Orthopedics

Case Report 

Selective Fasciotomy for Chronic Exertional Compartment Syndrome Detected With Exercise Magnetic Resonance Imaging

Sehan Park, MD; Ho Seong Lee, MD, PhD; Sang Gyo Seo, MD

Abstract

Chronic exertional compartment syndrome that is refractory to conservative management should be treated with surgical fasciotomy. However, owing to the limitations of intracompartmental needle manometry in reaching a definite diagnosis, the appropriate timing for fasciotomy and on which compartment remain unclear. The authors report the case of a 22-year-old male military cadet who reported pain in his left calf when running or walking for long distances. The pain was located at the lateral aspect of the calf, from the mid-calf level to the ankle. At another hospital, nonenhanced magnetic resonance imaging had been performed, which showed no considerable abnormality. The authors used exercise magnetic resonance imaging to diagnose chronic exertional compartment syndrome. They performed selective fasciotomy on the compartment that showed a high signal intensity. As a military cadet, the patient was required to jog for more than an hour per day and perform strenuous muscle exercises. He reported that he did not have calf pain or discomfort during such activities 13 months postoperatively. The authors obtained a follow-up exercise magnetic resonance image. Compared with the preoperative magnetic resonance image, the follow-up exercise magnetic resonance image did not show high signal intensity at the lateral compartment. Exercise magnetic resonance imaging is useful in confirming the diagnosis of chronic exertional compartment syndrome and enables the performance of selective fasciotomy on the affected compartment. [Orthopedics. 2017; 40(6):e1099–e1102.]

Abstract

Chronic exertional compartment syndrome that is refractory to conservative management should be treated with surgical fasciotomy. However, owing to the limitations of intracompartmental needle manometry in reaching a definite diagnosis, the appropriate timing for fasciotomy and on which compartment remain unclear. The authors report the case of a 22-year-old male military cadet who reported pain in his left calf when running or walking for long distances. The pain was located at the lateral aspect of the calf, from the mid-calf level to the ankle. At another hospital, nonenhanced magnetic resonance imaging had been performed, which showed no considerable abnormality. The authors used exercise magnetic resonance imaging to diagnose chronic exertional compartment syndrome. They performed selective fasciotomy on the compartment that showed a high signal intensity. As a military cadet, the patient was required to jog for more than an hour per day and perform strenuous muscle exercises. He reported that he did not have calf pain or discomfort during such activities 13 months postoperatively. The authors obtained a follow-up exercise magnetic resonance image. Compared with the preoperative magnetic resonance image, the follow-up exercise magnetic resonance image did not show high signal intensity at the lateral compartment. Exercise magnetic resonance imaging is useful in confirming the diagnosis of chronic exertional compartment syndrome and enables the performance of selective fasciotomy on the affected compartment. [Orthopedics. 2017; 40(6):e1099–e1102.]

Chronic exertional compartment syndrome (CECS) usually occurs in young athletes.1 When pressure increases at a specific muscle compartment, the intracompartmental neurovascular structure becomes compressed. This causes pain, paresthesia, and a squeezing sensation in the calf that is quickly relieved with rest.2,3

The diagnosis of CECS is based on a clinical history of pain that is aggravated by exercise and relieved with rest.4 The definite diagnosis is generally reached on the basis of the findings of direct intracompartmental needle manometry conducted before exercise and at 1 and 5 minutes after exercise. When the compartment pressure is more than 10 mm Hg before exercise, 30 mm Hg at 1 minute after exercise, and 20 mm Hg at 5 minutes after exercise, then the diagnosis of CECS can be made.5 However, intracompartmental needle manometry has limitations. It is an invasive and painful method. Moreover, the results are affected by the depth of catheter insertion and technique, the timing of measurement in relation to exercise, and ankle position.6–8

Chronic exertional compartment syndrome that is refractory to conservative management, such as resting, physical therapy, gait retraining, and forefoot running,9,10 should be treated with surgical fasciotomy.11,12 However, owing to the limitations of intracompartmental needle manometry in reaching a definite diagnosis, the appropriate timing for fasciotomy and on which compartment remain unclear.

