Orthopedics

Case Report 

Chronic Exertional Compartment Syndrome with Medial Tibial Stress Syndrome in Twins

Purnajyoti Banerjee, MBBS, Dorth, MRCS(Ed); Christopher Mclean, FRCS

Abstract

Chronic exertional compartment syndrome and medial tibial stress syndrome are uncommon conditions that affect long-distance runners or players involved in team sports that require extensive running. We report 2 cases of bilateral chronic exertional compartment syndrome, with medial tibial stress syndrome in identical twins diagnosed with the use of a Kodiag monitor (B. Braun Medical, Sheffield, United Kingdom) fulfilling the modified diagnostic criteria for chronic exertional compartment syndrome as described by Pedowitz et al, which includes: (1) pre-exercise compartment 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. Both patients were treated with bilateral anterior fasciotomies through minimal incision and deep posterior fasciotomies with tibial periosteal stripping performed through longer anteromedial incisions under direct vision followed by intensive physiotherapy resulting in complete symptomatic recovery. The etiology of chronic exertional compartment syndrome is not fully understood, but it is postulated abnormal increases in intramuscular pressure during exercise impair local perfusion, causing ischemic muscle pain. No familial predisposition has been reported to date. However, some authors have 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. We believe this is the first report of chronic exertional compartment syndrome with medial tibial stress syndrome in twins, raising the question of whether there is a genetic predisposition to the causation of these conditions.

Messrs Banerjee and Mclean are from South West London Elective Orthopadic Centre, Epsom, Surrey, United Kingdom.

Messrs Banerjee and Mclean have no relevant financial relationships to disclose.

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 activities.

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 muscle hernias.

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.…

Chronic Exertional Compartment Syndrome with Medial Tibial Stress Syndrome in Twins

Abstract

Chronic exertional compartment syndrome and medial tibial stress syndrome are uncommon conditions that affect long-distance runners or players involved in team sports that require extensive running. We report 2 cases of bilateral chronic exertional compartment syndrome, with medial tibial stress syndrome in identical twins diagnosed with the use of a Kodiag monitor (B. Braun Medical, Sheffield, United Kingdom) fulfilling the modified diagnostic criteria for chronic exertional compartment syndrome as described by Pedowitz et al, which includes: (1) pre-exercise compartment 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. Both patients were treated with bilateral anterior fasciotomies through minimal incision and deep posterior fasciotomies with tibial periosteal stripping performed through longer anteromedial incisions under direct vision followed by intensive physiotherapy resulting in complete symptomatic recovery. The etiology of chronic exertional compartment syndrome is not fully understood, but it is postulated abnormal increases in intramuscular pressure during exercise impair local perfusion, causing ischemic muscle pain. No familial predisposition has been reported to date. However, some authors have 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. We believe this is the first report of chronic exertional compartment syndrome with medial tibial stress syndrome in twins, raising the question of whether there is a genetic predisposition to the causation of these conditions.

Messrs Banerjee and Mclean are from South West London Elective Orthopadic Centre, Epsom, Surrey, United Kingdom.

Messrs Banerjee and Mclean have no relevant financial relationships to disclose.

Correspondence should be addressed to: Purnajyoti Banerjee, MBBS, Dorth, MRCS(Ed), South West London Elective Orthopadic Centre, 28 Singleton Close, London SW17 9JY, United Kingdom.
Posted Online: June 14, 2011

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 activities.

Case Reports

Patient 1

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 muscle hernias.

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 ).

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 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.)

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.)

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 soon after.

Patient 2

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 activities.

Discussion

Chronic exertional compartment syndrome most commonly occurs in long distance runners and players involved in team sports that require extensive running. 1 Detail history taking and physical examination are essential in making the diagnosis, which is confirmed with a formal compartment pressure testing.

Both the patients reported in this article fulfilled the modified diagnostic criteria for chronic compartment syndrome as reported by Pedowitz et al, 2 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. 3 Some authors have, however, found that no significant difference exists in the relative perfusion, in patients, diagnosed with chronic exertional compartment syndrome. 4 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. 5

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. 6,7

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. 8 Surgical management involves fasciotomy of the affected compartments. Fasciotomy is the only definitive treatment of chronic exertional compartment syndrome. 9 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. 10

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. 11 Other etiological factors associated with medial tibial stress syndrome include female sex and pronated feet. 12 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. 13 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. 12

References

  1. 1. Fraipont MJ, Adamson GJ. Chronic exertional compartment syndrome. J Am Acad Orthop Surg. 2003; 11(4):268–276.
  2. 2. Pedowitz RA, Hargens AR, Mubarak SJ, Gershumi DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990; 18(1):35–40. doi: 10.1177/036354659001800106 [CrossRef]
  3. 3. Shah SN, Miller BS, Kuhn JE. Chronic exertional compartment syndrome. Am J Orthop (Belle Mead NJ). 2004; 33(7):335–341.
  4. 4. Trease L, van Every B, Bennell K, et al. A prospective blinded evaluation of exercise thallium-201 SPET in patients with suspected chronic exertional compartment syndrome of the leg. Eur J Nucl Med. 2001; 28(6):688–695. doi: 10.1007/s002590100527 [CrossRef]
  5. 5. Amendola A, Rorabeck CH, Vellett D, Vezina W, Rutt B, Nott L. The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med. 1990; 18(1):29–34. doi: 10.1177/036354659001800105 [CrossRef]
  6. 6. Schepsis AA, Martini D, Corbett. Surgical management of exertional compartment syndrome of the lower leg. Am J Sports Med. 1993; 21(6):811–817. doi: 10.1177/036354659302100609 [CrossRef]
  7. 7. Englund J. Chronic compartment syndrome: tips on recognizing and treating. J Fam Pract. 2005; 54(11):955–960.
  8. 8. Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin J Sport Med. 2006; 16(3):209–213. doi: 10.1097/00042752-200605000-00004 [CrossRef]
  9. 9. Kitajima I, Tachibana S, Hirota Y, Nakamichi K, Miura K. One-portal technique of endoscopic fasciotomy: Chronic compartment syndrome of the lower leg. Arthroscopy. 2001; 17(8):33. doi: 10.1053/jars.2001.25261 [CrossRef]
  10. 10. Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am. 1983; 65(9):1245–1251.
  11. 11. Bouché RT, Johnson CH. Medial tibial stress syndrome (tibial fasciitis): a proposed pathomechanical model involving fascial traction. J Am Podiatr Med Assoc. 2007; 97(1):31–36.
  12. 12. Yates B, White S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med. 2004; 32(3):772–780. doi: 10.1177/0095399703258776 [CrossRef]
  13. 13. Moen MH, Tol JL, Weir A, Steunebrink M, De Winter TC. Medial tibial stress syndrome: a critical review. Sports Med. 2009; 39(7):523–546. doi: 10.2165/00007256-200939070-00002 [CrossRef]

10.3928/01477447-20110427-33

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