Compartmental Syndromes.

Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Thursday, February 10, 2005

Figure 1 - Tissue pressure monitoring

Figure 2 - Formal exercise tests

Recurrent compartmental syndromes

Syndromes due to exercise

Recurrent leg pain with exercise is a commonly observed symptom. A relatively small number of patients with this symptom have recurrent compartmental syndromes due to intensive use of muscles.

Recurrent compartmental syndromes often produce pain, muscle tightness, and weakness that require the patient to slow down or cease exercising altogether.

These syndromes may be diagnosed by examination of the patient during and after exercise as well as at rest. Tissue pressure monitoring during a standard exercise test is helpful.

Careful evaluation is required to differentiate this condition from tendinitis, shin splints, and fatigue fractures.

Patients with well-documented recurrent compartmental syndromes due to intensive use of muscles benefit from decompression of the affected compartment.

Intensive muscular work increases muscle volume and thus can lead to increased intracompartmental pressure. Although increased intramuscular pressure from exercise may resolve without producing any symptoms, it may also give rise to two varieties of compartmental syndromes: an acute form and a recurrent form. The acute compartmental syndrome from intensive use of muscles is diagnosed and treated as other compartmental syndromes along the lines presented in the foregoing chapters. Recurrent compartmental syndromes from exercise produce a somewhat different clinical picture and thus deserve a separate discussion. The term "recurrent" is preferred over the more familiar term "chronic" because the patient does not have chronic disability, but rather is asymptomatic between recurrences. l-6

Pathophysiology

Diagnosis

Clinically, recurrent compartmental syndromes differ from the acute variety in that symptoms are brought on by excessive exercise of the affected compartment and dissipate with a period of rest, generally in the order of minutes. Whereas a high degree of exertion is often required to precipitate the symptoms, a slower pace of exercise may allow these symptoms to resolve. In many cases symptoms recur predictably with approximately the same amount of exercise.

Recurrent compartmental syndromes of the leg are usually found in athletes and military recruits. The patient typically notes a painful, tight sensation in the affected compartment along with weakness of the muscles in that compartment. For example, a patient with a recurrent anterior compartmental syndrome of the leg may develop a foot-slap on heel strike due to weakness of the tibialis anterior muscle. Occasionally, paresthesias are experienced in the distribution of the nerves running through the affected compartment. Recurrent compartmental syndromes are encountered most frequently in the anterior and lateral compartments of the leg. 5 The deep and superficial posterior compartments of the leg may also be involved.

The physical examination of the nonexercising patient with a recurrent compartmental syndrome is often unremarkable. However, Reneman 5 noted fascial hernias in the majority of his patients with this condition. Garfin et al 11 pointed out that these fascial defects tend to occur at the site of emergence of the superficial peroneal nerve. Thus, symptoms may arise from the compartmental syndrome, from herniation of muscle through the defect, or from local compression of the nerve.

Because this syndrome is produced by exercise, it is most useful to examine the compartment during and after vigorous exertion of the muscles in the compartment. The compartment may be most conveniently exercised by asking the patient to repeatedly contract the compartmental muscles against manual resistance until characteristic symptoms are produced. At this point the compartment may be palpated for tenseness and the muscles examined for weakness. When involvement is unilateral, the opposite side is used for comparison. The patient may also be asked to perform exactly the exercise that causes his symptoms with the physician running or biking at his side. This type of "on the scene" evaluation gives the physician the most accurate idea of what is occurring in the patient's extremities. Pain that occurs with the first few steps, but that can be "run through," cannot be attributed to a recurrent compartmental syndrome. Pain that comes on after a more or less predictable amount of exercise and that requires the patient to slow his pace or stop exercising is much more typical, particularly if associated with a tight compartment and weakness of the intracompartmental muscles.

Reneman 5 provided good evidence that increased tissue pressure is important in recurrent compartmental syndromes. With the use of an injection technique, he measured tissue pressures in the anterior compartment of the leg before exercise and at zero, three, and six minutes after a standard exercise test (repeated dorsiflexion of the foot against resistance). This test was carried out in normal volunteers and in a group of male patients in whom the need for surgical decompression had been determined on clinical grounds. Resting pressures were only slightly elevated in the patients requiring surgical decompression. However, the tissue pressure six minutes after exercise was significantly increased in all 34 of these patients.

We have used the continuous infusion technique (see Chapter 2) in a similar exercise test to evaluate patients for recurrent compartmental syndromes. In this application an 18-gauge catheter and an infusion rate of 0.1 cc per hour provide a better dynamic response than the smaller catheter and slower infusion rate used in monitoring limbs at risk for acute compartmental syndromes. Use of the infusion technique provides continuous pressure monitoring during and immediately after exercise. With the catheter in the muscle of the compartment, base-line readings are obtained. The compartmental muscles are then contracted against resistance at a rate of one per second for three minutes. Particular notice is taken if the patient's symptoms are reproduced during the exercise test. In the examination of the anterior compartment of the leg, resistance to foot dorsiflexion may be applied manually or with the use of a hinged footboard connected through a pulley to a 6-kg weight.

