Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome is a rare condition of pain in the lower legs. This condition is exercise-induced, meaning that individuals who exercise or play sports, such as soccer, basketball, or track, are at a higher risk of developing this condition. Those at the highest risk are athletes around their twenties, with male and females equally affected. Often mistaken for shin splints, stress fractures, and artery impingements, chronic exertional compartment syndrome is underdiagnosed among individuals dealing with lower leg pain.

Pathophysiology

The pathophysiology, or the science behind an injury, of chronic compartment syndrome is complex. The lower leg is separated into four sections, or compartments, of muscles, each of which is surrounded by a thin layer of connective tissue called the fascia. Once an individual with chronic compartment syndrome begins to exercise, blood flow to the muscle increases, causing each section of muscle to expand. When the muscles expand, this puts pressure on the fascia, decreasing blood flow and nerve responses to that specific section of muscle (Bong).

As an individual who has chronic exertional compartment syndrome and was recently diagnosed with the condition, I have visited many doctors to try and get the surgery I need to fix the pain in my lower legs. Recently, my doctor told me an analogy to simplify the pathophysiology of chronic exertional compartment syndrome; after eating a Thanksgiving meal, your belt restricts the bloating that an individual's feels after eating, therefore, the belt must be taken off in order to relieve that pressure in the stomach, similar to the fascia and the muscle, the fascia being the belt and the bloating being the expanding muscles.

Symptoms

Therefore, what symptoms can the decrease in blood flow and blocked nerve signals cause within an individual while they are exercising? Due to the compression of the specific muscle section, the blood flow and nerve responses are cut off. As an individual who has been diagnosed with chronic exertional compartment syndrome, I can attest to how severe and painful these symptoms can be, ultimately hindering an individual's ability to perform in their respective sport. Symptoms include exercise induced tightness or burning in the calf, muscle bulging, paralysis, and drop foot. Drop foot occurs in the most severe cases and is when the muscles are so tight that they block the nerve, disallowing an individual the ability to pick up their foot from the ground. Symptoms will usually subside with rest and reoccur once again when the exercise is continued (Bong). Patients will usually realize that symptoms occur around the same point after exercise is initiated within both of the lower legs. For instance, a patient will express that their symptoms occur at the same point once physical activity is initiated.

Diagnostic Techniques

There is only one way to properly diagnose chronic exertional compartment syndrome, and that is to do a pressure testing before and after exercise to demonstrate an increase in muscle pressures during exercise. This test consists of exercising on a treadmill to elevate the pressures within the affected section of muscle in the leg. After the patient begins to feel those symptoms extremely, they are rushed back into the testing room and the medical professional takes a needle attached to a pressure reading machine that tests the pressures within the sections of muscle. If the medical professional finds that the pressures are elevated significantly, beyond the normal range, then the medical professional will diagnose you with chronic exertional compartment syndrome.

Pedowitz conducted a study to determine the minimal pressures within the legs that need to be present in order for the diagnosis of chronic exertional compartment syndrome to be given. Within Pedowitz's study, they used a slit catheter and measured the pressures of each compartment or section of muscle within the lower before exercise and tested the pressures of their patient after exercise while the patient was experiencing their symptoms (Bong). They determined that the pressures of a one-minute post-exercise pressure test should be greater than or equal to 30 mmHg or the pressures of a five-minute post-exercise pressure test should be greater than or equal to 20 mmHg (Bong). These are now the standard pressure numbers that professionals look for to diagnose chronic exertional compartment syndrome in a clinical setting.

Treatments

Once a diagnosis is established, there are numerous routes an individual can go to treat chronic exertional compartment syndrome. An individual could decide to rehabilitate the lower legs through physical therapy, strengthening the muscles to try and combat chronic exertional compartment syndrome (Bong). Another option is to try Botox injections, as Botox relaxes muscles, which can ultimately reduce the pressure in the legs during exercise (Bong). The final treatment option is surgery, where the orthopedic surgeon cuts the fascia around the sections of muscles in order to allow the muscle to expand during exercise, and ultimately decrease the pressures in the legs as well (Bong). Depending on the severity of the patient's symptoms or their pressures after the compartment testing, the medical professional can recommend the best course of action to treat the patient's pain and allow them to regain their mobility within their legs.

However, some individuals might elect not to go down any of these paths, causing them to either stop their sport or remain with the exercise induced pain. This is difficult for an athlete as they do not want to give up their sport, however, this condition significantly affects their playing performance. This demonstrates how chronic exertional compartment syndrome greatly affects not only the physical health of the athlete, but also the mental health, as these patients are not in pain when they are on the bench but are in excruciating pain with these symptoms when they are playing their sport. As an individual with chronic exertional compartment syndrome, I do not want to stop playing my sport entirely, therefore, I elected to get the surgery, as other options were not effective and did not address the underlying symptoms I was dealing with.

Mental Health in Athletes

As an athlete goes through constant testing and misdiagnoses trying to figure out the root of their lower leg pain, the athlete's mental health can take a drastic turn. Athletes go through numerous trainers and treatment plans with no alleviation of their symptoms, explaining the frustration and aggravation an athlete can experience while trying to be diagnosed with this condition. Usually misdiagnosed with shin splints and stress fractures, the time that is takes to diagnose the athlete with chronic exertional compartment syndrome can ultimately push back recovery time at a time in their careers where opportunities are limited and few. Acknowledging these athletes' mental health throughout the time they experience lower leg pain is essential in order to keep their interest in their sport for when they are able to return.

Chronic exertional compartment syndrome is a misunderstood and underdiagnosed condition that affects many athletes around the world. With the many misdiagnoses every year involving this condition, it is essential for doctors and athletes to understand the specific symptoms and signs of chronic exertional compartment syndrome. If more individuals learn about this condition, then athletes can advocate for themselves and their symptoms while doctors can give a proper diagnosis to help the athlete get back to their sport.

Journal Reference

Bong, Matthew, and Daniel Polatsch. "Chronic Exertional Compartment Syndrome." Health and Medicine. Gale Academic OneFile, go.gale.com/ps/i.do?id=GALE%7CA165576320&sid=googleScholar&v=2.1&it=r&linkaccess=fulltext&issn=19369719&p=HRCA&sw=w&casa_token=Q_HFLlR-q20AAAAA%3Ad3O-J38xjrvQP25TzKR14Gq60NLporkR_gFZK23O7wsCNhdTsQ9CNVPYXILPGPr9VdU7FImOoyVX&userGroupName=maine_hu. Accessed 22 Mar. 2023.

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