Note: I’m going to start by apologizing to all of my readers in the northeast who have received a tremendous amount of snow in recent days. It has been an amazing weekend here in Charleston, especially for the last weekend in January. Afternoon temperatures have been in the mid-60s, so we can enjoy the warm, sunny weather in long-sleeve T-shirts and shorts. This is one of the main reasons that it’s great to live here. The weather is probably also the reason there are so many runners outside this weekend, as it’s the first weekend in a long time that they can train outside instead of running on treadmills. With The Cooper River Bridge Run just over two months away, many runners are ramping up their training for the yearly event.
This week’s Ask Dr. Geier column deals with an uncommon problem, but one that is fairly disabling to a small number of runners. If you are a runner that has leg pain that isn’t improving, read this column and see if your symptoms are similar. Whether or not it is chronic exertional compartment syndrome, it might be worth checking out. As always, please refer to my disclaimer about discussing specific medical information by e-mail or online. Enjoy the weather!
Carl in San Bernardino, California asks:
I recently saw a podiatrist in California, and she said I probably have chronic exertional compartment syndrome, but she doesn’t have the equipment to perform the compartment pressure test. She has called some other podiatrists, and they don’t perform the test either. I have also contacted three other orthopaedic surgeons, and they do not do this test either. If I do I have CECS, I would like to get this test and get the surgery done by someone who has experience with this procedure. I love to run, and I want to get back to running as soon as possible.
This is a fantastic question. For readers unfamiliar with the problem, chronic exertional compartment syndrome is a somewhat rare but often difficult problem for athletes. In my experience, it is almost always seen in runners, as the repetitive impact exacerbates the problem.
The muscles of the leg are separated into compartments. Layers of tissue called fascia surround the muscles and separate the compartments. In chronic exertional compartment syndrome, the athlete starts to develop swelling in one or more of the muscle compartments of the leg. This happens to some extent in all runners, but in these athletes, the swelling is significant. Unfortunately there is only so much room in each compartment for the muscles to swell because the fascia binds them. With increased swelling, something has to give, so to speak. Usually the muscle swelling within tight compartments leads to compression of the nerves and blood vessels in those compartments.
An athlete with this problem complains of achy leg pain and tightness that comes on fairly quickly after starting to run. He or she often notices numbness and tingling in the foot due to the nerve compression. Initially the tightness and numbness and tingling improve after the runner stops, but as the problem continues, it can take longer and longer to improve after a run. Occasionally a patient with chronic exertional compartment syndrome also has symptoms with rapid walking.
Patients with symptoms such as these often seek evaluation because they cannot run effectively. Some of the patients don’t have classic symptoms and just complain of leg pain. The differential diagnosis of leg pain in a runner includes stress fractures, shin splints, and some less common problems. In these situations where the diagnosis is unclear, muscle testing is often used, as x-rays and MRIs are often not helpful.
Compartment pressure testing is not exactly the easiest or most enjoyable test. The sports medicine physician will place the patient on a treadmill for five minutes. Just before the test, at one minute, and at five minutes, the doctor will stick a needle in the muscles of each compartment to measure pressures within the muscle. If the values exceed a certain level at various times, the diagnosis of chronic exertional compartment syndrome is made.
Unfortunately, not all sports medicine offices have the monitors or treadmills. It is also somewhat labor-intensive and requires scheduling the test ahead of time, so many practices choose not to perform these tests. In my practice and in several practices of sports medicine physicians I know, if the patient has classic symptoms, one could consider skipping the test and going straight to treatment.
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Chronic exertional compartment syndrome is unfortunately a problem that is unlikely to improve with nonoperative treatment. I am a huge advocate of physical therapy, but it is unlikely to help this problem long-term. While runners might be willing to switch to other forms of exercise, if the symptoms return with a return to running, they usually do not want to give up running forever.
Surgery is usually necessary to resolve this problem. The surgeon makes incisions on one or both sides of the leg, releases the fascia, and closes the skin. This procedure allows the muscles to swell without being bound by the fascia. If the diagnosis of chronic exertional compartment syndrome is correct, and if surgery was performed before the muscle has suffered any long-term degeneration, surgery usually relieves the symptoms completely. It takes several weeks for the skin incisions to heal and the leg swelling to resolve, but the athlete can usually get back to running in 4-6 weeks.