We studied seven anterior compartments of the leg in five patients believed to have recurrent compartmental syndromes because of their clinical findings. We also studied a control group consisting of six male and six female volunteers (age range- 12 to 61 years; average age, 28 years). The results are quite interesting. In our patient group, resting anterior compartment pressure averaged 16+2 mm Hg compared with 11+2 mm Hg in our control group (mean +SD). The postexercise pressure curve in the patient group deviated dramatically from that of the control group. For the patients, the postexercise pressures were higher and did not return to pre-exercise levels within six minutes. These results are identical to those of Reneman. 5

Differential diagnosis

The common diagnoses requiring differentiation from recurrent compartmental syndromes include tendinitis, fatigue fractures, and the poorly understood entity known as shin splints. These conditions are probably more common causes of exercise-related leg pain than are recurrent compartmental syndromes. Although they may produce leg symptoms similar to those of recurrent compartmental syndromes, these conditions are not accompanied by indications of increased intracompartmental pressure. In addition, whereas many patients can run through symptoms due to these conditions, such is not the case with compartmental syndromes.

Symptoms of tendinitis usually persist after the exercise has been stopped; pain is often reproduced by passively stretching the affected tendon. In fatigue fractures, a sharply defined area of bone tenderness usually extends Mom one side of the bone to the other. Radiographic evidence of periosteal new bone formation may be present in long-standing cases. Bone scans frequently indicate locally increased bone turnover. In shin splints, pain is usually located just behind the medial tibial crest, often at the junction of the middle and distal thirds of the tibia. The area of tenderness is often 10 cm or more in length. While roentgenograms remain normal, the bone scan may show increased bone turnover along the area of tenderness. In our experience, patients with shin splints do not demonstrate increased tissue pressure at rest or after exercise. Therefore, we cannot recommend surgical decompression of the deep posterior compartment in the treatment of this condition as suggested by Puranen. 12

Treatment

Many patients with recurrent compartmental syndromes due to intensive use of muscles are relieved to gain an understanding of their condition and are willing to modify their exercise program to avoid the resulting symptoms. Some serious athletes, however, are unable to modify their exercise program and request surgical decompression.

In recurrent compartmental syndromes due to intensive use of muscles, the surgical procedure is quite different from that used for treating acute compartmental syndromes. First, the procedure is not an emergency. Second, one compartment can usually be clearly identified as being responsible for the patient's symptoms. Third, postischemic swelling is not anticipated after the operative procedure; thus, subcutaneous fasciotomy is appropriate. The fascial incision is made through two small skin incisions and runs the entire length of the compartment, leaving no fascial bridges. Care is required to avoid injuring the branches of the superficial peroneal nerve in decompressing the anterior compartment of the leg, as pointed out by Garfin et al. 11 At the end of the procedure, the skin is closed with a cosmetic suture. The patient is warned that the extremity may swell with dependency for a few days up to a few weeks after the procedure. A progressive exercise program is instituted one week after surgery.

To date we have operated on five anterior compartments of the leg in four patients. These have included a runner, a race walker, an ice skater, and a professional soccer referee. All had significant improvement after their surgical procedure and returned to their activities. Reneman 5 6 also noted excellent results from his treatment of patients with this condition. Thirty-six of 40 patients who submitted to surgery were able to resume physical activities that had been prohibited by symptoms before surgery. One patient did not experience improvement, and three were lost to follow-up.

The following case report presents an instructive example of a recurrent compartmental syndrome due to intensive use of muscles:

A 32-year-old white male world class race walker had a 15-year history of painful tightness in both anterior compartments during exercise. His symptoms would typically appear in the first three or four miles of race walking at a competitive speed, although they could be avoided if he walked at a somewhat slower pace. The pain was accompanied by weakness of foot dorsiflexion noted as a foot-slap on heel strike. The patient also observed a vague numbness over the dorsum of his foot after the onset of pain. Although he was able to complete longer races and marathons, his speed was retarded by his symptoms.

Routine physical examination was unremarkable. No fascial hernias were detected. Upon repeated dorsiflexion of his foot against resistance, his anterior compartments became tense and his symptoms were reproduced. Formal exercise tests were conducted while anterior compartmental pressures were monitored using the continuous infusion technique. Resting anterior compartment pressures measured 15 mm Hg on the left and 14 mm Hg on the right. Postexercise pressures were markedly elevated and showed a retarded return toward the pre-exercise level.

Subcutaneous fasciotomies of both anterior compartments were performed. Six weeks after operation the patient was asymptomatic. A repeat pressure test during exercise at this time revealed a normal response. The patient returned to full training and competition. He placed in the top five in the Pan American games six months after surgery and at this writing is a strong candidate for the United States Olympic race walking team.

Surgery for Compartmental Syndromes at the University of Washington

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