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 Diseases and Conditions
Chronic exertional compartment syndrome
From MayoClinic.com
Special to CNN.com Introduction Chronic exertional compartment syndrome is an exercise-induced neuromuscular condition that causes pain, swelling and sometimes even disability in affected muscles of the legs or arms. The condition can occur in both beginning and seasoned athletes in sports that involve repetitive movements, such as running, fast walking, biking and swimming. Chronic exertional compartment syndrome is sometimes called chronic compartment syndrome or exercise-induced compartment syndrome. In chronic exertional compartment syndrome, the repetitive activity causes tissue in the affected muscle area, or compartment, to swell. That, in turn, increases pressure within the compartment, leading to a decreased blood supply to the muscles. This can cause injury to the muscle and nerves, sometimes resulting in permanent damage. People with chronic exertional compartment syndrome typically experience pain that begins with activity, progressively worsens and then stops when at rest. As the condition worsens, however, the pain can take longer to subside. Chronic exertional compartment syndrome is uncommon and sometimes goes undiagnosed. It's not known how many people may be affected, but the number of diagnosed cases has been rising in recent years. The condition seems to affect primarily young athletes in their 20s, although younger and older people also can develop the condition. Chronic exertional compartment syndrome can be difficult to diagnose, partly because the affected limbs generally look perfectly normal — they may not even appear swollen. Unfortunately, conservative treatments typically aren't helpful. However, surgery to open the compartment and decrease pressure is usually highly successful, allowing recreational and serious athletes alike to return to their cherished sports. Signs and symptoms The hallmark of chronic exertional compartment syndrome is pain during exercise. The pain and other symptoms often are characterized by:
Muscles affected Most people with chronic exertional compartment syndrome of the lower legs have symptoms in both legs, not just one. The pain and pressure are typically located in the calves or the outer sides of the lower legs. In more severe cases involving the legs, you may develop footdrop, sometimes called foot slap, while walking or running. With this symptom, you may notice that your forefoot seems to strike the ground unusually loudly and forcefully, making a distinctive slapping sound. A pattern of symptoms Once you stop exercising, the symptoms typically go away within a few minutes to hours. However, over time, in people who continue to exercise despite the pain, the symptoms can developer sooner, be more severe and take longer to go away, sometimes lingering for a day or two. Taking a complete break from exercise may relieve your symptoms, but usually only temporarily. Once you take up running again, for instance, those familiar symptoms usually come back immediately. Causes Your arms and legs have several groupings, or compartments, of muscles, blood vessels and nerves. Each of these compartments is encased by a thick layer of connective tissue called fascia (FASH-e-uh), which supports the compartments and holds the tissues in place. The fascia is inelastic, which means it has little ability to stretch. In chronic exertional compartment syndrome, exercise or even simply repetitive muscle contraction causes the tissue pressure within a compartment to increase to an abnormally high level. But because the fascia can't stretch, the tissues in that compartment aren't able to expand sufficiently under the increased pressure. Imagine shaking up a soda bottle but leaving the cap on — an enormous amount of pressure builds up. As the pressure builds up within one of your muscle compartments, with no outlet for release, nerves and blood vessels are compressed. Blood flow may then decrease, causing tissues to get inadequate amounts of oxygen-rich blood, a condition known as ischemia (is-KE-me-uh). Nerves and muscles may sustain damage. Experts aren't sure why exercise or muscle contraction creates this excessive pressure in some people, leading to chronic exertional compartment syndrome. Some experts suggest that biomechanics — how you move, such as landing styles when you jog — may have a role. Other causes may include having enlarged muscles, an especially thick or inelastic fascia, or high pressure within your veins (venous hypertension). Risk factors People most at risk of developing chronic exertional compartment syndrome are those who engage in exercise that involves repetitive motions or activity. Young female athletes may be at particular risk, for reasons unknown. Risk factors include engaging in such sports, exercises and activities as:
There also have been reports of chronic exertional compartment syndrome of the forearm in wheelchair athletes, motorbike racers and mountain climbers — all people who engage in activities requiring muscle contraction of their forearms and upper limbs. Overuse of your muscles or overtraining — that is, working out too intensely or frequently — can also raise your risk of chronic exertional compartment syndrome. When to seek medical advice If you experience unusual pain, swelling or soreness related to exercise or sports activities, talk to your doctor. He or she may refer you to a doctor who specializes in sports medicine, orthopedics or orthopedic surgery. A thorough evaluation will help you get an appropriate diagnosis and treatment. In addition, these symptoms may occasionally be associated with conditions that require emergency medical treatment. Sometimes chronic exertional compartment syndrome is mistaken for shin splints. If you think you have shin splints but they don't get better with self-care, talk to your doctor. Don't try to keep exercising through the pain, as that may lead to permanent muscle or nerve damage — and jeopardize continued participation in your favorite sports. Screening and diagnosis Pain is common in athletes of all levels. It can have many causes, which can make diagnosis challenging. In fact, for many people with chronic exertional compartment syndrome, getting a diagnosis takes an average of two years, partly because of a delay in seeking help and partly because the condition hasn't been widely recognized among the medical profession, although that's now changing. Because other exercise-related problems are more common than chronic exertional compartment syndrome, your doctor may first try to determine if you have shin splints or stress fractures, for instance. As the more common problems are ruled out, your doctor will begin to focus on the less common potential causes, along with more specialized testing. Medical history and physical exam Your doctor will also examine the areas where you experience pain, such as your arms or legs. Sometimes your doctor may notice a muscle bulge, or herniation, if you have chronic exertional compartment syndrome. Less commonly, your doctor may discover areas of swelling or tightness around a muscle. But one problem that makes diagnosing chronic exertional compartment syndrome challenging is that the physical exam is usually completely normal. Imaging studies In addition, some medical centers are researching the use of a specialized magnetic resonance imaging (MRI) test to detect chronic exertional compartment syndrome. While you're lying down in the MRI machine, you contract muscles to bring on your symptoms. The MRI can detect changes that are characteristic of compartment syndrome, helping pinpoint a diagnosis. But further evaluation to measure your compartment pressure is still necessary. Compartment pressure testing This test, often called compartment pressure measurement, is the gold standard for diagnosing chronic exertional compartment syndrome. Because it's an invasive test, involving insertion of needles into your muscles, and can be painful, compartment pressure measurement usually isn't performed unless your medical history and other tests strongly suggest you may have this condition. Measurement of compartment pressures can be done in a clinic by someone trained in the procedure, such as an orthopedic surgeon. There are several ways to measure compartment pressure. The method becoming most popular uses a hand-held portable needle device that includes a pressure scale. You don't need any special preparation for the procedure. Your doctor will thoroughly clean the skin around the areas to be tested and inject a local anesthetic to help control the pain. A needle is then inserted through the skin and into the muscle of each compartment to be tested. A series of three measurements is usually taken on each compartment. The first is taken when you're at rest, the second immediately after exercising — such as on a treadmill in the clinic — and the third several minutes after exercise. Measurements that are abnormally high lead to a diagnosis of chronic exertional compartment syndrome. Be sure to get instructions for self-care after the pressure testing is done, as you may experience minor bruising, swelling and pain. Complications Chronic exertional compartment syndrome isn't a life-threatening condition and often doesn't cause any lasting or permanent damage. However, if you continue to exercise despite pain, the repeated increases in compartment pressure can lead to muscle, nerve and blood vessel damage. As a result, you may develop permanent numbness or weakness in affected muscles. Perhaps the biggest complication of untreated chronic exertional compartment syndrome is its impact on participation in your favorite sports — the pain may prevent you from being active. Treatment Options to treat chronic exertional compartment syndrome include both conservative and surgical methods. However, conservative measures have proved much less effective. Conservative options You can also consider switching to a different sport. For instance, if your symptoms are related to jogging, try biking instead. Many people, however, aren't willing to give up a beloved sport. Surgical options Surgery involves operating on the fascia — that inelastic tissue encasing each muscle compartment. Surgical 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 permanent nerve damage, numbness and scarring. In addition, since your muscles will no longer be encased by fascia, they may bulge out during exercise, creating a cosmetic concern. There also are different ways to perform each type of surgery. For instance, surgery that involves smaller incisions may leave smaller scars but could make it more difficult for your surgeon to navigate through the internal tissues — muscles, nerves and blood vessels, leading to a higher risk of complications. In addition, some surgeons prefer making just one incision, while others prefer two. Be sure to talk to your doctor about the method that's best for you. And also be sure to follow post-surgical instructions your doctor will give you to ensure a smooth return to your sport. Self-care There aren't any self-care measures that will specifically help prevent or treat chronic exertional compartment syndrome. But following basic sports and fitness guidelines can help protect your health and safety during exercise, including:
August 10, 2006 |
