Exercise-Induced Compartment Syndrome of the Leg
Brian J. Awbrey, MD Shingo Tanabe, MD, PhD
exercise results in increased muscle volume due to increased perfusion.
This expansion of muscles can cause increased pressure within an unyieldingosteofascial
compartment, particularly in the leg. In most people these elevated
muscular pressures return to normal within seconds following rest.1
Some people experience prolonged elevation of intracompartmental pressures.
When these abnormally high pressures are associated with pain or neurological
symptoms, the condition has been described as an exercise-induced compartment
compartment syndrome is one of many causes of exercise related pain
in the leg.4 Definitive diagnosis and distinction from other causes
of exercise-induced leg pain can be difficult. It is the general consensus
of most practitioners that the diagnosis must rest on measurement of
abnormal resting and post-exercise intracompartmental pressures, but
the threshold pressure values to define the condition and a rapid and
reliable method to measure pressures have not been consistent. In addition,
there are various techniques for performing intracompartmental pressure
measurement tests before, during, and after exercise, and technique
can have a substantial affect on recorded pressure. The difficulties
associated with reliable diagnosis of the condition make it difficult
to interpret data regarding treatment since patients from different
series may not be comparable.
been interested in chronic exercise-induced compartment syndromes for
many years. This paper will discuss our work in the context of an overall
review of the topic.
is commonly divided into four compartments on the basis of separate
fascial envelopes: the anterior, lateral, superficial posterior, and
deep posterior compartments. In the management of exercise-induced compartment
syndrome, some have suggested that the tibialis posterior functions
as if it were its own compartment (the so-called fifth compartment of
the leg) and may be selectively vulnerable to exercise-induced compartment
the four major compartments contains a nerve with a sensory component.
Increased pressure in the anterior compartment may cause diminished
sensation in the dorsum of the first web space of the foot (deep peroneal
nerve). Elevated pressure in the lateral compartment might cause sensory
loss of the dorsum of the foot (superficial peroneal nerve). The sural
nerve lies within the superficial posterior compartment and increased
pressures may cause numbness over the lateral aspect of the leg and
foot. The deep posterior compartment contains the tibial nerve and the
sole of the foot may therefore become numb with increased pressures.
Abnormalities of motor function, such as a transient foot drop, may
also occur with exercise-induced compartment syndrome. We have found
that this transient foot drop is present in nearly all patients with
exercise compartment syndrome and have coined the term “Slap Sign” to
describe the onset of weakness during the course of running exercise.
pressure elevation within a compartment during exercise is not abnormal
and reflects both transient increases in tissue perfusion and the pressure
of muscle contraction, which may cause pressures upwards of 80 mm Hg
in a normal muscle.6 The amount of stretch placed upon a muscle (i.e.
the position of adjacent joints) also affects compartment pressures.
These factors must be taken into account when interpreting pressure
herniation through fascial defects has been identified in upwards of
40% of patients with chronic compartment syndromes, compared to only
5% of controls.2 The importance of this finding is not known.
history associated with exercised-induced compartment syndrome was outlined
by Detmer and colleagues.7 Most patients are avid runners who are completely
asymptomatic in the off-season but gradually develop an aching pain
in the lower leg as training progresses. The pain is initially present
near the end of a run and disappears shortly thereafter. As symptoms
progress, the pain may persist after the activity, even into the next
day. Paresthesias may develop on the sole of the foot with a deep posterior
compartment syndrome and on the dorsum of the foot in an anterior compartment
syndrome. These two locations account for over 80% of all exercise-induced
compartment syndromes in the leg.2, 5 The physical examination is usually
normal. Athletes report a progression of the onset of symptoms with
time and severe pain with their sport, combined with weakness and a
positive Slap Sign.
