Ultrasound-Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg

Rehabilitation and return to activity criteria after operative management of chronic exertional compartment syndrome of the leg: a systematic review

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.

Chronic exertional compartment syndrome is frequently diagnosed through static compartment pressure measurements and managed with fasciotomy: A systematic review

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.

Compartments of the crural fascia: clinically relevant ultrasound, anatomical and histological findings

PURPOSE

Compartment syndrome is a surgical emergency that can occur in any part of the body and can cause cell necrosis when maintained over time. The resulting defects can affect the nerves, muscle cells, bone tissue, and other connective tissues inside the compartment, and fasciotomy has to be performed. The anatomical and histological characteristics of the leg make acute, chronic, and exertional compartment syndrome more likely in this limb. For these reasons, knowledge of the ultrasound, anatomical, and histological features of the crural fascia can help in the treatment of leg compartment syndrome.

METHODS

Twenty-one cryopreserved lower limbs from adult cadavers and from one 29-week-old fetus were obtained from the dissection room. They were examined by ultrasound and a subsequent anatomical dissection and microscopy to study the crural fascia and its relationship with the different muscles. Anthropometric measurements were taken of the distances from the head of the fibula and lateral malleolus to the origin of the tibialis anterior muscle in the crural fascia, the exit of the superficial fibular nerve, and the fascia covering the deep posterior muscles of the leg.

RESULTS

The crural fascia has very important clinical relationships, which can be identified by ultrasound, as the origin of the tibialis anterior muscle at 16.25 cm from the head of the fibula and the exit of the superficial fibular nerve that crosses this fascia at 21.25 cm from the head of the fibula. Furthermore, the presence of a septum that fixes the deep posterior muscles of the leg and the vessels and nerve can be seen by ultrasound and can explain the possible development of a posterior compartmental syndrome of the leg. Awareness of these features will help to keep these structures safe during the surgical treatment of compartment syndrome.

CONCLUSION

The ultrasound study allows identification of anatomical structures in the leg and, thus, avoids damage to them during surgery for compartmental syndromes.

Compartment Syndrome in the Foot and Leg

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.

Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Case Report

Chronic exertional compartment syndrome (CECS) is characterized by an excessive increase in intracompartmental muscle pressures after exercise. Athletes with CECS report pain, pressure, and occasionally neurologic symptoms in the affected compartment during exercise that abates with rest. Although many treatment options have been proposed, athletes often require a fasciotomy to return to unrestricted sports participation. Surgical success rates vary; complications are not uncommon; and after surgery, it usually takes athletes 6 or more weeks to return to unrestricted impact activities. This case report describes a new ultrasound-guided fasciotomy technique for the treatment of anterior leg compartment CECS. The procedure required a 3 mm incision, was performed in the office under local anesthesia, and allowed the athlete to resume running within 1 week of the procedure. Although the preliminary results of this study are promising, further translational research is required before the widespread adoption of this procedure is recommended.

Chronic Exertional Compartment Syndrome: A Clinical Update

Chronic exertional compartment syndrome is a debilitating condition primarily associated in highly active individuals with an estimated incidence of approximately 1 in 2000 persons/year. The etiology remains unclear to date. The differential diagnosis includes, but is not limited to stress fractures, medial tibial stress syndrome, and popliteal artery entrapment syndrome. Clinical signs and symptoms include pain in the involved compartment with exertion dissipating quickly after activity. Diagnostic tests include intramuscular compartment pressure testing, magnetic resonance imaging, near-infrared spectrometry as well as shear wave electrography. Treatments consist of nonsurgical, surgical, or the combination of the two. Gait retraining and the use of botulinum toxin appear most promising. Diagnostic lidocaine injections are emerging as a prognostic and mapping tool. Minimal invasive surgical options are being utilized allowing quicker return to activity and decreased morbidity. This article reviews the anatomy, clinical signs and symptoms, diagnostics, nonsurgical, and surgical treatments for chronic exertional compartment syndrome.

Ultrasound-Guided Fasciotomies of the Deep and Superficial Posterior Leg Compartments for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation

BACKGROUND

Chronic exertional compartment syndrome (CECS) is a type of leg pain related to elevated intracompartmental pressure with activity in one or more of the four compartments of the leg. Open fasciotomy is the definitive treatment for CECS but has a reported complication rate of up to 15.7% and return to full activity reported up to 16 weeks. Ultrasound-guided (USG) fasciotomy of the anterior and lateral compartments has been translated into clinical practice.

OBJECTIVE

To determine the safety and feasibility of a USG fasciotomy of the deep posterior compartment (DPC) and superficial compartment (SPC) of the leg in a fresh-frozen cadaveric model.

DESIGN

Prospective, cadaveric laboratory investigation.

SETTING

Procedural skills laboratory at an academic institution.

CADAVERIC COHORT

Ten fresh-frozen cadaveric knee-ankle-foot specimens from five female and five male donors aged 58 to 93 years (mean 77.4 years) with body mass indexes of 18.1 to 33.5 kg/m² (mean 25.1 kg/m² ).

METHODS OR INTERVENTIONS

One experienced operator performed 10 USG DPC and SPC fasciotomies. A clinical anatomist performed dissections of each.

MAIN OUTCOME MEASURES

Achievement of target length and continuity of release was recorded. Target lengths of 10 cm for the superficial posterior compartment (SPC) and 15 cm for the deep posterior compartment (DPC) were established based on previous studies. Tendinous and neurovascular structures were assessed for damage.

RESULTS

No tendon or neurovascular injuries were observed. In the SPC, target length was achieved in 90% and continuous release was observed in 80%. In the DPC, target length was achieved in 60% and continuity observed in 30%.

CONCLUSIONS

These findings suggest that SPC USG fasciotomies using the technique described in this study are feasible, may be safe, and warrant further translational research; however, DPC USG fasciotomies are more challenging and require more technical refinement prior to clinical translation.

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.

Ultrasound-Guided Ankle Lateral Ligament Stabilization

PURPOSE OF REVIEW

Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique.

RECENT FINDINGS

To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve. In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.

Brief Ultrasound-Aided Teaching to Improve the Accuracy and Confidence of Resident Musculoskeletal Palpation

BACKGROUND

Multiple studies demonstrate poor musculoskeletal palpation accuracy of physiatry residents. With the growing use of ultrasound clinically, it could serve as a powerful educational tool. However, there are no published studies examining the efficacy of ultrasound-aided education at the bedside, where much learning takes place during postgraduate training.

OBJECTIVE

To determine if brief ultrasound-aided teaching improves residents' accuracy and confidence of musculoskeletal palpation.

DESIGN

Before/After Trial.

SETTING

Academic Institution.

PARTICIPANTS

Ten physical medicine and rehabilitation residents were voluntary participants.

INTERVENTION

Each resident was given a survey to assess confidence in palpating the hook of the hamate and medial calcaneal tubercle. They then attempted to palpate and place a marker over these two structures in a model patient. Marker placement accuracy was verified by ultrasound. Faculty spent less than 1 minute per landmark, sonographically teaching its correct localization. The resident, after moving to a new model patient, was then re-tested on accurate marker placement for both landmarks. A repeat survey to assess confidence was administered.

MAIN OUTCOME MEASUREMENTS

Preintervention and postintervention accuracy and confidence of correct localization of both landmarks.

RESULTS

We used McNemar's and Wilcoxon's tests to determine whether the intervention improved the location accuracy and confidence of successful palpation, respectively. Confidence level of correct localization of two landmarks improved on average from 4.3 to 8.15 on a scale of 10 after intervention. Of 20 palpation attempts, 11 correctly placed the marker postintervention after an incorrect placement, 8 made no change, and one changed from correct to incorrect placement. The odds of improvement in accuracy was 11 (95% confidence interval [CI] 1.60-473.47, P < .01). Both tests showed significant improvements after the intervention at the significance level of .05.

CONCLUSIONS

Brief, ultrasound-aided teaching increases accuracy and confidence of residents' musculoskeletal palpation.

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.

Open 4-Compartment Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg

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.

Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature

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.