Service available for patients suffering from compartment syndrome / exercise related leg pain

Figure.1. Cross sectional anatomy (from left – right): leg, foot and forearm.

Clinical picture: The patient typically presents with pain and tightness on exercise, which is only relieved by variable period of rest, usually few minutes. When pain occurs they have to stop. They can usually differentiate between symptom of tightness and cramp. In some cases they may experience reversible transient paraesthesia and numbness. It is usually bilateral and commonly affects the anterior compartment but can occur in the deep posterior compartment. Superficial posterior and peroneal compartments are very rarely affected. There are however, large variation when the foot and forearm are involved.

Pathophysiology: It is postulated that increase in ICP in CECS may occur for 3 main reasons:
(1) Stiff fascia,
(2) Large muscle or,
(3) Small compartment.
Qvarfordt et al (1983) and Styf et al (1987) measured intramuscular pressure and muscle blood flow during exercise. They summarised that the intramuscular pressure was significantly increased at rest and during and after exercise as compared with normal subjects. Biopsies of the anterior tibial muscles showed increased water content, which may explain the elevated pressures. Muscle blood flow during exercise as measured by the xenon-133 clearance technique was decreased, and muscle lactate concentration was increased in the anterior tibial muscles. Fasciotomy relieved pain and normalised intramuscular pressure, muscle blood flow, and skeletal muscle metabolism.

Investigation: Gold standard investigation is dynamic intra-compartment pressure (DICP) test which should generate information on maximum, mean, relaxation and resting pressure, together with a pressure tracing for on the spot interpretation and evaluation.

Treatment: Surgery – Superficial fasciotomy or fasciectomy. Choosing the right surgeon is vital. Keep away from surgeon who operated in the middle 2 legs below.

DYNAMIC INTRA-COMPARTMENT PRESSURE MEASUREMENT (DICPM) FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME (CECS)

Currently there are 2 main methods of assessing intra-compartment pressure (ICP) in a muscle compartment:

1. Static method. This involves inserting a needle linked to a manometer into the compartment under investigation. This is widely used in UK mostly in A&E departments to monitor acute compartment syndrome but has limited use in investigating for Chronic Exertional Compartment Syndrome (CECS) as the latter is a problem that occurs at the time of exercise, despite best effort of clinicians to look at ICP pre and post-exercise, it has limitations. It is non-dynamic, limited to superficial compartments (usually anterior compartment), only one compartment is assessed at any one time, there is no tracing so difficult to check when the tip of the needle is blocked. There is a modified version of this but the catheter length is

short and not entirely suitable for observation of ICP change during exercise.

There has been criticism of this method¹ and further blog in Clinical Journal of Sports Medicinel² (http://cjsmblog.com/category/general-interest/page/2/

2. Dynamic method. A comprehensive system like the one I use is not widely available and the only other centre that provides this facility is in Leicester. This DICPM system involves cannulating the compartments (Fig.2.) under investigation under a local anaesthetic and threading a Rorabeck catheter which is then linked to a pressure transducer (Fig.3.) linked to digital box which records on-line pressure change which is displayed on a monitor in a form of tracing.

This system allows for monitoring of pressure in multiple compartments (maximum 4) at the same time and with long leads, allows patient to jog on the spot (Fig.4.) for 60 seconds (maximum, mean and relaxation pressures) with 30 seconds rest (Fig.5.) (resting pressure). The system is versatile enough to allow exercise in the activity (Fig.6A&B.) that brings on the symptoms. This is critical as ICP increase is often exercise specific³. The tracing is crucial as it allows assessment of the catheter, whether it is blocked, kinked, not in the compartment or, has slipped and sitting under the skin. It also allows for the assessment of 4 separate variables of ICP i.e. maximum pressure, mean pressure, relaxation pressure and the resting pressure.

Chronic exertional compartment syndrome – the case for the trace. Guest blog by Drs Nat Padhiar & Osama Aweid

July 17, 2012

In our view, looking at intra-compartment pressure for the diagnosis of chronic exertional compartment syndrome (CECS) without visualising a pressure tracing is like trying to interpret an ECG without the ECG tracing. How do you know what is wrong with the cardiac muscle? We are not for one minute suggesting that the two conditions are the same, but would like to put forward an argument for intra-compartmental pressure (ICP) testing using a pressure tracing as a very useful and more objective tool in making a diagnosis of CECS.

A pressure tracing can provide the following data which can be very useful.

(1) It allows an opportunity to check whether the catheter is in the right compartment and that the catheter is patent by squeezing the compartment that is being investigated (Fig.7.)

(2) One can measure maximum, mean, relaxation and resting pressures (Fig.8.)

(3) It can detect blockage at tip of the catheter, from wave form changes.
(4) It can detect whether the catheter has slipped and sitting under the skin, from wave form changes.
(5) It can detect whether it is part or fully in the blood vessel, from wave form changes.
(6) In some patients, the increase in ICP is exercise specific. ICP with tracing allows for comparison between different exercises at the time of testing. (Fig.9.)