patients complaining of exercise-induced leg pain may suffer from medial
tibial stress syndrome, stress fracture, nerve entrapment, or exercise-induced
compartment syndrome.4 Bone scans and radiographs can usually identify
the first two conditions. In medial tibial stress syndrome, the bone
scan shows diffuse activity along the posteromedial cortex. Stress fractures
cause a focal area of uptake. Radiologic investigations are normal with
nerve entrapment conditions and, generally, negative in exercise-induced
compartment syndrome, which may show areas of nucleotide uptake along
the tibia by bone scan.
|Office Standing Exercise Test Results: A Comparison
Compartment Syndrome vs. Medial Tibial Stress
|1. Exercise Test Time to Characteristic Pain (4-minute
| Exercise Compartment Syndrome
||In <2 minutes all tested
subjects develop severe pain
| Medial Tibial Stress Syndrome
| Normal Subjects
|2. Increase In Calf Size After 4-Minute Exercise
| Exercise Compartment Syndrome
| Medial Tibial Stress Syndrome
| Normal Subjects
Intracompartmental Pressure Monitoring
for an exercised-induced compartment syndrome, most authors have the
patient perform running or isokinetic exercises until either pain or
fatigue limit further activity. Measurements are taken pre and post-exercise.
The position of the knee and ankle must be standardized since joint
position can effect compartment pressure. The wick and slit catheter
techniques have been popular instruments for obtaining pressure measurements.
This abbreviated measurement method has several drawbacks, but does
provide the practitioner with a crude measure of muscular pressures
associated with exercise.
criteria for exercise induced compartment syndrome vary. Rorabeck and
co-workers required both a resting pre-exercise pressure of 10 mm Hg
and a 15 minute post-exercise pressure greater than 15 mm Hg for diagnosis.3
Pedowitz and colleagues accepted any one of the following as diagnostic:
1) pre-exercise pressure greater than 15 mm Hg; 2) a one-minute post-exercise
pressure greater than 30 mm Hg; or 3) a five-minute post-exercise pressure
greater than 20 mm Hg.2
Our initial studies focused on the development of a miniaturized fluid
pressure monitor for office use, which was found to be practical, accurate
and rapid.1 Our current technique involves pressure measurements of
symptomatic compartments in the office setting using a hand-held digital
monitor (Stryker Corporation, Kalamazoo, MI). In an effort to provide
complete and sophisticated pressure data, each compartment is monitored
continuously starting at rest, during the course of four minutes of
in-office exercise, and after exercise for five minutes.
this test has been adapted from a four-minute outdoor running test (which
proved to be inconsistent) to our present use of a four-minute provocative
supine exercise test. During the test the patient performs a vigorous
isometric muscle contraction against the force of the examiner during
pressure measurement. This brief office-based testing program consistently
reproduces the patient’s symptoms and provokes pressure elevation.
Our parameters for the diagnosis of chronic exercise-induced compartment
- Elevated resting muscular compartment pressures (>12 mmHg);
- Elevated relaxed muscle pressures during exercise (>60 mmHg),
- Post-exercise pressure elevated above rest pressure at 5 minutes,
- The onset of characteristic pain during the four minute study.
criteria were required for diagnosis. Those patients with compartment
syndrome were found to consistently have resting pressures in the low
twenties, exercise pressures of 90-110 and elevated post-exercise pressures.
also developed a noninvasive four-minute standing exercise test. In
a review of 33 patients, we found that this test accurately distinguished
patients with exercise-induced compartment syndrome from those with
medial tibial stress syndrome.(unpublished data) Patients with exercise-induced
compartment syndrome consistently reproduced their characteristic disabling
pain and all had a significantly diminished increase in calf circumference
with exercise compared to normal subjects.
|Primary Symptoms of Exercise-Induced
Severe pain with exercise
|* Slap Sign: Exercise-Induced
peroneal palsy leading to transient foot drop
with exercise-induced compartment syndrome do not require surgery if
they are willing to curtail inciting sports activities. In our experience,
95% of patients desire to remain active in exercise and sport. Nonoperative
treatment has not been effective. Patients that want to remain active
in their sport usually require operative treatment. Operative treatment
requires fascial release of the involved compartments. Many surgeons
attempt to do this through a limited incision.8 Our experience with
the operative treatment of exercise-induced compartment syndrome suggests
that limited skin incisions with extensive subcutaneous release of involved
compartments are preferable.
