Wright State University Sports Medicine Blog


The pressure is building

There are two types of compartment syndrome. One that can be life and limb threatening, acute compartment syndrome, and one that is a chronic condition called exertional compartment syndrome.

Chronic exertional compartment syndrome is uncommon and is an exercise induced neuromuscular condition. It causes pain, swelling and sometimes can disable the muscles in the arm and legs. Any person can develop exertional compartment syndrome but it is more common in athletes; especially those who participate in repetitive movements like running, biking and swimming.

In chronic exertional compartment syndrome, exercise or even repetitive muscle contraction causes the tissue pressure within a compartment to increase to an abnormally high level. But because the fascia can’t stretch, the tissues in that compartment aren’t able to expand sufficiently under the increased pressure. As the pressure builds up within one of your muscle compartments, with no outlet for release, nerves and blood vessels are compressed. Blood flow may then decrease, causing tissues to get inadequate amounts of oxygen-rich blood, a condition known as ischemia. Nerves and muscles may sustain damage. Chronic exertional compartment syndrome isn’t a life-threatening condition and usually doesn’t cause any lasting or permanent damage if you seek appropriate treatment. However, if you continue to exercise despite pain, the repeated increases in compartment pressure can lead to muscle, nerve and blood vessel damage. As a result, you may develop permanent numbness or weakness in affected muscles.

Testing:

A physical exam or imaging studies can’t definitively point to a diagnosis of chronic exertional compartment syndrome, but they can identify or rule out other problems. If you’ve undergone those tests and still haven’t been able to confirm a diagnosis, your doctor may suggest measuring the pressure within your muscle compartments. This test, often called compartment pressure measurement, is the gold standard for diagnosing chronic exertional compartment syndrome. Because it is an invasive, and mildly painful, test that involves insertion of needles into the muscle, compartment pressure measurement usually isn’t performed unless your medical history and other tests strongly suggest you may have this condition.

Treatment:

Conservatively the doctor may initially recommend pain medications, stretching and strengthening regimens. Also massage, orthotics and a break from exercise. Normally these types of changes do not provide long term relief for true chronic exertional compartment syndrome.

Surgical options are the most effective. Surgery involves operating on the fascia; an inelastic tissue encasing each muscle compartment. Surgical methods include either cutting open the fascia of each affected compartment (fasciotomy) or actually removing part of the fascia (fasciectomy). In either case, this release or decompression means the compartment is no longer trapped by the unyielding fascia, giving it room to expand when pressure increases. Although surgery is highly effective for most people, it’s not without risk. Complications of the surgery can include infection, permanent nerve damage, numbness and scarring. In addition, since your muscles will no longer be encased by fascia, they may bulge out during exercise, creating a cosmetic concern.

Acute compartment syndrome occurs after trauma where the tissue pressure within the closed muscle compartments exceeds the allowed pressure and can cause muscle and nerve ischemia. The cycle of events leading to acute compartment syndrome begins when the tissue pressure exceeds the venous pressure and impairs blood outflow. Late manifestations of compartment syndrome include the absence of a distal pulse and hypoesthesia because the cycle of elevating tissue pressure eventually compromises arterial blood flow. If left untreated or if inadequately treated, the muscles and nerve within the compartment undergo ischemic necrosis and a limb contracture; called a Volkmann contracture. This scenario recently happened to the LA Dodgers second baseman as he was attempting a double play and was hit in the lower leg just below his knee by another player. He went from having a routine shin contusion to needing an emergency fasciotomy less than 48 hours later. Early recognition and treatment is imperative. He ended up having a full recovery and was very lucky that his injury was noticed and dealt with in such a short amount of time.

Treatment:

With acute compartment syndrome it depends on the diagnosis time and the time from injury to treatment. It has been reported that almost as full recovery of limb function if the fasciotomy is performed within six hours. A fasciotomy is a surgical procedure where a surgeon goes in and cuts the fascia around the enlarged muscles to relieve the pressure. The longer it takes to have the fasciotomy the less likely the athlete is to return to full participation with full limb function. At 12 hours it is reported that normal limb function was regained in 68% of patients; if any longer than 12 hours and only 8% of patients’ recovery fully.

Interesting Sites:

http://www.mayoclinic.com/health/chronic-exertional-compartment-syndrome/DS00789/DSECTION=treatments-and-drugs

http://emedicine.medscape.com/article/307668-overview#aw2aab6b2b6

http://orthoinfo.aaos.org/topic.cfm?topic=a00204

http://trialexhibitsinc.com/legal-exhibits/compartment-syndrome-the-forearm-p-118.html

NATA News Magazine. Sept. 2012. 12-13


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