Sports Medicine: Just the Facts

CHAPTER 22 • COMPARTMENT SYNDROME TESTING 133

Anterior Compartment

• Identify the muscle belly of the anterior tibialis just
  lateral to the anterior tibial border. Approach should
  have needle penetrate through fascia and into muscle
  belly of anterior tibialis at the level of the mid third of
  the tibia.


• Anatomical structures to avoid include the neurovas-
  cular bundle containing the deep peroneal nerve, ante-
  rior tibial artery, and veins. This neurovascular bundle
  sits just above the interosseous membrane.

Lateral Compartment

• The muscle bellies of the peroneus longus and brevis
  are palpable on the lateral surface of the leg just
  superficial to the shaft of the fibula.


• Helpful technique to enter this compartment involves
  palpation of the head of the fibula and lateral malleo-
  lus and palpating the muscle bellies at the midpoint
  between these two bony landmarks.


• The superficial peroneal nerve resides within this
  compartment and provides innervation. The lateral
  compartment receives it blood supply from branches
  of the peroneal artery, but does not itself run through
  the lateral compartment.

Posterior Superficial Compartment

• The muscle bellies of the gastrocnemius and soleus
  muscles are easily identified and palpated.


• Approach to this compartment just medial to the mid-
  line will avoid the small saphenous vein and the
  medial and lateral sural cutaneous nerves.


• Branches of the tibial nerve innervate these muscles.

Posterior Deep Compartment

• The approach to the posterior deep is technically more
  difficult because of the proximity of neurovascular
  structures.
  •Two bundles are contained within this compartment
  that should be understood anatomically prior to
  needle insertion. A vascular bundle consisting of the
  peroneal artery and veins lies medial to the posterior
  aspect of the fibula. A neurovascular bundle consist-
  ing of the tibial nerve, posterior tibial artery, and veins
  lies in the posterior aspect of this compartment behind
  the mass of the tibialis posterior muscle.


• The posterior medial aspect of the mid tibia must first
  be palpated. The needle should then be inserted just
  posterior to the tibia, closely approximating the pos-
  terior border of the bone. The needle will first enter
  the flexor digitorum longus muscle and if guided
  deeper will enter the posterior tibialis muscle. As
  long as not driven too deeply, this approach will keep
  the needle anterior and medial to the neurovascular
  structures.

DIAGNOSTIC CRITERIA

• Compartment pressure must be obtained both preex-
  ercise and postexercise. Postexercise pressures should
  be performed immediately after an exercise challenge
  that reproduces the patient’s symptoms.


• Findings consistent with the diagnosis of CECS
  include an elevated resting pressure, and increased
  postexertion pressure, and/or a delayed return to
  normal pressure after exertion.
  •For chronic exertional compartment syndrome, the
  diagnostic criteria described by Pedowitz and col-
  leagues are commonly used (Pedowitz et al, 1990).
  One or more of the following criteria must be met in
  addition to an appropriate history and physical exam-
  ination:
  
  
  1. Preexercise ≥15 mmHg
  
  
  2. 1 min postexercise ≥30 mmHg
  
  
  3. 5 min postexercise ≥20 mmHg
  
  
  
  

DIFFERENTIALDIAGNOSIS

• Stress fractures, periostitis/medial tibial stress syn-
  drome, and tendonitis can usually be differentiated
  from CECS by clinical presentation; however, several
  syndromes present very similar to CECS and must be
  suspected when intracompartmental pressures are
  found to be normal.
  •Nerve entrapment and compression may cause exer-
  tional leg pain. This diagnosis should always be sus-
  pected when patient presents with symptoms
  consistent with CECS, but who has normal pressures.
  
  
  • Common peroneal nerve entrapment presents as
    activity related pain, paresthesias, and/or numbness
    in the anterolateral aspect of the leg.
  
  
  • Superficial peroneal nerve entrapment presents with
    a history very similar to that of CECS of the lateral
    compartment.
  
  
  • Saphenous nerve entrapment presents as medial
    knee and medial leg pain.
  
  
  • Sural nerve entrapment will present with posterior
    calf symptoms and can be almost indistinguishable
    from CECS of the superficial posterior compartment.
  
  
  • Proximal tibial nerve entrapment also presents sim-
    ilar to CECS of the posterior compartment.
  
  
  
  


• Lumbosacral radiculopathy should be suspected in
  athletes with the complaints of leg pain, especially if
  associated with back or buttock discomfort.


• Popliteal artery entrapment is often misdiagnosed as
  chronic posterior exertional compartment syndrome,
  because of the ischemic etiology in the pathogenesis
  of symptoms in both syndromes (Glorioso and
  Wilckens, 2001b).