requiring operative release of an exercise-induced compartment syndrome
under our care 55% involved the anterolateral compartments, 24% the
posterior compartments, and in 21% both areas. Both legs were involved
in 82% of patients. We performed two-incision fasciotomy, with the subcutanous
fascial incisions extended from ankle to knee. As a gauge of complete
fasciotomy, compartment pressures were measured before and after release.
Pre-operative pressure measurements recorded in the operating room matched
those measured at rest in the office setting. In 32% of patients, post-fasciotomy
pressure measurements were found to be greater than 15 mm Hg. Exploration
of the release identified numerous fibrous bands overlying the fascia
in each case. When these additional bands were released, the final resting
pressure was below 9 mm Hg in each case. Overall, the resting pressure
had decreased from an average of 23 mm Hg pre-op to an average of 7
mm Hg post-op. Nearly all of the patients had satisfactory relief of
pain with return to full sports activities.
attempted to simplify the office diagnosis of exercise-induced compartment
syndrome of the leg and have developed methods for measurement. Measurement
of muscle pressures during the described exercise test differentiates
exercise compartment syndrome from other disorders causing exercise
pain. Although conservative treatment methods have failed, the results
of operative fascial release have been highly successful. We recommend
extensive subcutaneous fascial release of each involved compartment
and intraoperative pressure monitoring. With careful diagnosis and treatment,
the results of operative treatment can be rewarding.
Brian J. Awbrey, MD is an Attending Surgeon at Massachusetts
General Hospital and Clinical Instructor of Orthopaedic Surgery at Harvard
Shingo Tanabe, MD, PhD was a visitor from the Departments of
Physiology and Sports Medicine at the The University of Tokushima School
of Medicine and The Kanzaki Central Hospital, Tokushima, Japan
Address Correspondence to:
Brian J. Awbrey, M.D.; Department of Orthopaedic Surgery; Massachusetts
General Hospital; 151 Merrimac Street, Suite 202; Boston, MA 02114
||Awbrey B, Sienkiewicz P, Mankin H. Chronic exercise-induced
compartment pressure elevation measured with a miniaturized fluid
pressure monitor. Am J Sports Med 1988;16:610-615.
||Pedowitz R, Hargens A, Mubarak S, Gershuni D.
Modified criteria for the objective criteria for the objective diagnosis
of chronic compartment syndrome of the leg. Am J Sports Med 1990;18:35-40.
||Rorabeck C, Bourne R, Fowler P, Finlay J, Nott L.
The role of tissue pressure measurement in diagnosing chronic
anterior compartment syndrome. Am J Sports Med 1988;16:143-146.
||Andrish J. The leg. In: DeLee J, Drez D, eds.
Orthopaedic sports medicine: Principals and practice. Philadelphia:
W.B. Saunders, Co., 1994:1603-1631. vol 2.
||Davey J, Rorabeck C, Fowler P. The tibialis posterior
muscle compartment. Am J Sports Med 1984;12:391-397.
||Logan J, Rorabeck C, Castle G. The measurement
of dynamic compartment pressure during exercise. Am J Sports Med 1983;11:220-223.
||Detmer D, Sharpe K, Sufit R, Girdley F. Chronic
compartment syndrome: Diagnosis, management, and outcomes. Am J Sports
||Fronek J, Mubarak S, Hargens A, et al. Management
of chronic exertional anterior compartment syndrome of the lower extremity.
Clin Orthop 1987;220:217-227.
||Mubarak S, Owen C. Double-incision fasciotomy
of the leg for decompression in compartment syndromes. J Bone Joint