What is the suspected diagnosis?

Chronic exertional compartment syndrome (CECS). It is defined as “reversible ischemia secondary to a non-compliant osseofascial compartment that is unresponsive to the expansion of muscle volume that occurs with exercise [1].”

• Pearl: CECS is most commonly seen in younger age groups and most commonly affects distance runners and military personnel. It is often reproducible by the patient and they will begin to recognize a pattern in the onset of symptoms after a certain amount of time or distance [2].

• Pearl: The MR imaging in figure 1 does show swelling and increased signal intensity in the anterior and lateral compartments following exercise. MR imaging is not routinely used for the diagnosis of CECS and likely will not be used in the ED to make the diagnosis.

Figure 1. MR of the bilateral legs. Case courtesy of Dr. Owen Kang, Radiopaedia.org, rID:22182

What history and physical exam findings are expected?

Typically the patient will report symptoms of pain, tightness, cramps, weakness, and diminished sensation typically over a specific compartment or compartments of the lower leg commonly  experienced bilaterally [3]. Other neurologic symptoms can include temporary foot drop and/or paresthesias secondary to affected nerves in those compartments. The physical exam is often benign as the symptoms the patient experiences will resolve with rest [2,3]. Complete resolution of the pain is key to making this diagnosis and will occur within 45 minutes or less of rest [4].

• Pearl: Click to review the anatomy of the lower leg and the associated compartments.

How is the diagnosis made?

The diagnosis of CECS is made by an exercise challenge provoking symptoms and elevated compartment pressures following exercise challenge. A convincing history and physical along with one or more of the following are used to make the diagnosis [1]:

1. Pre-exercise pressure 15mmHg or higher

2. 1 minute post exercise pressure 30mmHg or higher

3. 5 minute post exercise pressure 20mmHg or higher

• Sports Pearl: Compartment pressures should be measured bilaterally in the following anatomic locations:

• Anterior Compartment: 1 cm lateral to the anterior border of the tibia

• Lateral Compartment: Just anterior to the posterior border of the fibula

• Deep Posterior Compartment: Just posterior to the medial border of the tibia

• Superficial Posterior Compartment: Middle of the gastrocnemius

Figure 2. Author’s own image

What is the management in the ED?

If the patient is evaluated immediately after exercise and symptoms are still ongoing, compartment pressure can be measured based on institutional practice and provider skillset though proper timing after exercise is crucial for a valid test. In this case, the patient can be discharged and referred for outpatient follow-up with sports medicine to confirm the diagnosis. No further ED management is needed. 

• Pearl: Caution the patient to avoid exercise that provokes their symptoms as it can lead to significant morbidity such as permanent nerve damage or even amputation. A sports physician can properly guide the patient back to sport with outpatient management.

What is the outpatient management?

Management can be surgical or non-surgical. Non surgical management includes rest, anti-inflammatories, manual therapy and soft tissue release, stretching and strengthening of the involved muscles, and orthotics [1]. Surgical management includes fasciotomy of the affected compartment [1].