Search

Background: Patients with chronic exertional compartment syndrome (CECS) have pain during exercise that subsides with rest. Diagnosis is usually confirmed by intramuscular compartment pressure (IMCP) measurement. Controversy exists regarding the accuracy of existing diagnostic criteria., Purpose: (1) To compare dynamic IMCP measurement and anthropometric factors between patients with CECS and asymptomatic controls and (2) to establish the diagnostic utility of dynamic IMCP measurement., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: A total of 40 men aged 21 to 40 years were included in the study: 20 with symptoms of CECS of the anterior compartment and 20 asymptomatic controls. Diagnoses other than CECS were excluded with rigorous inclusion criteria and magnetic resonance imaging. The IMCP was measured continuously before, during, and after participants exercised on a treadmill, wearing identical footwear and carrying a 15-kg load., Results: Pain experienced by study subjects increased incrementally as the study progressed (P < .001). Pain levels experienced by the case group during each phase of the exercise were significantly different (P = .021). Subjects had higher IMCP immediately upon standing at rest compared with controls (23.8 mm Hg [controls] vs 35.5 mm Hg [subjects]; P = .006). This relationship persisted throughout the exercise protocol, with the greatest difference corresponding to the period of maximal tolerable pain (68.7 mm Hg [controls] vs 114 mm Hg [subjects]; P < .001). Sensitivity and specificity were consistently higher than the existing criteria with improved diagnostic value (sensitivity = 63%, specificity = 95%; likelihood ratio = 12.5 [95% CI, 3.2-49])., Conclusion: Anterior compartment IMCP is elevated immediately upon standing at rest in subjects with CECS. In patients with symptoms consistent with CECS, diagnostic utility of IMCP measurement is improved when measured continuously during exercise. A cutoff of 105 mm Hg in phase 2 provides better diagnostic accuracy than do the Pedowitz criteria of 30 mm Hg and 20 mm Hg at 1 and 5 minutes after exercise, respectively., (© 2014 The Author(s).)

Objective: To compare the intramuscular pressure (IMP) of the tibialis anterior in healthy persons under several exercise conditions with the IMP diagnostic criteria in use for diagnosing chronic exertional compartment syndrome (CECS)., Data Sources: A search of MEDLINE for the period 1966 to March 2010 used the words "intramuscular," "intracompartment," "anterior compartment," and "anterior tibial compartment" linked with "pressure." Reference lists of relevant studies were searched for further articles., Study Selection: Articles published in English that tested IMP in the tibialis anterior in asymptomatic humans were included if they used no interventions before or during IMP testing. Studies were excluded if data were given as a percentage of IMP or if the data could not be extracted for the tibialis anterior compartment alone. From 515 articles identified, 38 studies met selection criteria, Data Extraction: : Details of the studies included IMP measurement technique, timing of measurement (before, during, and/or after exercise), type and duration of exercise, the number of compartments measured, and participants' ages. Mean or median pressure was recorded in mm Hg., Diagnostic Standard: Criteria for the upper limit of normal pressure under different conditions were the Pedowitz criterion for preexercise IMP (15 mm Hg), the Puranen criterion for IMP during exercise (50 mm Hg), the Styf criterion for relaxation pressure (30-55 mm Hg), and the Pedowitz criteria for mean 1-minute postexercise and 5-minutes postexercise pressures (30 mm Hg and 50 mm Hg, respectively)., Main Results: Exercise was mostly treadmill walking/running (duration, 1.5-120 min) or ankle dorsiflexion (duration, 10 sec-20 min). Methods of measuring IMP varied from study to study. The lowest mean IMP was identified preexercise at rest (range, 0-20 mm Hg). Five of the 34 studies found a higher mean resting pressure than the criterion (15 mm Hg). Mean pressure during exercise (10 studies, 9 of running, with durations of 5-20 min) varied between 23 mm Hg and 66 mm Hg. Two of these studies found a higher mean peak pressure during exercise than the criterion (50 mm Hg). Mean relaxation IMP, measured in 9 studies, was approximately 25 mm Hg in the 1 treadmill study in which it was measured, whereas studies of dorsiflexion found a range of approximately 5 to 15 mm Hg. All the studies found lower mean relaxation IMP than the criterion (35-50 mm Hg). One of 11 studies and 1 of 10 studies found the mean postexercise IMP after 1 minute and 5 minutes to be above the criteria of 30 mm Hg and 20 mm Hg, respectively., Conclusions: The limits of anterior tibialis IMP before, during, and after exercise that are used as diagnostic criteria for CECS would include many asymptomatic persons. Intramuscular pressure values were not valid criteria for the presence of the syndrome.

