Chronic Exertional Compartment Syndrome
Exertional lower leg pain is a commonly diagnosed overuse injury in recreational runner and in the military with an incidence of 27-33% of all lower leg pain presentations. Typically, runners will present with increasing pain on exercise, which is described as ‘tightness’, or ‘constricting pain’. Symptoms can increase with up-hill running or by increasing running speed with a fixed cadence. Symptoms tend to worsen to a point when you are no longer able to run. The pain and symptoms are eased by rest and occasionally can present with short term numbness or weakness or foot slapping, however these usually settle quickly. Classically you are pain free when not exercising. The underlying pathophysiology was thought to be decreased blood flow to the muscle compartment, and termed chronic exertional compartment syndrome (CECS) due to the covering of the muscle – the fascia being too tight or muscle getting too big but to date no evidence of reduced blood flow, or muscle damage due to this has been seen.
has been described in the anterior, peroneal and deep posterior compartments of the lower leg but the anterior is the most commonly detailed but even described in the forearm in rowers and cyclists, and in the foot.
The diagnosis is typically confirmed with intracompartmental pressure measurement but Andy Roberts and I wrote a systematic review of diagnostic pressures which revealed substantial overlap of criteria and significant confounding variables of measurement technique, throwing doubt on the diagnostic process.
Other diagnoses do exist of course, including medial tibial stress syndrome( Commonly referred to as ‘Shin splints’, stress fracture, popliteal artery and common peroneal nerve entrapment which may need to be excluded but these conditions have all proved difficult to treat conservatively with limited success of stretching, acupuncture, massage and activity modification. To date, patients commonly undergo surgical decompression of the compartment by fasciotomy but many of these are unsuccessful – presumably as the pathology is inconsistent.
Recent work on running technique and kinematic and kinetic changes of gait may provide the underlying mechanism behind the propagation of muscle overload. Reduction in the stride length, ground contact time, vertical oscillation and lower extremity angle all contribute to improved running economy, reduced ground reaction force and movement efficiency
Our research has led us to believe that chronic exertional compartment syndrome is a mechanical muscular overload rather than a pathological process and suggest it be considered Biomechanical Overload Syndrome.
We have recently published on our successful treatment of these patients: