Chronic Exertional Compartment Syndrome of the Lower Extremity: Diagnosis and Surgical Treatment.

Background: Chronic exertional compartment syndrome of the lower extremity is a condition that characteristically presents as recurrent anterior, posterior, and/or lateral lower-extremity pain on repetitive activity and physical exertion¹. This condition is commonly seen in athletes, runners, and military personnel². Open fasciotomy has been demonstrated to be a highly effective surgical treatment for patients with this condition who do not experience symptomatic relief after a thorough trial of nonoperative treatment³.

Description: Diagnostic compartment pressure management is achieved through direct insertion of a compartment-pressure-measuring device into the anterior, lateral, and posterior compartments of the lower extremity⁴. Surgical treatment of the anterior and lateral compartments with use of open fasciotomy employs longitudinal proximal and distal incisions that are made on the lateral surface of the leg approximately 3 finger-breadths distal and proximal to the fibular flare, respectively, and 3 finger-breadths lateral to the tibial crest. Surgical treatment of the posterior compartments with use of open fasciotomy employs a single, mid-shaft incision made approximately 2.5 cm medial to the tibial ridge. Dissection is carried down to the deep fascia at both sites, beginning at the distal operative site. Care is taken to avoid transection of the superficial peroneal nerve at the distal anterolateral incision and saphenous vein and nerve at the medial incision. Once down to the deep fascia, a scalpel is utilized to incise the fascia. Metzenbaum scissors are then employed under the incision, spreading the scissors while sliding them over the muscles proximally and distally to release the muscular attachments from the fascia as well as to release the fascia itself³. This process is repeated in the anterior, lateral, and superficial posterior compartments through the proximal and distal incisions. In the deep posterior compartment, the fascia is released from the tibial ridge with a large Cobb elevator. Closure is achieved with deep dermal and superficial sutures.

Alternatives: Nonoperative alternatives have been reported to include nonpharmacological modalities such as walking modification and shoe inserts, pharmacological therapy with nonsteroidal anti-inflammatory drugs, and physical therapy targeted at conditioning the lower extremity⁵. Nonoperative intervention has been demonstrated to increase endurance in select patients; however, most patients must either stop the activity associated with the compartment syndrome altogether or proceed to surgery for complete resolution of symptoms⁵. There are a few surgical alternatives that differ in their utilization of minimally invasive approaches versus a direct open approach⁶; however, all existing surgical treatments of this condition involve physical release of the fascial compartment.

Rationale: Diagnostic compartment-pressure measurement is useful in confirming or ruling out the presence of this condition in patients with unclear symptoms⁴. Furthermore, diagnostic compartment-pressure management ensures accuracy in diagnosis and validates invasive treatment when patients desire surgical intervention. Surgical management of exertional compartment syndrome of the lower extremity is indicated in patients when nonoperative treatment has failed despite clinically notable symptoms and objectively elevated lower-extremity compartment pressures. Open fasciotomy has been postulated to prevent compression of local vasculature and effectively prevent ischemia; however, the definitive mechanism is unclear¹.

Expected outcomes: Surgical treatment of chronic exertional compartment syndrome with use of open fasciotomy is highly successful in the civilian population. One study showed excellent return to activity/sport in 15 of 16 patients (25 of 26 limbs; 96%), with patients often reporting no symptoms postoperatively³. Military personnel have been reported to experience satisfactory results, with another study showing positive subjective feedback in 35 (76%) of 46 patients on long-term follow-up; however, only 19 patients (41%) were able to return to full active duty postoperatively⁷.

Important tips: Balloting the fascial compartment with ∼1 cc of saline solution can be helpful in determining successful placement of the pressure-measuring device at the time of needle entry.Identifying the course of the superficial peroneal nerve via physical examination can help avoid iatrogenic injury to this important superficial structure during the dissection leading to the distal fasciotomy.Deep posterior compartment release with use of open fasciotomy may not provide symptomatic relief; patients who demonstrate elevation of pressures in this specific compartment should be counseled accordingly.

Acronyms & abbreviations: ROM = range of motionSPN = superficial peroneal nerve.