Sports Medicine: Just the Facts

CHAPTER 22 • COMPARTMENT SYNDROME TESTING 131

• Characterized by recurrent episodes of a transient
  elevation in the intracompartmental pressure, which
  subsides with rest or cessation of activity.
  •Any athlete can develop CECS; however, runners are
  most commonly affected (Martens and Moeyersoons,
  1990; Detmer et al, 1985; Pedowitz et al, 1990).


• Although compartment syndrome testing is useful in
  the diagnosis of acute compartment syndrome, the
  following discussion applies to the use of intracom-
  partmental pressure measurements for the chronic
  exertional form of compartment syndrome.

THE LEG COMPARTMENTS

• The leg contains four anatomically distinct muscle
  compartments with structural support provided by the
  tibia and fibula. Each compartment is covered by a
  tight fascia.


• The anterior compartment contains muscles used for
  extension of the toes and dorsiflexion of the ankle: the
  tibialis anterior, the extensor hallucis longus, and the
  extensor digitorum longus. Blood supply to the ante-
  rior compartment is from the anterior tibial artery. The
  deep peroneal nerve provides innervation as it passes
  through the compartment.


• The lateral compartment contains the evertors of the
  foot: the peroneus longus and the peroneus brevis.
  Nerve supply is via the superficial peroneal nerve.
  Blood supply is from branches of the peroneal artery.


• The superficial posterior compartment contains the
  plantarflexors of the foot: the gastrocnemius, soleus,
  and plantaris. These muscles are supplied by branches
  of the tibial nerve.


• The deep posterior compartment contains the muscles
  of toe flexion, ankle plantarflexion and inversion, the
  flexor hallicus longus, the flexor digitorum longus,
  and the tibialis posterior. These muscles are supplied
  by the tibial nerve and posterior tibial artery.
  •A 5th compartment has been described. The fascia
  surrounding the posterior tibialis has been described
  as a separate and distinct compartment (Davey,
  Rorabeck, and Fowler, 1984).

PATHOPHYSIOLOGY

• Four factors have been identified that may contribute
  to an increase in the intracompartmental pressure seen
  during exercise (McDermott et al, 1982):
  
  
  1. Enclosure of compartmental contents in an inelas-
     tic fascial sheath
  
  
  2. Increased volume of the skeletal muscle with exer-
     tion resulting from blood flow and edema
  
  
  3. Muscle hypertrophy as response to exercise
  
  
  4. Dynamic contraction factors due to the gait cycle
     
     
     • The transient increase in pressure within the myofas-
       cial compartment compromises blood flow. When
       tissue perfusion is not adequate to meet the metabolic
       demands, the result is traversing neurologic and mus-
       cular ischemia, pain, and impairment of muscular
       function.
     
     
     
     
  
  
  
  

CLINICALPRESENTATION

• In chronic exertional compartment syndrome, the
  characteristic complaint is recurrent exercise induced
  leg discomfort that occurs at a well-defined and repro-
  ducible point of activity and increases if the training
  persists.


• The quality of pain is described as a tight, cramplike,
  or squeezing ache over a specific compartment of the
  leg. Relief of symptoms occurs only with discontinu-
  ation of activity.


• Neurologic complaints such as paresthesias of the leg
  or foot with exertion may indicate involvement of the
  nerve traversing the compartment.
  •Nerve entrapment syndromes of the lower extremity
  often present with similar complaints and should be
  included in the differential diagnosis.


• At rest, the physical examination is commonly unre-
  markable with a normal gait and normal lower
  extremity examination. A muscle herniation through a
  fascial defect may be the only clinical abnormality
  noted.


• An exercise challenge followed by post exercise clin-
  ical examination is helpful in establishing the diagno-
  sis (Glorioso and Wilckens, 2001a).
  
  
  • After reproduction of discomfort, the athlete should
    be assessed for tenderness, tightness, and swelling
    over the involved compartment.
  
  
  • The tenderness noted should involve the muscle
    mass and not the bone or muscle–tendon junction.
  
  
  • Neurologic and vascular examination should be
    completed.
  
  
  
  


• Though history may be suggestive of CECS, no
  physical examination finding can firmly establish
  the diagnosis (Styf and Korner, 1987; Kiuru et al,
  2003). Diagnosis based solely on clinical presenta-
  tion can lead to misdiagnosis, inappropriate therapy,
  and/or delay of proper therapy (Pedowitz et al,
  1990).

INDICATIONS FORINTRACOMPARTMENTALPRESSURE

MEASUREMENTS

•Any patient with clinical evidence of CECS should be

considered for intracompartmental testing.

• Significant historical features include a recurrent,
  exercise induced leg discomfort which increases as
  the training persists and dissipates on cessation of
  activity.