Chronic Exertional Compartment Syndrome

Chronic Exertional Compartment Syndrome
And Exertional leg pain

1. 1 Chronic Exertional Compartment Syndrome Ahmed Youssef Mubarak Alkabeer Hospital

2. Outline Designed by Graphic Node Definition Anatomy Pathophysiology History and Physical Exam Diagnostic Evaluation DD Treatment

3. Definition Designed by Graphic Node Reversible ischemia secondary to a noncompliant osteofascial compartment that is unresponsive to the expansion of muscle volume that occurs with exercise

4. Epidemiology Designed by Graphic Node CECS is most common in young adult recreational runners, elite athletes, and military recruits Bimodal distribution (20 vs. 48 years). Male>Female Associated with sports (Running) Diabetic patients with exertional leg pain and normal vascular studies may have CECS

5. Location Designed by Graphic Node Can present in various regions of the body Lower leg, thigh, foot, and forearm Lower leg (anterior compartment) most common region affected. Bilateral lower leg involvement commonly occurs.

6. 40-60% 4,5 32-60% 4,5 12-35% 4,5 2-20% 4,5 Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000. Anatomy

7. Pathophysiology Designed by Graphic Node ↓↓Compliance of facial structures → ↑ ↑ Compartment pressure Reduced microcirculatory capacity Vascular congestion as a result of decreased venous return ↑↑ muscle volume (Anabolic steroid and creatine use)

8. CLINICAL EVALUATION Designed by Graphic Node Typical patient with CECS is Competitive runner, 20 to 30 years old, Exercise-induced burning pain ↑↑ after 20 to 30 minutes of running. The pain usually resolves within 15 to 30 minutes of cessation of exercise. Paresthesias of the nerves running through the involved compartment often are reported.

9. Signs of CECS Designed by Graphic Node Patients should be examined after completing the exercise Tenderness over the musculature of the involved compartment Muscle herniation through defects in fascia may be palpated Diminished sensation along the affected nerve. Weakness is often reported

10. COMPARTMENT PRESSURE TESTIING Pedowitz criteria (One or more required): Resting pressure > 15 mm Hg 1-minute postexercise > 30 mm Hg 5-minute postexercise > 20 mm Hg

11. Other investigations Designed by Graphic Node Useful to eliminate other pathology Xrays,MRI,Bone scan MRI in-scanner exercise protocol —>>(smoothing and segmentation of bone and blood vessels useful for screening)

12. Differential Diagnosis Designed by Graphic Node Medial tibial stress syndrome (shin splints) —vague diffuse pain reduced with training Stress fracture —Xrays & Bone scan(localized, intense uptake) Periostitis —Bone scan, with diffuse uptake often covering outer third of the bone. Superficial peroneal nerve syndrome pain during active, resisted dorsiflexion and eversion of the ankle, Tinel sign also may be positive

13. Differential Diagnosis Designed by Graphic Node Tenosynovitis (Achilles tendon, peroneal tendon, or tibialis posterior) Lumbosacral radiculopathy — Lumbar tension signs Popliteal artery entrapment syndrome —(vascular studies) Deep venous thrombosis Neurogenic & Vascular claudication Others (Infection, Myopathy, Tumors)

14. Treatment Designed by Graphic Node Conservative Interventional Surgery

15. Conservative Treatment Designed by Graphic Node Limiting activity to a level that avoids all but minimal symptoms. Antiinflammatory medications Stretching and strengthening of the involved muscles Orthotics

16. Treatment(Interventional) Designed by Graphic Node The American journal of sports medicine. Nov 2013;41(11):2558-2566. medicine. Nov 2013;41(11):2558-2566.

17. OPERATIVE TREATMENT Designed by Graphic Node Single incision (open) technique One or two incision (subcutaneous) technique Endoscopic Compartment release (Removal of a strip of fascia)

18. SINGLE-INCISION FASCIOTOMY for Ant.&Lat. CECS Designed by Graphic Node Incision between tibial crest and fibular shaft, over anterolateral intermuscular septum, when no fascial hernia exists. In presence of fascial hernia, incision is directly over fascial defect. Defect is enlarged across intermuscular septum (1). and E , Complete longitudinal release of anterior compartment (2 and 3) and lateral compartment (4 and 5).

19. DOUBLE MINI-INCISION FASCIOTOMY for anterior CECS Designed by Graphic Node Two vertical 2-cm skin incisions (15cm apart). Development of subcutaneous flap with blunt dissection. Skin retraction to allow fasciotomy under direct vision. After wound closure.

20. Designed by Graphic Node A transverse incision at the anterolateral aspect of the knee between the fibular head and Gerdy’s tubercle is used to access the anterior and lateral compartments. The deep fascia encasing the compartment is exposed. The balloon dissector is inserted down to the level of the ankle under direct palpation The balloon is inflated. Endoscopic Compartment release for CECS

21. Endoscopic Compartment release for CECS Designed by Graphic Node Anterior compartment release in a left leg. The black arrow points to the intermuscular septum between the anterior and lateral compartments. The white arrow denotes the superficial peroneal nerve exiting the fascia of the lateral compartment distally. Endoscopic visualization of the posterior fascia of a left leg. The black arrow denotes the deep posterior release directly off the tibia. The white arrow denotes the superficial posterior compartment release.

22. Designed by Graphic Node POD 1-2 The limb is elevated for 24 to 48 hours and ice is applied
Gentle active and passive ROM, weight bearing as tolerated
Basic activities of daily living POD 3-4 Achieve independence with activities of daily living, and begin unassisted ambulation Weeks 1-4 Add stair climbing and increase walking distance Weeks 4-6 Begin non-impact lower extremity aerobic exercise Weeks 6+ Initiate unrestricted impact lower extremity activities Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000. Post Operative Care

23. Complications of Surgery Designed by Graphic Node Infection Nerve (SPN) most common or vascular injury Deep vein thrombosis Wound dehiscence Complex regional pain syndrome Scar hypersensitivity Seroma/hematoma formation

24. Tibial Stress Syndrome (Shin Splints) Overuse injury or repetitive-load injury of the shin area that includes: medial (posteromedial) tibial stress syndrome (most common) anterior (anterolateral) tibial stress syndrome

25. 60% of leg pain syndromes Vague, diffuse pain along middle-distal tibia that decreases with running Radiographs to exclude stress fracture Differentiate from stress fracture, which shows "dreaded black line" Tibial Stress Syndrome (Shin Splints)

26. Triphasic bone scan: to exclude stress fracture Diffuse, longitudinal increased uptake along posteromedial border of tibia in   delayed phase MRI: periosteal edema, progressive marrow involvement Tibial Stress Syndrome (Shin Splints)

27. Treatment Nonoperative treatment: First line of treatment and successful in vast majority Activity modification with shoe modification Operative: Failed non operative treatment Deep posterior compartment fasciotomy + release of painful portion of periosteum

28. Take Home Messages Designed by Graphic Node CECS is most common in young adult recreational runners, elite athletes, and military recruits. Diabetic patients with exertional leg pain and normal vascular studies may have CECS. Anterior compartment of lower leg most common region affected. Bilateral affection is common.

29. Take Home Messages Designed by Graphic Node Exercise-induced burning pain↑↑ after 20 to 30 minutes of running. The pain usually resolves within 15 to 30 minutes of cessation of exercise. D.D.: Tibial stress syndrome—-> pain ↓↓ with activity. Fasciotomy (SC,open,endoscopic ) will resolve the problem.

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