Chronic exertional compartment syndrome
- William P Meehan, III, MD
William P Meehan, III, MD
- Director of The Micheli Center for Sports Injury Prevention
- Division of Sports Medicine, Boston Children's Hospital
- Assistant Professor of Pediatrics and Orthopedics
- Harvard Medical School
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
First described by Mavor in 1956 , chronic exertional compartment syndrome (CECS) is an overuse injury that typically affects young endurance athletes, especially those who run extensively. Like acute compartment syndrome, it is thought to result from increased pressure within the confines of the osteofascial planes of a muscle compartment. CECS occurs primarily in the lower leg, although it has been reported in the upper extremity and elsewhere in the body .
The presentation, diagnosis, and management of chronic exertional compartment syndrome are reviewed here. Acute compartment syndrome is discussed separately. (See "Acute compartment syndrome of the extremities".)
The true prevalence of chronic exertional compartment syndrome (CECS) in the general population is unknown . It is likely that many people suffering from early symptoms of CECS decrease or modify their activity level to manage their condition and never seek medical attention. In addition, CECS is likely under-diagnosed by the coaches, athletic trainers, and primary care physicians to whom symptoms are first presented . The gold standard for diagnosis requires invasive pressure measurements in the affected muscle compartment, something rarely done in training rooms or primary care clinics.
Observational studies provide some sense of the prevalence of CECS among certain populations:
●A retrospective study of active Unites States military personnel reported 4100 cases of CECS between 2006 and 2011, for an incidence rate of 0.49 cases per 1000 person-years . Age was the most significant risk factor with the adjusted incidence rate ratio for personnel over 40 years almost nine times that of personnel under 20 years (IRR 8.77; 95% CI 7.31-10.52). Further study is needed to determine whether comparable results would be found in a civilian adult running population.
- MAVOR GE. The anterior tibial syndrome. J Bone Joint Surg Br 1956; 38-B:513.
- Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med 1997; 31:21.
- Detmer DE. Diagnosis and management of chronic compartment syndrome of the leg. Semin Orthop 1988; 3:223.
- Turnipseed WD. Diagnosis and management of chronic compartment syndrome. Surgery 2002; 132:613.
- Waterman BR, Liu J, Newcomb R, et al. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med 2013; 41:2545.
- Qvarfordt P, Christenson JT, Eklöf B, et al. Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clin Orthop Relat Res 1983; :284.
- Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990; 18:35.
- Styf JR, Körner LM. Diagnosis of chronic anterior compartment syndrome in the lower leg. Acta Orthop Scand 1987; 58:139.
- Touliopolous S, Hershman EB. Lower leg pain. Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Med 1999; 27:193.
- Reneman RS. The anterior and the lateral compartmental syndrome of the leg due to intensive use of muscles. Clin Orthop Relat Res 1975; :69.
- Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med 1985; 13:162.
- Padhiar N, Allen M, King JB. Chronic exertional compartment syndrome of the foot. Sports Med Arthrosc 2009; 17:198.
- Fontes D, Clement R, Roure P. [Endoscopic aponeurotomy for chronic exertional compartmental syndrome of the forearm: report of 41 cases]. Chir Main 2003; 22:186.
- Botte MJ, Fronek J, Pedowitz RA, et al. Exertional compartment syndrome of the upper extremity. Hand Clin 1998; 14:477.
- Birnbaum J. Recurrent compartment syndrome in the posterior thigh. Am J Sports Med 1983; 11:48.
- Black KP, Schultz TK, Cheung NL. Compartment syndromes in athletes. Clin Sports Med 1990; 9:471.
- Shah SN, Miller BS, Kuhn JE. Chronic exertional compartment syndrome. Am J Orthop (Belle Mead NJ) 2004; 33:335.
- Wilder RP, Magrum E. Exertional compartment syndrome. Clin Sports Med 2010; 29:429.
- Matsen FA 3rd, Wyss CR, Krugmire RB Jr, et al. The effects of limb elevation and dependency on local arteriovenous gradients in normal human limbs with particular reference to limbs with increased tissue pressure. Clin Orthop Relat Res 1980; :187.
- Mohler LR, Styf JR, Pedowitz RA, et al. Intramuscular deoxygenation during exercise in patients who have chronic anterior compartment syndrome of the leg. J Bone Joint Surg Am 1997; 79:844.
- Styf J, Körner L, Suurkula M. Intramuscular pressure and muscle blood flow during exercise in chronic compartment syndrome. J Bone Joint Surg Br 1987; 69:301.
- Turnipseed WD, Hurschler C, Vanderby R Jr. The effects of elevated compartment pressure on tibial arteriovenous flow and relationship of mechanical and biochemical characteristics of fascia to genesis of chronic anterior compartment syndrome. J Vasc Surg 1995; 21:810.
- Bong MR, Polatsch DB, Jazrawi LM, Rokito AS. Chronic exertional compartment syndrome: diagnosis and management. Bull Hosp Jt Dis 2005; 62:77.
- Turnipseed W, Detmer DE, Girdley F. Chronic compartment syndrome. An unusual cause for claudication. Ann Surg 1989; 210:557.
