Compartmental Syndrome Article

[Spook]

Compartment Syndromes

Last Updated: December 22, 2003

Synonyms and related keywords: exertional compartment syndrome, ECS, chronic exertional compartment syndrome, CECS, compartment syndrome, exercise-induced pain, exercise-induced swelling, increased intracompartmental pressure, mechanical damage theory.


AUTHOR INFORMATION

Author: Basim Abdelkarim, MD, Staff Physician, Department of Internal Medicine, University of California at Irvine Medical Center

Coauthor(s): Federico E Vaca, MD, FACEP, Team Physician, University of California Irvine; Clinical Assistant Professor, Department of Emergency Medicine, University of California at Irvine School of Medicine
Basim Abdelkarim, MD, is a member of the following medical societies: American Medical Association

Editor(s): Joseph P Garry, MD, Director of Sports Medicine, Assistant Professor, Department of Family Medicine, East Carolina University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Russell White, MD, Clinical Associate Professor, Department of Family Medicine, University of South Florida College of Medicine; Director, Center for Sports Medicine, Associate Program Director, Bayfront Medical Center; Jon Whitehurst, MD, Fellow, Sports Medicine, Southern California Orthopedic Institute; and William Jay Bryan, MD, Clinical Professor, Department of Orthopedic Surgery, Baylor University College of Medicine



INTRODUCTION

Background:

Exertional compartment syndrome (ECS) is a condition of the lower extremities that can occur in athletes from repetitive loading or exertional activities. Even though physicians have been aware of ECS symptoms since the early part of the 20th century, not until the late 1950s were the first reports on the chronicity of ECS documented. This article focuses on the chronic form of ECS because the acute form, outside of trauma, is believed to be an exacerbation or rapid progression of chronic exertional compartment syndrome (CECS). Unlike acute compartment syndrome, the chronic form is not well understood and the amount of conflicting data on the pathophysiology of this syndrome is significant.

Mavor was the first to describe the entity in 1956 in a patient experiencing recurrent anterior leg pain with exertion associated with herniation of the muscle and numbness of the affected extremity.

Acute ECS and CECS are characterized by exercise-induced pain and swelling, which is relieved by rest. In severe cases, weakness and paresthesias may accompany the pain and may be the result of ischemic changes within the compartment.

In 1975, Reneman defined the clinical manifestations of this condition and identified increased intracompartmental pressure as the cause. Case studies of CECS in the forearm, thigh, and gluteal regions have been described but are rare. The foreleg remains the most common site of involvement. CECS is a relatively common problem among runners and is frequently misdiagnosed.
Frequency:

· In the US: True prevalence is uncertain; however, one study found a 14% prevalence rate of anterior CECS in individuals who reported lower leg pain. Males and females are affected equally, with bilateral involvement common. CECS usually occurs in well-conditioned athletes younger than 40 years. Athletes with CECS who markedly increase their training are at risk of developing acute ECS, as are inactive patients who initiate rigorous training.
· Internationally: The true prevalence is unknown.
Functional Anatomy: A firm grasp of lower extremity anatomy is central to understanding the pathophysiology, diagnosis, and treatment of CECS.
The lower leg is divided into 4 compartments; however, a fifth compartment has recently been documented. The compartments are as follows:
· Anterior: This consists of the tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius. The borders of this compartment are the tibia, fibula, interosseous membrane, and anterior intermuscular septum.
· Lateral: The lateral compartment includes the peroneus longus and brevis. Within the compartment lie the common peroneal nerve and its superficial and deep branches. This compartment is bordered by the anterior intermuscular septum, the fibula, the posterior intermuscular septum, and the deep fascia.
· Superficial posterior: The superficial posterior compartment is surrounded by the deep fascia of the leg and contains the gastrocnemius, soleus, and plantaris.
· Deep posterior: The deep posterior compartment lies between the tibia, fibula, deep transverse fascia, and interosseous membrane. The muscles within the compartment are the flexor digitorum longus, flexor hallucis longus, popliteus, and tibialis posterior. Also within this compartment lie the posterior tibial artery and vein and the tibial nerve.
· Tibialis posterior: This compartment (a subdivision of the deep posterior compartment) is newly described and consists of the tibialis posterior, which has recently been shown to have its own fascial layer.
Typically, the anterior compartment of the leg is the most frequently affected compartment (45%), followed by the deep posterior compartment (40%).