Ringler et al13 performed a validation test by using exercise magnetic resonance imaging (MRI) and reported that exercise MRI had a high reliability and reproducibility for diagnosing CECS. However, to the current authors' knowledge, there has been no study reporting the results of selective fasciotomy based on diagnosis with exercise MRI.

The authors report the case of a 22-year-old male military cadet. Exercise MRI was used to diagnose CECS in this patient. The authors performed selective fasciotomy on the compartment that showed a high signal intensity.

Case Report

The patient was to be commissioned as a military officer a year after his presentation. He regularly ran for more than an hour per day. His height was 185 cm, weight was 71 kg, and body mass index was 20.74 kg/m2.

The patient reported pain in his left calf when running or walking for long distances. The symptom started 4 years before his first visit, and he had no trauma history. The pain was located at the lateral aspect of the calf, from the mid-calf level to the ankle (visual analog scale score, 6–7). There was no pain during rest periods. At a military hospital, he had been prescribed an orthotic shoe; however, it provided no symptom relief. He had also received epidural steroid injection because spinal disease was suspected, but there was no improvement. At a local hospital, nonenhanced MRI had been performed, which showed no considerable abnormality.

On physical examination, no tenderness or swelling of the calf was found, and the range of motion of the ankle was within the reference range. The calf was softly palpated and showed no muscle atrophy. No other specific abnormality was found on physical examination. Also, the authors did not find abnormalities on plain radiographs.

Exercise MRI

The authors performed exercise MRI on the left leg and compared the results with those of a resting MRI obtained at a local hospital. The patient ran on a tread-mill until pain occurred, which was 10 minutes after starting. The MRI was then immediately performed. Compared with the resting MRI, the T2-weighted exercise MRI showed higher signal intensity at the lateral compartment, in the peroneus muscle. The high signal intensity was prominent at the mid-calf to the distal calf level, where the patient mainly felt the pain. However, at the lateral compartment of the proximal calf, where the patient had no symptoms, there was no high signal intensity (Figure 1). The T1-weighted MRI showed no significant signal difference when compared with the resting MRI.

Preexercise axial magnetic resonance images of the proximal calf (A), mid-calf (B), and distal calf (C). Postexercise axial magnetic resonance images of the proximal calf (D), mid-calf (E), and distal calf (F). The lateral compartment of the mid-calf to the distal calf, where the patient felt pain, showed significant high signal intensity. However, the proximal part of the lateral compartment, where the patient had no pain, did not show high signal intensity.

Figure 1:

Preexercise axial magnetic resonance images of the proximal calf (A), mid-calf (B), and distal calf (C). Postexercise axial magnetic resonance images of the proximal calf (D), mid-calf (E), and distal calf (F). The lateral compartment of the mid-calf to the distal calf, where the patient felt pain, showed significant high signal intensity. However, the proximal part of the lateral compartment, where the patient had no pain, did not show high signal intensity.

Selective Fasciotomy for the Lateral Compartment

On the basis of the above results, the authors concluded that the lateral compartment was the cause of the pain. The authors measured the intramuscular compartment pressure before surgery by using Whitesides' technique. The pressure was 20 mm Hg at the lateral compartment, 16 mm Hg at the anterior compartment, 14 mm Hg at the deep posterior compartment, and 14 mm Hg at the superficial posterior compartment.

With the patient under general anesthesia, an 8-cm longitudinal skin incision was made at the mid-calf level, in the lateral aspect. The underlying fascia was cut from proximal to distal, 8 cm in the longitudinal direction (Figure 2). The muscle under the fascia was pushed out through the fascial incision. No sign of muscle necrosis or damage was observed. The authors placed a Jackson–Pratt drain (Sewoon Medical, Cheonan, Korea), closed the wound layer by layer, and applied compressive dressing.

An 8-cm longitudinal skin incision was made at the mid-calf level, in the lateral aspect (A). The underlying fascia was cut from proximal to distal, 8 cm in the longitudinal direction (B).

Figure 2:

An 8-cm longitudinal skin incision was made at the mid-calf level, in the lateral aspect (A). The underlying fascia was cut from proximal to distal, 8 cm in the longitudinal direction (B).

The Jackson–Pratt drain was removed 1 day postoperatively. Full weight-bearing ambulation was allowed. No specific complication was found during the postoperative period. The stitches were removed 2 weeks postoperatively.