- Fronek J, Mubarak SJ, Hargens AR, et al. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res 1987; :217.
- Balduini FC, Shenton DW, O'Connor KH, Heppenstall RB. Chronic exertional compartment syndrome: correlation of compartment pressure and muscle ischemia utilizing 31P-NMR spectroscopy. Clin Sports Med 1993; 12:151.
- Rennerfelt K, Zhang Q, Karlsson J, Styf J. Changes in Muscle Oxygen Saturation Have Low Sensitivity in Diagnosing Chronic Anterior Compartment Syndrome of the Leg. J Bone Joint Surg Am 2016; 98:56.
- Owens S, Edwards P, Miles K, et al. Chronic compartment syndrome affecting the lower limb: MIBI perfusion imaging as an alternative to pressure monitoring: two case reports. Br J Sports Med 1999; 33:49.
- Amendola A, Rorabeck CH, Vellett D, et al. The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med 1990; 18:29.
- Trease L, van Every B, Bennell K, et al. A prospective blinded evaluation of exercise thallium-201 SPET in patients with suspected chronic exertional compartment syndrome of the leg. Eur J Nucl Med 2001; 28:688.
- Takebayashi S, Takazawa H, Sasaki R, et al. Chronic exertional compartment syndrome in lower legs: localization and follow-up with thallium-201 SPECT imaging. J Nucl Med 1997; 38:972.
- Hargens AR, Mubarak SJ, Owen CA, et al. Interstitial fluid pressure in muscle and compartment syndromes in man. Microvasc Res 1977; 14:1.
- Martens MA, Backaert M, Vermaut G, Mulier JC. Chronic leg pain in athletes due to a recurrent compartment syndrome. Am J Sports Med 1984; 12:148.
- Qvarfordt P, Eklöf B, Ohlin P. Reference values for intramuscular pressure in the lower leg in man. Clin Physiol 1982; 2:427.
- Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am 1983; 65:1245.
- Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med 1993; 21:811.
- Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Am J Sports Med 1988; 16:165.
- Almdahl SM, Samdal F. Fasciotomy for chronic compartment syndrome. Acta Orthop Scand 1989; 60:210.
- Mannarino F, Sexson S. The significance of intracompartmental pressures in the diagnosis of chronic exertional compartment syndrome. Orthopedics 1989; 12:1415.
- Sudmann E. The painful chronic anterior lower leg syndrome. A prospective clinical and experimental study. Acta Orthop Scand 1979; 50:573.
- Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin J Sport Med 2006; 16:209.
- Aweid O, Del Buono A, Malliaras P, et al. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clin J Sport Med 2012; 22:356.
- Roberts A, Franklyn-Miller A. The validity of the diagnostic criteria used in chronic exertional compartment syndrome: a systematic review. Scand J Med Sci Sports 2012; 22:585.
- Wiley JP, Short WB, Wiseman DA, Miller SD. Ultrasound catheter placement for deep posterior compartment pressure measurements in chronic compartment syndrome. Am J Sports Med 1990; 18:74.
- Micheli LJ, Solomon R, Solomon J, et al. Surgical treatment for chronic lower-leg compartment syndrome in young female athletes. Am J Sports Med 1999; 27:197.
- Slimmon D, Bennell K, Brukner P, et al. Long-term outcome of fasciotomy with partial fasciectomy for chronic exertional compartment syndrome of the lower leg. Am J Sports Med 2002; 30:581.
- Roscoe D, Roberts AJ, Hulse D. Intramuscular compartment pressure measurement in chronic exertional compartment syndrome: new and improved diagnostic criteria. Am J Sports Med 2015; 43:392.
- Yang LJ, Gala VC, McGillicuddy JE. Superficial peroneal nerve syndrome: an unusual nerve entrapment. Case report. J Neurosurg 2006; 104:820.
- Fabre T, Montero C, Gaujard E, et al. Chronic calf pain in athletes due to sural nerve entrapment. A report of 18 cases. Am J Sports Med 2000; 28:679.
- Ni Mhuircheartaigh N, Kavanagh E, O'Donohoe M, Eustace S. Pseudo compartment syndrome of the calf in an athlete secondary to cystic adventitial disease of the popliteal artery. Br J Sports Med 2005; 39:e36.
- Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med 1988; 16:224.
- Styf JR, Körner LM. Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. J Bone Joint Surg Am 1986; 68:1338.
- Wallensten R, Eklund B. Intramuscular pressures and muscle metabolism after short-term and long-term exercise. Int J Sports Med 1983; 4:231.
- van Zoest WJ, Hoogeveen AR, Scheltinga MR, et al. Chronic deep posterior compartment syndrome of the leg in athletes: postoperative results of fasciotomy. Int J Sports Med 2008; 29:419.
- Waterman BR, Laughlin M, Kilcoyne K, et al. Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. J Bone Joint Surg Am 2013; 95:592.
- Winkes MB, Hoogeveen AR, Scheltinga MR. Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review. Br J Sports Med 2014; 48:1592.