms from high compartment pressures can be secondary to involvement of the entire compartment or to localized constrictions from postsurgical fibrosis, as well as to entrapment of the superficial peroneal nerve.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Eighteen patients who underwent revision surgery for exertional anterior compartment syndrome were available for follow-up. All were athletes who had either a failure or a recurrence of symptoms at a mean of 23.5 months (range, 8-54 months) after the index fasciotomy. Pressure measurements using a slit catheter at rest, at 1 minute postexercise, and at 5 minutes postexercise were performed in 2 places within the compartment: in the area of the previous incision and in the proximal muscle belly of the tibialis anterior. Surgical technique consisted of a 2-incision approach with partial fasciectomy, exploration and decompression of the superficial peroneal nerve, and excision of all fibrotic tissue. An objective examination and a comprehensive subjective questionnaire previously described were performed at a mean follow-up of 42 months (range, 22-67 months).

RESULTS

Sixty percent of patients had abnormal pressures only in a localized area, whereas 40% had high pressures throughout the compartment. Eight of 18 (44%) patients had symptoms, signs, and surgical findings of entrapment of the superficial peroneal nerve. At follow-up, 72% of patients had a satisfactory outcome (5 excellent, 8 good), and 28% had an unsatisfactory outcome for intense running sports (4 fair, 1 poor), although 3 patients with the fair results reported improvement with low-level activity. All 8 patients with documented peroneal nerve entrapment had a satisfactory outcome.

CONCLUSION

Symptoms from high pressures can be secondary to involvement of the entire compartment or localized to a certain area from postsurgical fibrosis. Pressure measurements should be performed in at least 2 separate areas.

One-portal endoscopically assisted fasciotomy for exertional compartment syndrome

A newly described method of single-incision endoscopically assisted fasciotomy for chronic exertional compartment syndrome is outlined. The procedure affords a small 2- to 3-cm incision with visualization of the anterior compartment fascia, lateral compartment fascia, superficial peroneal nerve, perforating vessels, and underlying muscle. The single-portal endoscopically assisted fasciotomy for chronic exertional compartment syndrome in the anterior and lateral compartments of the lower leg is a safe and reliable technique with excellent outcomes and patient satisfaction. Moreover, this technique affords the patient an expeditious recovery because of the small incision and decreased soft tissue trauma throughout the lower leg.

Leg pain in the running athlete

Leg pain is a common complaint among recreational and professional athletes who compete in running sports. Evaluation of the individual with intermittent or constant leg pain should be well organized and inclusive. Duration of the pain, its relation to injury, intensity of the pain, and its pattern are important factors. Additionally, changes in the training regimen, its level, intensity, or duration, or in the nature of the routine are critical components of the assessment. Physical examination can help differentiate bony from soft-tissue etiologies. Studies are dictated by the differential diagnosis but include radiographs in almost all patients and selected use of other modalities. These include bone scans and magnetic resonance imaging for medial tibial stress syndrome and stress fractures and intracompartmental pressure measurements for chronic compartment syndrome. Treatment often requires either rest or a change in training regimen. Surgery for conditions such as chronic compartment syndrome frequently allows a return to preinjury activities.

Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints

Approximately 50% of all sports injuries are secondary to overuse and result from repetitive microtrauma that causes local tissue damage. Injuries are most likely with changes in mode, intensity, or duration of training and can accumulate before symptoms appear. Intrinsic factors contributing to injuries are individual bio-mechanical abnormalities such as malalignments, muscle imbalance, inflexibility, weakness, and instability. Contributing extrinsic (avoidable) factors include poor technique, improper equipment, and improper changes in duration or frequency of activity. Injuries are often related to biomechanical abnormalities removed from the specific injury site, requiring evaluation of the entire kinetic chain. This article discusses common overuse injuries of the lower leg, ankle, and foot: tendinopathies, stress fractures, chronic exertional compartment syndrome, and shin splints.

Anatomic structures at risk during minimal-incision endoscopically assisted fascial compartment releases in the leg

BACKGROUND

Although minimal-incision surgical techniques are recommended for treatment of chronic exertional compartment syndrome of the leg, which is an increasing problem among endurance athletes, there is little information about anatomic correlation with structures at risk.

HYPOTHESIS

Fascial releases performed with endoscopic assistance are safer than the percutaneous method.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten endoscopically assisted and six percutaneous fascial releases were performed on 16 human cadaveric lower limbs. Formal dissection documented length of release and proximity of structures at risk.

RESULTS

Endoscopically assisted fascial release led to reduced risk of superficial peroneal nerve injury compared with a blind percutaneous release through a 2- to 3-cm incision. Both techniques had unacceptable rates of saphenous vein injury (30% to 100%), and releases performed percutaneously had greater length.

CONCLUSIONS

Risk of superficial peroneal nerve injury was less with single-incision endoscopically assisted fascial release. Risk of injury to the saphenous vein from either technique appeared to be unacceptable.