Sport Specific Biomechanics: CECS pain was thought to derive from the same pathologic processes that cause pain in acute ECS, ie, compromise of the vascular supply, which leads to myoneural ischemia. Various proposed theories attribute the pain of CECS to tissue ischemia. These theories suggest that ischemia results from arterial spasm, capillary obstruction, arteriovenous collapse, or venous obstruction. However, an MRI study recently conducted by Amendola et al showed that significant tissue ischemia does not develop.

Other theories have been proposed and suggest that muscle and/or fascial hypertrophy is the origin of pain in patients with CECS. However, not all athletes with muscle hypertrophy develop compartment syndrome. CECS is associated with increased pressure in relaxed muscles. Transient increases in compartmental pressure have been demonstrated in patients who do not develop compartment syndrome. These pressures usually normalize within 5 minutes after exercise. In patients with CECS, pressures remain elevated for 30 minutes or longer.

Another theory, known as the mechanical damage theory, states that exercise results in myofibril damage and release of protein-bound ions. Frequent damage, such as that occurring in the anterior compartment of runners, results in an increased release of ions, increased osmotic pressure, and decreased blood flow within the compartment.

The pathophysiology of the syndrome may be associated with the stress of hard-surface exercise, leading to edema formation in the involved compartments.

Despite these various explanations for the cause of pain in CECS, no single theory has been overwhelmingly accepted. Further investigation is needed, including the relationship between pain and compartment metabolites.


CLINICAL

History:

Patients have a history of chronic exercise, burning, aching, or cramping in an extremity during activity.

· Patients report pain or tightness, cramping, burning, or aching.
· Fullness in the extremity typically has a gradual onset, which may worsen as activity progresses.
· Pain is constant, related directly to exertion.
· Pain typically begins at a predictable time after starting exercise or after reaching a certain intensity level.
· Pain relieved with rest recurs upon resuming exercise, and nonsteroidal anti-inflammatory drugs (NSAIDs) are not sufficient to relieve it.
· Pain is increased with active contraction and passive stretching.
· The affected extremity may develop muscle weakness, with possible motor deficits during the episode.
· Paresthesias or anesthesia develops in the distribution of the affected nerve.
· Symptoms may persist for minutes, hours, or days.
· The radiation of pain may vary in relation to the compartments involved.

Physical:

Physical examination findings from persons with CECS are usually normal unless the patient has a history of recent exercise.
· Musculature is firm or tense to palpation.
· Evidence of muscle hernias is present in 20-60% of patients with anterior CECS and is more pronounced with dorsiflexion.
· If anterior CECS is a possibility, the patient experiences weakness of dorsiflexion and loss of sensation in the web of the first toe, due to involvement of the deep peroneal nerve.
· If the lateral compartment is affected, the patient experiences weakness upon inversion, with loss of sensation on the anterolateral part of the shin and the dorsum of the foot.
· If the deep posterior compartment is affected, the patient experiences weakness in the foot muscles and loss of sensation in the foot arch.
· If the patient has arterial insufficiency, distal pulses may be decreased; this is a rare complication and is observed with very high pressures.
· In severe cases, the patient may have foot drop.
· Patients with ECS do not have tenderness over the posterior medial tibial cortex in the distal leg, which contrasts with medial tibial stress syndrome in which tenderness is quite specific and located in this area.
Causes: Suggested causes for CECS include rapidly increased vigorous activity by the unconditioned individual, a rapid increase of training level in conditioned athletes, or repetitive loading or exertional activities.


DIFFERENTIALS

Other Problems to be Considered:
Stress fracture of tibia or fibula
Tenosynovitis
Periostitis
Vascular and neurologic entrapment syndromes
Claudication
Infection
Myopathy (to include thyroid myopathy)
Tumor
Deep venous thrombosis
Medial tibial stress syndrome


WORKUP

Lab Studies:

· Lab studies generally are not helpful in the case of a true CECS. However, some lab studies may be ordered to help rule out other causes of lower leg pain on an individual case-by-case basis. The diagnosis of CECS may be one of exclusion, based on the history, the physical examination findings, and the exclusion of various differential diagnoses.
o Serum creatine kinase and myoglobin level (myopathy or rhabdomyolysis)
o Urinalysis and urine myoglobin (rhabdomyolysis)
o Prothrombin time/activated partial thromboplastin time (deep venous thrombosis)
o D-dimer level (deep venous thrombosis)
o CBC count with differential (infection, osteomyelitis)
o Complete metabolic panel (metabolic derangements, acidosis, hypercalcemia, hyperkalemia)
o Thyroid-stimulating hormone (thyroid myopathy)
o Sedimentation rate (infection, rheumatologic conditions)
Imaging Studies:
· Generally, imaging studies are not helpful in the diagnosis of CECS, but, similar to the physical examination, they may help rule out related disorders.
o X-ray films of the extremity: Anteroposterior, lateral, and oblique views may help rule out stress fractures. In addition, radiographs of the spine may help identify spinal stenosis or disk degeneration that may be the source of lower extremity pain.
o Bone scan: This study helps exclude stress fracture, periostitis, and malignancy of the lower extremity.
o Ultrasound: This can be performed to visualize blood flow (ie, to rule out hematoma, deep venous thrombosis, or vascular entrapment).
o CT scan and MRI: Findings can help rule other significant causes of chronic lower leg pain.
· MRI may be helpful in the diagnosis of CECS, although its exact role is unclear.
· Thallous chloride scintigraphy with single-photon emission computed tomography scanning has recently been studied in the diagnosis of CECS. One recent study showed that thallous chloride scintigraphy with single-photon emission computed tomography scanning was a sensitive method of diagnosis. The study was able to show (1) reversible areas of ischemia in the affected compartment during exercise testing and (2) multiple compartments with elevated pressures. However, larger studies need to be conducted to prove its efficacy.

Other Tests:

· Compartment pressure readings with and without exercise are helpful. Pain reproduced during exercise in combination with elevated compartment pressures can confirm the diagnosis of CECS. If pain is not reproduced with exertion, the diagnosis is questionable.
· Nerve conduction studies may be helpful for detecting neurological involvement of affected compartments. However, its role is questionable in aiding the diagnosis of CECS. Such studies may be helpful for excluding other related disorders such as peripheral nerve entrapment.
Procedures:
· Compartment pressure testing is considered the criterion standard for diagnosing CECS. A large-bore needle or a wick catheter is inserted into the affected muscular compartment and is then connected to a solid-state pressure monitor.
o Testing must be performed under sterile conditions. The needle tip location, the depth of penetration, and knee and ankle position are controlled to obtain reliable measurements. Patients are tested supine with their knees extended and their ankles in neutral dorsiflexion. The generally accepted method of testing is to measure the resting compartment pressure, exercise the patient until a symptomatic level is reached, and then measure again.
o The anterior compartment is relatively easy to test; testing the posterior compartment is more difficult and the results are less reliable. The anterior compartment is reached by inserting the catheter halfway between the tibial crest and the lateral intermuscular septum in the central portion of the compartment. Numerous methods are available for reaching the deep posterior compartment, but ultrasound guidance is recommended because of the difficulty in accessing this compartment.
o Pressure testing is repeated 1 minute postexercise and again at 5-minute intervals. Not all centers have facilities to perform this test, and the clinician may have to rely on history and physical examination findings. However, history and examination findings alone may not be sufficient to confirm the diagnosis.
· Pedowitz et al defined the criteria for the diagnosis of anterior CECS in the leg. They are (1) a preexercise pressure of greater than 15 mm Hg, (2) a 1-minute postexercise pressure of greater than 30 mm Hg, and (3) a 5-minute postexercise pressure of greater than 20 mm Hg. One or more must be met to make the diagnosis.

TREATMENT

Acute Phase:

· Rehabilitation Program:
o Physical Therapy: Conservative therapy has been attempted but generally is unsuccessful once the patient returns to normal activity. Massage therapy and physical therapy have been reported to be successful, but these reports remain largely anecdotal in regard to successful treatment.
· Medical Issues/Complications: One must perform a full evaluation and assessment to appropriately diagnose CECS. An error in diagnosis can lead to unnecessary surgical procedures (eg, fasciotomy, fasciectomy), which may lead to further complications.
· Surgical Intervention: If conservative therapy has failed, surgical intervention is usually initiated. Fasciotomy may be performed once consultation with a surgeon has been obtained; fasciotomy is indicated for pressures of 30-40 mm Hg, although some experts site clinical signs as the threshold for intervention. Fasciotomy of the anterior compartment has a better outcome than fasciotomy of the posterior compartment.
Furthermore, the rehabilitation phase is prolonged for patients who undergo deep posterior compartment fasciotomy compared to those who undergo anterior compartment fasciotomy. The reasons for this difference in outcome remain unclear. Acute ECS requires fasciotomy immediately after diagnosis.
A 2-incision technique is used, with generous medial and lateral incisions to completely release all surrounding compartments. Skin incisions are left open to keep intracompartmental pressure low; delayed closure is performed 48-72 hours later.
If symptoms recur after fasciotomy, they can usually be traced to the deep posterior compartment, particularly if this compartment was not adequately released. If fasciotomy fails, the diagnosis of ECS should be fully reevaluated.
· Consultations: Orthopedist, vascular surgeon, radiologist (imaging specialist)

