Page 34 - ISAKOS 2018 Winter Newsletter

CURRENT CONCEPTS
Chronic Exertional Compartment Syndrome
Introduction
Gonzalo Samitier, MD, PhD Hospital General de Villalba Madrid, SPAIN
Scott C. Faucet, MD, MS
The Orthopaedic Center Washington DC, UNITED STATES
Mark R. Hutchinson, MD University of Illinois Chicago, UNITED STATES
Diagnosis
History, physical examination and provocative tests are the cornerstones. Patients typically complains of five cardinal symptoms: pain, tightness, cramps, weakness, and diminished sensibility limiting their sports performance or forcing them to stop; pain with passive stretch of the compartment may be present after exercising. Fascial defects may also be detected on palpation in 39% to 46% of affected patients.
Intracompartmental pressure (ICP) values: in lower extremity resting and timed post-exercise ICP values obtained after a provocative test (running, hopping, tip-toeing, heel walking) are considered the gold standard for CECS. No specific numerical values have been demonstrated as fully reliable, being the most important to detect a rise in pressure numbers from resting to 1 and 5 min post-exercise accompanied by delayed normalization.
Table 1–Classical ICP diagnostic criteria
Chronic exertional compartment syndrome (CECS) is defined as a condition presenting transient increases in pressures of muscle compartments during exercise or intense activities that typically resolves with rest; the intramuscular volume expand by up to 20% increasing pressure within the compartments that leads to transient ischemia.
Typically, CECS is seen in the young adult athlete; the leg, accounts for more than 95% of all cases with variable involvement of the forearm, hand, thigh and foot in narrow high-risk cohorts. CECS of the leg, has been described in multiple sports as soccer, volleyball, basketball, lacrosse, skiing and others involving intense running, jumping or pivoting maneuvers, but it has been characteristically described in endurance runners, which accounts for up to 2 / 3 of cases. CECS may also be present in activities as dancing, military duty, labor activities and occasionally in less-active population, which makes the diagnosis even more challenging.
Upper extremity presentations appears typically in the forearm and can result of either manual labor, rowing, motocross riding or motor racing, gymnastics, weight lifting, climbing, kayaking and/or piano players.
Resting (pre-exercise) Post-exercise Immediate at 1´ Post-exercise at 5´ Post-exercise at 15´
MRI: pre- and post-exercise
increased diffuse intracompartmental signal on T2 sequences when compared with baseline; MRI is also useful in excluding fascial defects, medial tibial stress syndrome, stress fracture or other structural lesions.
Near-infrared spectroscopy (NIRS): it has recently been studied in Europe as a measure of oxygen saturation in muscle which is reduced when CECS is present. It is a noninvasive test and has been demonstrated to be as efficacious as MRI or ICP monitoring patients with known CECS.
In upper extremity there is also no consensus on the ICPs reference values. Currently, handgrip stress tests eliciting classic CECS symptoms provides the best clinical information for diagnosis.
32 ISAKOS NEWSLETTER 2018: VOLUME I
> 15 mmHg > 30 mmHg > 20mmHg > 15 mmHg
MRIs have demonstrated