CLINICAL RELEVANCE

Single-incision endoscopically assisted fascial release of the anterior and lateral compartments may be a useful technique with low risk of peroneal nerve injury. Clinical studies will confirm whether this technique proves safer or more effective than those currently used for chronic exertional compartment syndrome of the leg.

Long-term outcome of fasciotomy with partial fasciectomy for chronic exertional compartment syndrome of the lower leg

BACKGROUND

Fasciotomy with partial fasciectomy for compartment syndrome has had good short-term results, but no long-term studies have been performed.

HYPOTHESIS

Combining a partial fasciectomy with fasciotomy for compartment syndrome relieves pain and eliminates symptoms in the long term.

STUDY DESIGN

Retrospective cohort study.

METHODS

A self-administered questionnaire was given to 62 patients at a mean follow-up of 51 months after surgery.

RESULTS

Of the 50 patients who underwent a single operation, 60% (30) reported an excellent or good outcome. Average pain and pain-on-running were significantly reduced, although some subjects still reported considerable levels of pain. Fifty-eight percent (36 of 62) were exercising at a lower level than before injury and, of these, 36% (13) cited the return of their compartment syndrome or the development of a different lower leg compartment syndrome as the reason for a reduction in exercise levels. Some subjects indicated early initial improvement followed by subsequent deterioration.

CONCLUSION

This surgical technique reduces pain and allows the majority of patients to return to sports; however, patients should be counseled that they may not be able to return to their preinjury level of exercise or remain pain-free.

Analysis of pre- and postexercise compartment pressures in the medial compartment of the foot

Growing awareness of chronic exertional compartment syndrome of the foot has led to the need for site-specific analysis of normative resting and postexertional intracompartment pressures. Thirty-four asymptomatic athletes underwent pressure testing of the medial foot compartment with an intracompartmental pressure measurement apparatus. Pressure measurements were recorded before exercise and after 20 minutes of running. Mean resting intracompartment pressure was 7.7 mm Hg, whereas mean pressures 1 and 5 minutes after exercise were 19.1 mm Hg and 10.7 mm Hg, respectively. These data were then compared with data from compartment pressure studies performed in nine symptomatic subjects, each with a clinical history suggestive of chronic exertional compartment syndrome of the medial foot compartment. The results demonstrated normative compartment pressures of the medial foot compartment are comparable with previously measured pressures of the leg. This study shows that previously defined criteria for diagnosis of chronic exertional compartment syndrome of the leg may also be used for diagnosis of chronic exertional compartment syndrome of the foot.

Endoscopically assisted fasciotomy: description of technique and in vitro assessment of lower-leg compartment decompression

We describe a reliable method of endoscopically assisted fasciotomy for treating chronic exertional compartment syndrome in the lower leg and for assessing compartment decompression in an in vitro model. Endoscopically assisted fasciotomy was performed in the anterior and lateral compartments of 14 matched, fresh-frozen, through-the-knee amputation specimens using a 30 degrees endoscope. A one-incision technique used in 4 specimens failed to provide complete visualization, and a two-incision technique was then performed in 10 specimens. After decompression, the skin and subcutaneous tissues were removed to assess adequacy of release, nerve decompression, anatomic course of the superficial peroneal nerve, and potential complications. Endoscopic visualization of the fascial layer and subcutaneous neurovascular structures permitted consistent compartment decompression. Fascial release, expressed as a percentage of length from the proximal origin of the fascia to the inferior retinaculum, was 99.8% (range, 98.4% to 100%) for the anterior compartment and 96.4% (range, 82% to 100%) for the lateral compartment. There were no retained fascial bands, unrecognized fascial defects, or neurovascular injuries. Optimal visualization with endoscopically assisted fasciotomy may improve clinical outcome through 1) reliable compartment decompression, 2) identification of fascial defects, 3) decompression of nerve branches at the fascial foramen, and 4) reduction of iatrogenic risk to neurovascular and muscular structures.

Common athletic injuries in adolescent girls

Teenaged girls constitute the fastest growing segment of children and adolescents participating in organized athletics. Adolescent girls appear to have similar injury rates as boys in comparable activities but different injury patterns. To properly diagnose and manage athletic injuries in adolescent girls, pediatric health care providers must be aware of these differences, especially as the literature and their knowledge base may be skewed to the traditional predominance of males in sport. This review identifies athletic injuries that are unique to or especially common in adolescent girls, including apophyseal injuries; breast and pelvic injuries; scoliosis and spondylolysis; multidirectional shoulder instability and "gymnast's wrist"; anterior cruciate ligament injuries and patellofemoral pain syndrome; chronic exertional lower-leg compartment syndrome, ankle sprains, and reflex sympathetic dystrophy; and stress fractures. It also briefly discusses possible risk factors for these injuries, emphasizing the female athlete triad.