Recovery phase:

· Rehabilitation Program:
o Physical Therapy: This includes rest, muscle stretching prior to exercise, shoe modification, and NSAIDs to reduce inflammation. Do not cast, splint, or compress the affected limb.
o Recreational Therapy: Presurgical therapy includes reduction of activity with encouragement of cross-training exercises (eg, swimming, bicycling, other low-impact activities).
· Surgical Intervention: Consider fasciotomy if symptoms persist and exertional compartment pressures are elevated.
· Consultations: Orthopedist, vascular surgeon
Maintenance Phase:
· Rehabilitation Program:
o Physical Therapy: Postsurgical therapy includes assisted weightbearing with some variation dependent on surgical technique. Some physicians recommend immediate postsurgical range-of-motion activity that may include walking (unaided by 3-5 d).
o Recreational Therapy: Postsurgical therapy includes cycling and swimming after healing of the surgical wounds (weeks later). Running can be performed at 3-6 weeks and full activity within approximately 6-12 weeks.
· Medical Issues/Complications: The surgical result in a true case of CECS is usually good, with significant improvement of exertional pain.
o Pain can recur, and, if so, consider the possibility of an error in the initial diagnosis.
o Additionally, if pain persists with activity, consider the possibility of incomplete or incorrect decompression of a muscle compartment.
· Surgical Intervention: In the case of recurrent exertional pain, a repeat fasciotomy may be needed.
Consultations: Orthopedist

MEDICATION

Analgesics are warranted in patients with CECS, but they should not be used as diagnostic interventions.

Drug Category: Analgesics/nonsteroidal anti-inflammatory drugs -- NSAIDs are important because they reduce inflammation and provide analgesia. However, anti-inflammatory medication is not believed to significantly improve exertional pain as a result of CECS.

Drug Name Ibuprofen (Motrin, Ibuprin) -- DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose 600-800 mg PO tid prn
Pediatric Dose 10 mg/kg PO q6-8h
Contraindications Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Drug Name Ketoprofen (Orudis, Actron, Oruvail) -- For relief of mild to moderate pain and inflammation.Small initial dosages are indicated in small and elderly patients and in those with renal or liver disease.Doses >75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult Dose 25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose 3 months to 12 years: 0.1-1 mg/kg PO q6-8h>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy D - Unsafe in pregnancy
Precautions Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Drug Name Naproxen (Naprelan, Anaprox, Naprosyn) -- For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose <2 years: Not established>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia is rare, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation


Drug Category: Narcotic analgesics -- Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.

Drug Name Hydrocodone and acetaminophen (Vicodin, Lortab) -- Drug combination indicated for moderate to severe pain.
Adult Dose 1-2 tab PO q4-6h prn
Pediatric Dose Not established
Contraindications Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure
Interactions Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or TCAs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
Drug Name Hydrocodone and aspirin (Lortab ASA, Alor 5/500, Panasal 5/500) -- Drug combination indicated for moderate to severe pain.
Adult Dose 1-2 tab PO q4-6h prn
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Phenothiazines may decrease analgesic effects; toxicity increases when administered concurrently with CNS depressants or TCAs; may potentiate anticoagulant effects of warfarin
Pregnancy D - Unsafe in pregnancy
Precautions Caution in impaired renal function, peptic ulcer disease, and erosive gastritis; duration of action may increase in elderly persons
Drug Name Hydrocodone and ibuprofen (Vicoprofen) -- Drug combination indicated for short-term (<10 d) relief of moderate to severe acute pain
Adult Dose 1-2 tab PO q4-6h prn pain; not to exceed 5 tab/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; third trimester of pregnancy
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in elderly persons
Drug Name Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox) -- Drug combination indicated for the relief of moderate to severe pain.
Adult Dose 1-2 tab or cap PO q4-6h prn
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of CNS depressants or TCAs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen; do not exceed 4000 mg/d of acetaminophen; higher doses may cause liver toxicity
Drug Name Oxycodone and aspirin (Percodan, Roxiprin) -- Drug combination indicated for the relief of moderate to severe pain.
Adult Dose 1-2 tab or cap PO q4-6h prn
Pediatric Dose Not established
Contraindications Documented hypersensitivity; liver damage, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, and asthma; due to association of aspirin with Reye syndrome, do not use in children with the flu who are <16 y
Interactions Phenothiazines may decrease analgesic effects; conversely, toxicity increases when administered concurrently with CNS depressants or TCAs; may also potentiate anticoagulant effects of warfarin
Pregnancy D - Unsafe in pregnancy
Precautions Duration of action may increase in elderly persons; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis


FOLLOW-UP

Return to Play: For the athlete with CECS, return to play may not be a viable option without surgical intervention. Consultation with a primary care sports medicine specialist and/or sports medicine orthopedic specialist may be needed.

After surgical intervention to release the involved compartment, range-of-motion activity often begins immediately or within 3 days after surgery.
Weightbearing begins within the first week by means of aided or unaided walking. Upgrade activity to stationary cycling or swimming after wounds heal. Isokinetic muscle strengthening exercises begin at 3-4 weeks. Running is integrated into the activity program at 5-6 weeks. Full activity is introduced at approximately 6-12 weeks, with focus on speed and agility.
Complications: Surgical intervention generally has good success in persons with CECS, with success being defined as the return to athletics without significant symptoms. In the anterior compartment of the leg, success rates usually exceed 85%. In the deep posterior compartment, success rates are approximately 70%.

For unknown reasons, the deep posterior compartment does not respond as quickly or as well to fasciotomy as the anterior compartment. The majority of complications can be attributed to surgical intervention or misdiagnosis. Other reasons include postoperative hemorrhage, postoperative infection, recurrent compartment syndrome, Volkmann contracture, and permanent disability.

Prevention: Limited information is available on true prevention of CECS. Encourage cross-training exercises (eg, swimming, bicycling, other low-impact activities) and muscle stretching prior to exercise.

Prognosis: The postsurgical prognosis is good if the initial diagnosis of CECS is correct.

Education: eMedicine has excellent sports injury patient education resources available at http://www.emedicinehealth.com/collections/1599.asp. These resources may be printed free of charge.


MISCELLANEOUS

Medical/Legal Pitfalls:
· Failure to make the correct initial diagnosis: This is key to the successful management and treatment of CECS. Misdiagnosis can lead to complications resulting from unnecessary surgery.

Special Concerns:

Consider the significant overlap between CECS and other lower extremity pain syndromes and entities. These may include periostitis, tibial stress fracture, and anterior tibial pain syndrome (ie, medial tibial stress syndrome, lateral tibial stress syndrome).


BIBLIOGRAPHY

· Abramowitz AJ, Schepsis AA: Chronic exertional compartment syndrome of the lower leg. Orthop Rev 1994 Mar; 23(3): 219-25[Medline].
· Amendola A, Rorabeck CH, Vellett D, et al: The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med 1990 Jan-Feb; 18(1): 29-34[Medline].
· Black KP, Taylor DE: Current concepts in the treatment of common compartment syndromes in athletes. Sports Med 1993 Jun; 15(6): 408-18[Medline].
· Blackman PG: A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc 2000 Mar; 32(3 Suppl): S4-10[Medline].
· Detmer DE, Sharpe K, Sufit RL, Girdley FM: Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med 1985 May-Jun; 13(3): 162-70[Medline].
· Fronek J, Mubarak SJ, Hargens AR, et al: Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop 1987 Jul; (220): 217-27[Medline].
· Hayes AA, Bower GD, Pitstock KL: Chronic (exertional) compartment syndrome of the legs diagnosed with thallous chloride scintigraphy. J Nucl Med 1995 Sep; 36(9): 1618-24[Medline].
· Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990 Jan-Feb; 18(1): 35-40[Medline].
· Rorabeck CH: Exertional tibialis posterior compartment syndrome. Clin Orthop 1986 Jul; (208): 61-4[Medline].
· Rorabeck CH, Fowler PJ, Nott L: The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med 1988 May-Jun; 16(3): 224-7[Medline].
· Schepsis AA, Martini D, Corbett M: Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med 1993 Nov-Dec; 21(6): 811-7; discussion 817[Medline].
· Styf JR, Korner LM: Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. J Bone Joint Surg [Am] 1986 Dec; 68(9): 1338-47[Medline].
Veith RG, Matsen FA 3rd, Newell SG: Recurrent anterior compartmental syndromes. Phys Sportsmed 1980; 8(1

[Spook]

Sorry if portions of the article doesn't read very well. Its just that I can't post tables in a thread.

[mac83]

good article, crazy shit actually. i know a bro who had it in his calf, had to have surgery, still had the scar.