Practice recommendations
- A patient’s description of symptoms and pattern of occurrence is the most reliable clinical guide. Confirm suspicion of chronic compartment syndrome by documenting intracompartmental pressures. Other diagnostic modalities, though promising, have no place in the work up currently (C).
- Study data are sparse for conservative treatments, which seem largely unsuccessful in common clinical experience. Base any decision to offer conservative therapy on an individual’s circumstances. It is usually impractical to ask competitive athletes to change sports or reduce intensity (C).
- Fasciotomy is an effective treatment for chronic compartment syndrome. Fasciectomy is preferred by some practitioners (C).
Shin splints and stress fractures are injuries we are accustomed to seeing among younger athletes. A less wellknown painful injury becoming more prevalent—perhaps especially among young female athletes—is chronic compartment syndrome (CCS).
The patient’s history offers more important clues to CCS than does the physical exam. Direct measurement of intracompartmental pressure—as described in this article—is the best means of confirming the diagnosis. Because it’s an invasive procedure, first rule out shin splints and other more common disorders. In older, even nonathletic persons, who can also suffer from CCS, the list of disorders to rule out grows longer.
Outpatient surgical treatment relieves the pain of CCS and most often prevents recurrences.
Clinical presentation
The classic presentation of CCS is a young athlete who complains of an aching pain or a crampy ache in the lower leg during exercise, in an area of the leg corresponding to 1 of its 4 compartments (FIGURE 1). Symptoms are bilateral in 70% to 80% of athletes who develop compartment syndrome.1,2,3
Symptom traits vary. Other patients describe a sensation of tightness, and some even notice a swelling or bulge over the affected compartment. Many patients describe a numbness or tingling at the affected site that occasionally radiates to the foot. They also often report a feeling of weakness and, in severe cases, may develop true muscle weakness such as drop foot (slap sign). Less often, patients with CCS report a severe shooting pain.
Symptoms usually resolve within minutes to hours following the cessation of activity. However, they can linger for 1 to 2 days following intense activity, especially when the athlete continues to participate despite symptoms.3
Symptoms follow regular pattern. While the onset of symptoms can vary among CCS sufferers, patients often note that symptoms recur consistently at a specific distance (if running or cycling) or duration of exercise.7 Temporary rest from or complete cessation of the associated activity may relieve symptoms, but a return to full participation inevitably leads to more severe symptoms. Those who ignore symptoms and continue their activity may over weeks or months experience a worsening in severity and an earlier onset of symptoms.2
Clinical exam much less helpful than the history. With most patients who have CCS, the exam is completely normal. In fact, the real value of the exam may be to detect signs associated with other disorders in the differential (TABLE).
However, occasionally positive findings support the diagnosis of CCS. The finding most commonly encountered is muscle herniation, seen in 40% to 50% of patients.7,8 These hernias result from a defect in the overlying fascia and are evidenced by a soft tissue bulge that becomes more prominent with muscle contraction. Hernias can be tender to palpation or asymptomatic.2
Another finding, in the absence of herniation, is tenderness of the affected area when palpated. Less frequently, the examiner may note swelling or tightness over the affected compartment.
A few patients with anterior or lateral compartment syndromes have significant weakness on dorsiflexion.2,8
Examining the patient immediately after exercise may increase the sensitivity of all tests for abnormal sensations and weakness.
TABLE 1
Differential diagnosis for chronic compartment syndrome
| Shin splints |
| Stress fracture |
| Gastrocnemius/Soleus strain |
| Claudication |
| Disk herniation |
| Spinal stenosis |
| Peripheral neuropathy |
| Popliteal artery entrapment syndrome |
| Peroneal nerve entrapments |
| Osteomyelitis |
| Tumor |
Rule out other disorders early
Since confirmatory testing for CCS is invasive, rule out alternative diagnoses before proceeding with the workup. Two much more common diagnoses in young athletes are shin splints and stress fractures. Diffuse tenderness along the posteromedial aspect of the tibia suggests shin splints. Point tenderness along the anterior or posteromedial tibia suggests a stress fracture.
Another common diagnosis to consider in all age groups is disk herniation. Concomitant low back pain or pain that radiates from above the knee in a dermatomal distribution makes this diagnosis more likely. In older patients, spinal stenosis can cause radicular pain that must be distinguished from CCS. A thorough neurologic examination is imperative to rule out these conditions.