Chronic exertional compartment syndrome (CECS) of the lower limb is part of a group of overuse lower limb injuries with common presenting features. It is commonly diagnosed by the measurement of raised intramuscular pressures in the lower limb. The pathophysiology of the condition is poorly understood, and the criteria used to make the diagnosis are based on small sample sizes of symptomatic patients. We carried out a systematic review to compare intramuscular pressures in the anterior compartment of healthy subjects with commonly used criteria for CECS. Thirty-eight studies were included. With the exception of relaxation pressure, the current criteria for diagnosing CECS, considered to be the gold standard, overlap the range found in normal healthy subjects. Several studies reported mean pressures that would prompt a positive diagnosis for CECS, despite none of the subjects reporting any symptoms. The intramuscular pressure at all time points has also shown to vary in relation to a number of other factors other than the presence of CECS. Taken together, these data have major implications on the ability to use these published criteria for diagnosis and question the underlying pathophysiology. Clinicians are recommended to use protocol-specific upper confidence limits to guide the diagnosis following a failed conservative management., (© 2011 Crown Copyright.)

Despite more recent non-invasive modalities generating some credence in the literature, intracompartmental pressure testing is still considered the 'gold standard' for investigating chronic exertional compartment syndrome (CECS). Intracompartmental pressure testing, when used correctly, has been shown to be accurate and reliable. However, it is a user-dependent investigation, and the manner in which the investigation is conducted plays a large role in the outcome of the test. Despite this, a standard, reproducible protocol for intracompartmental pressure testing has not been described. This results in confusion regarding interpretation of results and reduces the tests' reliability. A summary of the current understanding of CECS is presented, along with the results of a survey of specialists in Australia and New Zealand who perform intracompartmental pressure testing, which confirms that a uniform approach is currently not used in clinical practice. This highlights the need for a consensus and standardised approach to intracompartmental pressure testing.

Compartment syndrome has rarely been reported associated with acute rhabdomyolysis. In the case described, the rhabdomyolysis was severe enough to cause compartment syndrome and acute renal failure after moderate exercise and alcohol intake and had the appearance of a myositis. The case emphasizes the importance of early recognition of compartment syndrome, as loss of pulses is a very late sign, and the examination of the urine to detect myoglobinuria in rhabdomyolysis. Measurement of creatine kinase is predictive of the extent of muscle damage and the development of renal failure.

Acute, exertional rhabdomyolysis typically follows strenuous exercise of the eccentric type, such as that which occurs during military training or repetitive weight lifting in unconditioned individuals. Complications can be significant and include compartment syndrome and acute renal failure due to myoglobinuria, especially in the setting of volume depletion. Rhabdomyolysis may also be precipitated by viral infections, usually influenza virus. I report an unusual case of a female patient who had acute rhabdomyolysis, complicated by compartment syndrome of both legs, after beginning an exercise regimen on a treadmill. The patient reported a viral-like illness several days before and was found to have a rise in antibodies to coxsackieviruses B4 and B5.

Clinical examination following an exercise test that elicits the symptoms of lower leg pain is most helpful in diagnosing the causes. Location of swelling, pain, impaired muscle function and impaired nerve function should all be analysed. History and clinical signs alone are insufficient to establish the diagnosis of chronic anterior compartment syndrome, and for this reason intramuscular pressure recordings have an important role in diagnosis. Different techniques for pressure recording and different pressure parameters are reviewed. Muscle relaxation pressure during exercise and intramuscular pressure at rest after exercise are the best parameters to study. Fasciotomy relieves pain in between 60% and 100% of patients. Closure of a fascial defect is never indicated, because it decreases the compartment size and may precipitate an acute compartment syndrome. Recording of nerve conduction velocity is a helpful complement in the diagnosis and evaluation of superficial peroneal nerve compression. Decompression by local fasciectomy and fasciotomy of the lateral compartment gives good results in more than 50% of patients. The value of periostitis as a clinical sign and the possibility of chronic pain following eccentric exercise are discussed.