Chronic exertional compartment syndrome

Chronic exertional compartment syndrome is an exercise-induced muscle and nerve condition that causes pain, swelling and sometimes even disability in affected muscles of your legs or arms.

Anyone can develop chronic exertional compartment syndrome, but it’s more common in athletes who participate in sports that involve repetitive impact exercise, such as running and fast walking. Chronic exertional compartment syndrome is sometimes called chronic compartment syndrome or exercise-induced compartment syndrome.

If conservative treatment doesn’t help with chronic exertional compartment syndrome, your doctor may recommend surgery. Surgery is successful for many people,  allowing you — whether you’re a recreational or serious athlete — to return to your sport.

The pain and other symptoms associated with chronic exertional compartment syndrome may be characterized by:

• Aching, burning or cramping pain in the affected limb — usually the lower leg
• Tightness in the affected limb
• Numbness or tingling in the affected limb
• Weakness of the affected limb
• Foot drop, in severe cases, if nerves in your legs are affected
• Occasionally, swelling or bulging as a result of a muscle hernia

Pain due to chronic exertional compartment syndrome typically follows this pattern:

• Begins soon after you start exercising the affected limb
• Progressively worsens as long as you exercise
• Stops within 30 minutes after the affected limb comes to rest
• Over time, may begin to persist longer after exercise, possibly lingering for a day or two

Taking a complete break from exercise or performing only low-impact activity may relieve your symptoms, but usually only temporarily. Once you take up running again, for instance, those familiar symptoms usually come back.

When to see a doctor

If you experience unusual pain, swelling, weakness, loss of sensation, or soreness related to exercise or sports activities, talk to your doctor immediately, because these symptoms may be associated with conditions that require emergency medical treatment. Don’t try to exercise through the pain, as that may lead to permanent muscle or nerve damage — and jeopardize continued participation in your favorite sports.

Sometimes chronic exertional compartment syndrome is mistaken for shin splints, a more common cause of leg pain in young people who do lots of vigorous weight-bearing activity, such as running. If you think you have shin splints but they don’t get better with self-care, talk to your doctor.

Excessive pressure within an isolated segment of muscle (a muscle compartment) causes chronic exertional compartment syndrome. Exercise increases the blood supply to working muscles, making them expand. If the connective tissue (fascia) that holds the muscle fibers together in a compartment doesn’t also expand, pressure builds up in the compartment. Over time, the pressure cuts off some of the muscle’s blood supply, leading to chronic exertional compartment syndrome.

Some experts suggest that biomechanics — how you move — may have a role in causing chronic exertional compartment syndrome. Other causes may include having enlarged muscles, an especially thick or inelastic band of tissue (fascia) surrounding a section of muscle, or high pressure within your veins (venous hypertension).

Certain factors increase your risk of developing chronic exertional compartment syndrome, including:

• Age. Although people of any age can develop chronic exertional compartment syndrome, the condition is most common in athletes under 30.
• Type of exercise. Exercise that involves repetitive impact activity — such as running or fast walking — increases your risk of developing the condition.
• Overtraining. Working out too intensely or too frequently also can raise your risk of chronic exertional compartment syndrome.
• Certain drugs. Taking anabolic steroids or the supplement creatine may increase the water content and mass of a muscle segment, contributing to the development of chronic exertional compartment syndrome.

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 permanent numbness or weakness in affected muscles.

Perhaps the worst complication of untreated chronic exertional compartment syndrome is its impact on participation in your favorite sports. The pain may prevent you from being active.

You’re likely to start by first seeing your family doctor or a general practitioner. He or she may refer you to a doctor who specializes in sports medicine or orthopedic surgery.

Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well prepared. Here’s some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements that you’re taking.
• Get copies of any imaging tests you’ve had done, if possible. Ask your doctor’s staff how you can get these forwarded to your doctor before the appointment.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For chronic exertional compartment syndrome, some basic questions to ask your doctor include:

• What’s causing my symptoms?
• Are there any other possible causes for my symptoms?
• What kinds of tests do I need?
• Is my condition likely temporary or chronic?
• What treatment do you recommend?
• What are the risks involved with surgery?
• What might happen if I don’t have surgery?
• Are there alternatives to the primary approach that you’re suggesting?
• Are there any restrictions that I need to follow, such as avoiding certain activities or limiting the amount of physical activity I participate in?
• Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• How soon do your symptoms start after you begin your activity?
• How quickly do your symptoms resolve after you stop your activity?
• Do you notice any weakness in the legs or feet associated with your symptoms?
• Do you experience any numbness or tingling?

What you can do in the meantime

Don’t try to exercise through your pain. Limit your physical activities to those that don’t cause pain. For example, if running bothers your legs, you may be able to swim. Use ice or take pain relievers such as ibuprofen (Advil, Motrin IB, others) or acetaminophen (Tylenol, others) to ease symptoms until you can see your doctor.

Other exercise-related problems are more common than chronic exertional compartment syndrome, so your doctor may first try to rule out other causes — such as shin splints or stress fractures — before moving on to more specialized testing.

Physical exams for chronic exertional compartment syndrome are often normal. Your doctor may prefer to examine you after you’ve exercised, when the condition is more likely to be apparent. Your doctor may notice a muscle bulge (herniation), tenderness or tension in the affected area.

Imaging studies

Your doctor may suggest that you have imaging studies done, such as magnetic resonance imaging (MRI) or near infrared spectroscopy (NIRS). A typical MRI scan of your legs can be used to evaluate the structure of the muscles in the compartments and rule out other possible causes of your symptoms. NIRS is a newer technique that uses light wavelengths to measure tissue oxygen saturation in your blood. This helps to determine if your muscle compartment has decreased blood flow. Both techniques have had good results in noninvasively diagnosing chronic exertional compartment syndrome.

Compartment pressure testing

If imaging studies fail to uncover an abnormality like a stress fracture or similar cause of pain, 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’s invasive and mildly painful, involving insertion of needles into your muscles, compartment pressure measurement usually isn’t performed unless your medical history and other tests strongly suggest you may have this condition.

Options to treat chronic exertional compartment syndrome include both conservative and surgical methods. However, conservative measures are typically only successful if you stop or drastically change your activity.

Conservative options

Your doctor may initially recommend pain medications, stretching or strengthening regimens, orthotics, massage, a break from exercise, or the use of different biomechanical techniques, such as changing how you land when you jog. However, these kinds of conservative options typically don’t provide lasting benefit for true chronic exertional compartment syndrome.

You can also consider switching to a different sport. For instance, if your symptoms are related to jogging, try biking instead.

Surgical options

Surgery is the main treatment of chronic exertional compartment syndrome, and the most effective. Surgery involves operating on the fascia — the inelastic tissue encasing each muscle compartment. 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.

There aren’t any self-care measures that will specifically help prevent chronic exertional compartment syndrome. But following basic sports and fitness guidelines can help protect your health and safety during exercise:

• Warm up before starting exercise.
• Cool down when you’re done exercising.
• Stop if you’re in pain.
• Check with your doctor before starting a new exercise program if you have any health issues.
• Eat a healthy, balanced diet.
• Stay hydrated.
• Engage in a variety of physical activities.

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