Sports Medicine: Just the Facts

• There are important aspects of the patient’s history
  that can guide one to consider the diagnosis of exer-
  tional compartment syndrome.
  
  
  • The patient is usually asymptomatic upon initiating
    exercise. The pain will begin at a predictable time
    during the workout.
  
  
  • The pain is described as aching or cramping associ-
    ated with feelings of swelling, fullness, or tightness.
  
  
  • Dysesthesias often accompany the pain along the
    nerve within the affected compartment.
    •Patients may also complain of altered running style.
    For example, a runner may state that the foot seems
    to be slapping the ground when the pain comes on.
    •Physical examination
  
  
  • The physical examination at rest is often normal. In
    advanced cases, there may be tenderness to deep
    palpation along the affected compartment.
  
  
  • There may be a palpable fascial defect with hernia
    within the affected compartment.
  
  
  • Examination immediately after exercise usually
    reveals a firm, tender compartment with increased
    pain on passive stretch.
    •Fascial defects with resultant herniations are more
    identifiable after exercise.
  
  
  • There may be altered sensation in the distribution of
    the nerve that traverses the affected compartment.
  
  
  
  


• Compartment pressure testing
  
  
  • The most useful diagnostic test in the evaluation for
    exertional compartment syndrome.
    •Several techniques have been described for measur-
    ing compartment pressures: these include needle
    manometry, wick catheter, and slit catheter. Our pre-
    ferred method of measuring compartment pressure
    is with a battery-operated, hand-held, digital, fluid
    pressure monitor. The Stryker Intracompartmental
    Pressure Monitor (Stryker Corporation, Kalamazoo,
    MI) is a convenient and easy to use measuring
    device for use in clinical setting.
    
    
    1. The equipment needed for pressure measure-
       ment includes the stryker pressure monitor and
       a disposable packet designed for use with it
       (sterile 18 gauge needle, diaphragm chamber,
       syringe filled with 3 cc of normal saline).
       Betadine solution, alcohol pads, gauze, a 25–27
       gauge needle and syringe for local anesthesia,
       1% xylocaine without epinephrine and bupivi-
       caine 0.5% for anesthesia.
    
    
    2. The first step is to identify the compartment and
       sterilize the overlying skin.
    
    
    3. The next step is to anesthetize the skin by
       injecting 1–3 mL of 1% lidocaine without epi-
       nephrine subcutaneously being sure to avoid
       penetration of the fascial compartment.
       4. The third step in the process involves preparing
       the monitor unit for insertion and measurement.
       Connect the disposable syringe and the sterile
       needle to the diaphragm transducer. Turn the
       unit on and press the syringe until a drop of
       saline is expressed from the needle tip. Press the
       “zero” button to clear the unit; however, it is
       important to zero at the same angle at which the
       needle will enter the skin.
       5. The measurement should be done by inserting
       the needle at 90° to the anesthetized skin,
       through the fascia and into the appropriate com-
       partment. Inject a small amount of saline to
       ensure a solid fluid column. Wait a few seconds
       for the reading to equilibrate, record the read-
       ing, and remove the needle.
       6. Cover the needle site with a bandage. Instruct
       the patient on postprocedure complications:
       infection, neurologic injury, and vascular injury.
       7. To approach the anterior compartment, palpate
       the tibialis anterior just lateral to the anterior
       tibial border at the level of the mid-third of the
       tibia.
       8. To approach the lateral compartment, palpate
       the muscle bellies of the peroneus longus and
       brevis at the midpoint between the head of the
       fibula and lateral malleolus.
       9. To approach the superficial posterior compart-
       ment, palpate the muscle bellies of the gas-
       trocnemius and soleus. This is a medial
       approach just posterior to the medial border of
       the tibia.
    
    
    
    
  
  
  
  

10. To approach the deep posterior compartment,
    use the same approach as for the superficial
    posterior compartment. This compartment can
    be measured after completing the superficial
    posterior compartment then advancing the
    needle until a second “pop” is felt when the
    fascia is penetrated.

• Compartment pressures should be taken before
  exercise, 1 min after exercise, and if necessary,
  5min after exercise.


• Compartments can be measured based on history;
  for example if the history is suggestive on anterior
  compartment then only that compartment may be
  measured; however, if the symptoms are vague it
  may be necessary to measure all four compartments.


• One or more of the following pressure criteria must
  be met in addition to a history and physical that is
  consistent with the diagnosis of exertional compart-
  ment syndrome. Preexercise pressure >15 mm-Hg,
  1 minpostexercise pressure >30 mm-Hg, or 5 min
  postexercise pressure > 20 mm-Hg.

374 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE