Chronic Exertional Compartment Syndrome
Mark R. Hutchinson, MD; Mary Lloyd Ireland, MD
Department Editor: William O. Roberts, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 5 - MAY 1999
Compartment syndromes are potentially serious problems in athletes. Acute compartment syndrome is an emergency that usually requires prompt surgical treatment. Chronic exertional compartment syndrome (CECS), though less serious, is painful and persistent and may halt physical activity, so primary care physicians should be able to recognize CECS in athletes.
Measuring compartment pressure is an effective way to confirm the diagnosis of CECS. Several measurement methods and devices are available (1,2): Whiteside's technique, using intravenous (IV) tubing, a three-way stop-cock, and a wall blood pressure gauge; the wick catheter technique, employing a specially prepared catheter that is connected to a pressure transducer; the continuous infusion technique, utilizing an ordinary needle or IV catheter, a pressure transducer, and a syringe infusion pump; and a commercially available, battery-operated, hand-held device, the Stryker Intracompartmental Pressure Monitor System (Stryker Instruments, Kalamazoo, Michigan).
The first three techniques all require some practice to use effectively, and thus they may not be good choices for physicians who see patients with compartment syndrome only occasionally or rarely. The Stryker device, however, is simple enough to operate that physicians can reasonably expect to get accurate results even with only occasional use. Accordingly, measurement of compartment pressure with this device is our focus here.
Causes and Signs
Each of the many muscle compartments in the body is wrapped in a relatively inflexible fascia. Exertion-related fiber swelling and increased intracompartmental blood volume or increased osmotic pressure associated with myofiber damage may cause intracompartmental pressure to rise. If the fascia does not stretch to accommodate the pressure, an athlete can develop CECS.
An athlete who has CECS typically presents with exercise-related pain in a defined muscle compartment, most commonly the anterior compartment of the leg (figure 1). The pain is generally absent at rest and occurs only with exertion, usually after some delay. For example, runners rarely hurt on first impact, but pain and tightness develop 30 to 40 minutes into their runs. In rare cases, the onset can occur within 2 to 3 minutes of beginning activities.
The athlete may feel tightness develop in the compartment and may complain of paresthesias, which involve a nerve traversing the compartment. The pain can become so severe that the athlete is unable to continue to exercise or compete, but it usually resolves within a short time after cessation of exercise (for more information on the diagnosis of CECS, see "Exertional Syndrome of the Leg: Steps for Expedient Return to Activity," April 1996, page 31 and "Chronic Leg Pain: Putting the Diagnostic Pieces Together," July 1998, page 37).
If signs and symptoms of CECS do not resolve, an athlete may, in rare cases, be in danger of developing acute compartment syndrome, a much more serious condition. Acute syndromes are associated with severe pain secondary to ischemia, pain with passive stretching, palpably tight compartments, skin pallor, and, occasionally, paresthesias. Prompt treatment or referral is imperative.
Patients whose history or physical exam raises the suspicion of chronic compartment syndrome should undergo compartment pressure testing before and after exercise. All compartments can be safely and efficiently evaluated in an outpatient setting, but knowledge of anatomy is essential for identifying the appropriate compartment and avoiding neurovascular structures.
Pressure criteria. Normal compartment pressures should be less than 10 mm Hg but may rise a few millimeters with muscle contraction. The commonly accepted pressure criteria for the diagnosis of CECS are as follows:
Skin preparation. The first step in compartment pressure measurement is, of course, to identify the compartment and sterilize the overlying skin.
Next, anesthetize the skin by injecting 1 to 3 mL of 1% lidocaine hydrochloride subcutaneously, being sure to avoid penetration of the fascial compartment.
Monitor prep. The third step involves preparing the unit for insertion and measurement. The monitor kit comes with a disposable syringe filled with 3.0 mL of 0.9% saline and a sterile needle. These must be connected to the diaphragm transducer, and the whole assembly clipped into the monitor (figure 2: not shown). The batteries should then be checked for freshness, and the unit turned on. Press the syringe until a drop of saline exudes from the needle tip; this will prime the diaphragm and ensure a solid column of fluid from the needle tip to the transducer. Press the "zero" button to clear the unit.
Taking the reading. Insert the needle at 90° to the anesthetized skin, through the fascia, and into the appropriate compartment. Inject a small amount of saline to ensure a solid fluid column. Wait a few seconds for the reading to equilibrate, record the reading, and remove the needle. Cover the insertion site with a bandage and have the patient exercise until pain develops by running on a treadmill or up and down stairs or by repeating movements unique to his or her sport. Reinsert the needle at the same site and repeat the reading.
Since CECS can have serious outcomes, it should be included in the differential diagnosis of limb injuries and complaints. Awareness of the clinical signs and symptoms and early confirmation using intracompartmental pressure measurement will help identify CECS and avert potentially catastrophic sequelae.
Dr Hutchinson is director of sports medicine services, an assistant professor of orthopedics and sports medicine, and head team physician at the University of Illinois in Chicago. Dr Ireland is an orthopedic surgeon, director and president of the Kentucky Sports Medicine Clinic in Lexington, and head team physician at Eastern Kentucky University in Richmond. Dr Roberts is a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota, and medical director of the Twin Cities Marathon. Drs Hutchinson and Roberts are editorial board members of The Physician and Sportsmedicine.