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CHRONIC EXERTIONAL COMPARTMENT SYNDROME
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What is it?
Chronic exertional compartment syndrome (CECS) is one cause of exercise-related lower leg pain.  There are four compartments in the lower leg.   Each compartment has a wall that is surrounded by “fascia,” a thin layer of tissue that surrounds muscles.  The compartments contain muscles, nerves, and blood vessels.   During exercise, muscles swell and fluid enters the compartment spaces.  However, if the fascial wall of a compartment is too tight, blood flow may be cut off to the nerves and muscles.  This results in pain in the compartment, as well as pain or tingling in the area of the lower leg supplied by the compartment’s nerves.  

Men and women athletes are equally affected by the problem.  Athletes often get CECS in both legs. It is more common in running sports, basketball, gymnastics, soccer, field hockey, and dance.

Symptoms
CECS causes a dull or crampy lower leg pain which starts at some point during exercise.  If athletes stop and rest, the pain gradually goes away.  With each workout, the leg pain returns at the same time in the exercise routine.  If athletes do not stop exercising and try to push through the discomfort, the pain will increase in severity.  Athletes also may develop a squeezing sensation over the involved compartment, and may experience numbness, tingling, and/or burning in the lower leg and foot.  Some athletes may even feel like their foot is heavy or slaps the ground firmly while running.

Sports Medicine Evaluation and Treatment
A sports medicine physician will examine the athlete’s legs, which will likely appear normal.  X-rays and MRI studies may be ordered to exclude other causes of lower leg pain, but will be normal in CECS.  Athletes may be asked to run to reproduce the pain.  The sports medicine physician will then re-examine the legs when the pain is present.  To confirm that the problem is CECS, the physician will measure the pressure inside the compartments of the lower legs before and after exercise.  In CECS, the pressure in at least one of the leg’s compartments will be higher than expected after exercise..

Treatment for CECS initially involves rest and exercise modification to reduce symptoms. If athletes are willing to reduce the amount of exercise required for their sport, symptoms of CECS may go away. If athletes cannot change their exercise routine, or if changing the exercise program does not help, CECS is a condition that can be treated with surgery. An orthopedic surgeon can open up the tight fascial wall.  This procedure is called a “fasciotomy.”

Injury Prevention
Changing the way an athlete runs can prevent some types of CECS.  For athletes with very flat feet, arch supports may also help prevent CECS. Creatine use may increase the risk of developing CECS, and discontinuing this over-the-counter supplement may prevent the development of CECS symptoms.

Return to Play
Athletes with mild CECS may be able to continue to train. They tend to exercise at a level below the onset of their symptoms. If athletes require surgery for CECS, it typically takes about a month to return to sport, and some rehabilitation is usually required prior to returning to play.

AMSSM Author: Peter Seidenberg, MD

References

  1. Jackson KL, Abell BE. Soft tissue injuries of the leg, ankle and foot. In: O’Connor FG, Casa DJ, Davis BA, St. Pierre P, Sallis RE, Wilder RP, ed. ACSM’s Sports Medicine: a comprehensive review, Lippincott Williams & Wilkins, 2013.
  2. 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; 18(1):35-40.
  3. Edwards P, Myerson M. Exertional compartment syndrome of the lower leg: steps for expedient return to activity. Phys Sportsmed 1996; 24:31-7.
  4. Bruckner P. Exercise related lower leg pain: bone.  MSSE 2000; 32(3S):15-26.

Category: Leg and Thigh, Overuse Injuries,

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