This article presents 2 cases of chronic exertional compartmental syndrome, with medial tibial stress syndrome in identical
twin brothers. Chronic exertional compartment syndrome was confirmed with ambulatory intracompartmental pressure measurements.
They were treated surgically with decompressing fasciotomies of the affected compartments along with tibial periosteal stripping
in the painful areas. This resulted in symptomatic relief, in both patients, and they returned to full occupational and sporting
A 28-year-old male police officer presented with exercise-induced pain in both legs of 2-years’ duration, since he joined
the police force. His pain had worsened over time, restricting him from playing rugby and football. He also failed riot squad
fitness test due to the same problem. He reported no numbness or pins and needles in his legs. On examination, he had a body
mass index (BMI) of 33. He had tenderness along the posteromedial border of the distal half in both tibiae. There were no
Neurological and vascular examinations of the leg were normal. Conservative measures including physiotherapy and off-shelf
insoles offered no relief. Ambulatory intracompartment pressure measurements were performed to the most symptomatic right
leg. The anterior and deep compartment pressures recorded at rest and after running at 8 km per hour on a treadmill. He underwent
bilateral anterior fasciotomies through minimal incision (Figure ). Deep posterior fasciotomies with tibial periosteal stripping were performed through longer anteromedial incisions under
direct vision (Figure ).
Figure 1:. Fasciotomy of the Anterior Compartment with 2 Minimal Incisions. (Reprinted with Permission from Rorabeck et al. The Surgical
Treatment of Exertional Compartment Syndrome in Athletes.
J Bone Joint Surg Am. 1983; 65(9):1245–1251. Copyright © 1983, The Journal of Bone and Joint Surgery, Inc.)
Figure 2:. Stripping of the Tibial Periosteum Performed Through a Large Incision for Medial Tibial Stress Syndrome. (Reprinted with Permission
from Yates et al. Outcome of Surgical Treatment of Medial Tibial Stress Syndrome.
J Bone Joint Surg Am. 2003; 85(10):1974–1980. Copyright © 2003, The Journal of Bone and Joint Surgery, Inc.)
The patient underwent intensive physiotherapy commencing 1 week postoperatively. Follow-up was conducted at 2 and 12 weeks.
He returned to full sporting activities with no further problems and was expecting to re-take his riot squad fitness test
The twin brother of patient 1, an office administrator, presented with a similar 4-year history of exercise-induced pain in
both legs. Symptoms affected him in recreational rugby and football. His pain was aggravated on bending down or walking up
or down the stairs. On examination, he had tenderness in the posteromedial border of the distal half of his tibia to the ankle.
He had no neurological or vascular deficit. His BMI was 30. He had tenderness in the posteromedial border of the distal half
of his tibia. He had no neurological or vascular defect.
Ambulatory intracompartment pressure measurement with an intracompartmental catheter attached to a portable monitor allowing
for both single and continuous monitoring was performed. His right anterior and deep compartment pressures were recorded at
rest and after running at 8 km per hour on a treadmill.
He underwent bilateral fasciotomies and medial tibial periosteal stripping followed by intensive physiotherapy commencing
1 week postoperatively. Follow-up was conducted at 6 and 12 weeks postoperatively, by which time he had returned to full sporting
Chronic exertional compartment syndrome most commonly occurs in long distance runners and players involved in team sports
that require extensive running.
Detail history taking and physical examination are essential in making the diagnosis, which is confirmed with a formal compartment
Both the patients reported in this article fulfilled the modified diagnostic criteria for chronic compartment syndrome as
reported by Pedowitz et al,
which includes: (1) pre-exercise pressure level >15 mm Hg; (2) 1 minute post-exercise pressure >30 mm Hg; and (3) 5 minutes
post-exercise pressure >20 mm Hg in the presence of clinical features.
Chronic exertional compartment syndrome can occur in any fascia enclosed muscle compartment, if used for long periods, repetitively.
Chronic exertional compartment syndrome of the lower leg is an important problem as it prevents the affected athletes from
running with full potential. The etiology of chronic exertional compartment syndrome is not fully understood, but it is postulated
that abnormal increases in intra-muscular pressure during exercise impair local perfusion, causing ischemic muscle pain. It
usually occurs in young athletes but can present in older people and non-athletes.
No familial predisposition has been reported to date.
Some authors have, however, found that no significant difference exists in the relative perfusion, in patients, diagnosed
with chronic exertional compartment syndrome.
Magnetic resonance images of affected compartments have indicated that the pain is not due to ischemia, but rather from a
disproportionate oxygen supply versus demand.
The differential diagnosis for chronic exertional compartment syndrome includes stress fractures, medial tibial periostalgia,
tendinitis, nerve entrapment disorders, fascial herniations, vascular or neurogenic claudication, popliteal artery entrapment,
and venous stasis.
Chronic exertional compartment syndrome is not limb or life threatening. Conservative treatment primarily involves activity
modification with or without ice, taping, use of orthotics, stretching, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Unless patients are willing to avoid the offending activity, nonoperative management of chronic exertional compartment syndrome
is often unsuccessful.
Surgical management involves fasciotomy of the affected compartments. Fasciotomy is the only definitive treatment of chronic
exertional compartment syndrome.
Several techniques are described, including 1-incision, 2-incision, and percutaneous endoscopic techniques. The fascia can
be released under direct vision, with a fasciotome, or with scissors percutaneously avoiding injury to the superficial peroneal
nerve. The 2 most commonly affected compartments are the anterior and the deep posterior compartments. The overlying fascia
of the affected compartments must be released completely.
Medial tibial stress syndrome is defined as exercise-related pain in the posteromedial tibia commonly seen in athletes. This
syndrome has been poorly defined and has previously been referred to as shin splints. Medial tibial stress syndrome is usually
due to overuse and is not caused from an acute injury. Two popular theories have been proposed to account for this condition:
tibial bending and fascial traction.
Other etiological factors associated with medial tibial stress syndrome include female sex and pronated feet.
No familial distribution has ever been reported.
Medial tibial stress syndrome is characterized by pain and tenderness along the posteromedial tibial border. Runners and athletes
involved in jumping activities are prone to develop this syndrome. Increased stress used to stabilize the foot when excessive
pronation is present could explain the occurrence of this condition.
Treatment comprises of patients being advised relative rest. This involves a significant decrease in the activity level,
but not cessation of activities. During that time, the patient may benefit from a NSAID and icing of the posteromedial tibia
after exercise. Additionally, they may benefit from physical therapy modalities. Surgical intervention is reserved for patients
who have failed conservative management. This involves either release of the soleus fascia on the posteromedial border of
the tibia or excision of a strip of periosteum from the posteromedial tibial border.