Results

The patient visited the outpatient department 3 weeks postoperatively. He reported that he no longer had pain while running. No complication related to the vascular structure or nerve was found.

Three months postoperatively, he had no pain on exertion and no discomfort in the lower leg and ankle. The authors performed a follow-up MRI of the left leg. Compared with the preoperative MRI, the follow-up MRI showed that the peroneus muscle swelling at the lateral compartment had decreased. Furthermore, the high signal intensity at the lateral compartment that was observed on the preoperative exercise MRI was no longer detected. The intracompartmental pressure was again measured. The pressure was 16 mm Hg at the lateral compartment, 16 mm Hg at the anterior compartment, 14 mm Hg at the deep posterior compartment, and 14 mm Hg at the superficial posterior compartment.

At final follow-up, 13 months postoperatively, the patient had no pain on exertion. As a military cadet, he was required to jog for more than an hour per day and perform strenuous muscle exercises. He reported that he had no calf pain or discomfort during such activities.

Discussion

Using exercise MRI, the authors were able to diagnose CECS in a patient whose condition had not been diagnosed for a long period. They used follow-up exercise MRI to confirm that a selective fasciotomy at the lateral compartment had been successful.

Although criteria have been established for the diagnosis of CECS using intramuscular pressure measurement,5 this measurement is invasive and painful. Therefore, it is difficult to perform in the outpatient setting. Moreover, because the results of intramuscular pressure measurement are influenced by the depth of catheter insertion and technique, the timing of measurement in relation to exercise, and ankle position, using them to decide whether to perform surgery can be difficult.6–8 When the symptom is vague and pain occurs in multiple compartments, it is difficult to determine which compartment fasciotomy to perform, and the results are unpredictable. Exercise MRI is a noninvasive method that can precisely identify which compartment is causing the pain. Thus, it is useful in determining the treatment strategy. When CECS is not diagnosed by using resting MRI or intracompartmental pressure measurement, and the patient consistently experiences pain, the authors suggest exercise MRI as the next diagnostic step to consider.

The current patient had pain without trauma history, and plain radiographs and physical examination showed no specific abnormal results. For patients with chronic leg pain without trauma or specific findings on radiography, stress fracture, muscle herniation, nerve entrapment syndrome, vascular claudication, lumbar disk herniation, medial tibial stress syndrome, and popliteal entrapment syndrome could be considered in the differential diagnosis.14 All of these conditions, except for lumbar disk herniation, could be diagnosed with MRI of the lower leg. Therefore, exercise MRI may be useful for diagnosing other causes of chronic leg pain without additional tests.

During the past decade, exercise-based MRI has been discussed as a useful tool for diagnosing CECS.13 Previous studies have reported high signal intensity on T2-weighted postexercise MRIs for patients with CECS.15

Ringler et al13 tested both exercise MRI and intramuscular pressure measurement and reported that exercise MRI had a high reliability and reproducibility. However, they did not report the results of fasciotomy and postoperative exercise MRI.13 Van den Brand et al16 reported the validity of exercise MRI; however, in contrast to Ringler et al,13 they found that exercise MRI had a high sensitivity but a low specificity. Van den Brand et al16 also did not report the results of exercise MRI, present MRI, or perform stress MRI after the surgery. Unlike the previous studies, in the current case, the authors found lateral compartment abnormality by using exercise MRI. They achieved symptom relief for the patient by performing selective fasciotomy. The authors also found normal results on the exercise MRI after surgery.

Van den Brand et al16 and Tucker17 reported that CECS was not caused by permanent muscle compartment damage due to ischemia but rather by increased fluid content at the muscle compartment. Similarly, in the current study, increased signal intensity was seen on T2-weighted images but not on T1-weighted images. This seems to reflect increased fluid content in the muscle compartment and is consistent with previous studies. Therefore, for patients in whom CECS is suspected, the authors suggest that T2-weighted images could be useful for detecting the possibility of CECS and T1-weighted images could be helpful for determining the presence of chronic muscle disorders or other diseases. Moreover, the authors believe that further studies of exercise MRI concerning the degree and location of increased signal intensity and the severity of pain should be conducted with more patients.

Conclusion

Exercise MRI is helpful in confirming the diagnosis of CECS and enables the performance of selective fasciotomy at the affected compartment. It is a useful diagnostic tool in planning the treatment strategy.

References

  1. Davis DE, Raikin S, Garras DN, Vitanzo P, Labrador H, Espandar R. Characteristics of patients with chronic exertional compartment syndrome. Foot Ankle Int. 2013; 34(10):1349–1354. doi:10.1177/1071100713490919 [CrossRef]
  2. Wilder RP, Magrum E. Exertional compartment syndrome. Clin Sports Med. 2010; 29(3):429–435. doi:10.1016/j.csm.2010.03.008 [CrossRef]
  3. Fraipont MJ, Adamson GJ. Chronic exertional compartment syndrome. J Am Acad Orthop Surg. 2003; 11(4):268–276. doi:10.5435/00124635-200307000-00006 [CrossRef]
  4. George CA, Hutchinson MR. Chronic exertional compartment syndrome. Clin Sports Med. 2012; 31(2):307–319. doi:10.1016/j.csm.2011.09.013 [CrossRef]
  5. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni 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]
  6. Mohler LR, Styf JR, Pedowitz RA, Hargens AR, Gershuni DH. Intramuscular deoxygenation during exercise in patients who have chronic anterior compartment syndrome of the leg. J Bone Joint Surg Am. 1997; 79(6):844–849. doi:10.2106/00004623-199706000-00007 [CrossRef]
  7. Tsintzas D, Ghosh S, Maffulli N, King JB, Padhiar N. The effect of ankle position on intracompartmental pressures of the leg [in Turkish]. Acta Orthop Traumatol Turc. 2009; 43(1):42–48. doi:10.3944/AOTT.2009.042 [CrossRef]
  8. Hislop M, Tierney P. Intracompartmental pressure testing: results of an international survey of current clinical practice, highlighting the need for standardised protocols. Br J Sports Med. 2011; 45(12):956–958. doi:10.1136/bjsports-2011-090368 [CrossRef]
  9. Packer JD, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Am J Sports Med. 2013; 41(2):430–436. doi:10.1177/0363546512471330 [CrossRef]
  10. Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. Int J Sports Phys Ther. 2011; 6(4):312–321.
  11. Mathis JE, Schwartz BE, Lester JD, Kim WJ, Watson JN, Hutchinson MR. Effect of lower extremity fasciotomy length on intracompartmental pressure in an animal model of compartment syndrome: the importance of achieving a minimum of 90% fascial release. Am J Sports Med. 2015; 43(1):75–78. doi:10.1177/0363546514554601 [CrossRef]
  12. Wittstein J, Moorman CT III, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. Am J Sports Med. 2010; 38(8):1661–1666. doi:10.1177/0363546510363415 [CrossRef]
  13. Ringler MD, Litwiller DV, Felmlee JP, et al. MRI accurately detects chronic exertional compartment syndrome: a validation study. Skeletal Radiol. 2013; 42(3):385–392. doi:10.1007/s00256-012-1487-1 [CrossRef]
  14. Braver RT. Chronic exertional compartment syndrome. Clin Podiatr Med Surg. 2016; 33(2):219–233. doi:10.1016/j.cpm.2015.12.002 [CrossRef]
  15. 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]
  16. Van den Brand JG, Nelson T, Verleisdonk EJ, van der Werken C. The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients. Am J Sports Med. 2005; 33(5):699–704. doi:10.1177/0363546504270565 [CrossRef]
  17. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med. 2010; 3(1–4):32–37. doi:10.1007/s12178-010-9065-4 [CrossRef]
Authors

The authors are from the Department of Orthopedic Surgery, Asan Medical Center, Songpagu, Seoul, South Korea.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Sang Gyo Seo, MD, Department of Orthopedic Surgery, Asan Medical Center, Olympicro 43 gil 88, Songpagu, Seoul, South Korea ( sgseo@amc.seoul.kr).

Received: February 08, 2017
Accepted: April 24, 2017
Posted Online: June 15, 2017

10.3928/01477447-20170608-03

Sign up to receive

Journal E-contents