The Impact Of Exercise-Induced Compartment Syndrome On Athletes

Are we as podiatrists accurately diagnosing and treating athletes with exercise-induced compartment syndrome? Although scope of practice or privilege restrictions may not allow all podiatrists to do compartment releases of the leg, shouldn’t we all be able to spot this diagnosis? I stress to my residents the importance of developing a differential diagnosis for chronic leg and ankle pain. We see this weekly among our athletes and my soldiers at Ft. Leonard Wood Community-Based Hospital in Missouri.

In 2010, Tucker characterized exercise-induced compartment syndrome as an underdiagnosed condition, concluding that providers often overlook or ignore leg pain, leading to an average delay in diagnosis of 22 months.¹ One only has to do a literature search on compartment releases to see that everyone has their own take. Tucker concluded that release should only include involved compartments. Anterior and lateral compartments have a greater than 80 percent success rate. The deep posterior compartment has a much lower success rate of 50 percent.¹ Once you start looking at a military population, overall success is substantially worse. In 2020, Vogels and colleagues’ comprehensive review of the literature found that the military did far worse than civilian patients with exercise-induced compartment syndrome irrespective of surgical technique.² They cited higher re-operation, complication and recurrence rates among the military cohort (see table above).

The focus of this column is on evaluation, diagnosis, and the evermore complicated discussion on treatment for this condition. In classic cases, I think we all can identify exercise-induced compartment syndrome in patients who say, “I run, my foot goes numb, my leg gets tight, I often trip when running hills after a few miles, etc.” Nevertheless, how many of our athletes simply complain of shin splints, when the case is really not so simple? Unfortunately, thanks to the internet, some patients present to us already thinking they know their diagnosis and precise treatment needs. A runner, for instance, may come in expecting a seven-degree extrinsic post on their insert for their pronation. We cannot allow these assumptions to steer us in the wrong direction. Conversely, I have Marines that simply present with the mantra, “Fix me!” No internet searches for them.

Diagnostic Clues And Pertinent Aspects Of The Patient Presentation

So many of our athletes present to our practices with shin splints, posterior tibial tendonitis, peroneal tendonitis, anterior tarsal tunnel, or are simply over-pronators; however, are we missing the big picture? My point is simple, we must perform a good biomechanical examination and keep exercise-induced compartment syndrome in the back of our minds. So few patients present with definitive symptoms. Why? Because we are not necessarily making our patients run on the first visit. Symptoms purely rely on the patient’s memory, which I frankly find isn’t that reliable.    

When one sees as many exercise-induced compartment syndrome cases as we do in the military, one starts to see less textbook presentations and may initially dismiss tell-tales clues because the patient does not fit the “classic” profile. In my experience, we tend to classify that classic patient with exercise-induced compartment syndrome as short in stature, with thick calves, and short legs. Whether the cause is too-intense training or not being in optimal sport shape (which we discussed in my previous “Occult Stress Fracture” column), this condition occurs in all shapes and sizes, just as we see with stress fractures. It is all part of the continuum of stress.       

I have worked with a handful of surgeons who took patients to the operating room and performed four-compartment releases based solely on the patient’s description of their symptoms. That is simply unacceptable, especially considering patients can continue to have pain and inability to resume sports or military activities. Salzler and team, in 2020, reported that despite the literature reporting very high satisfaction rates for compartment releases, their series of competitive runners found only 56 percent returned to competitive level activity and 19 percent had recurrent symptoms.³ So, we owe it to our patients to work them up properly and diligently.

Once you determine that a patient has all the clues for exercise-induced compartment syndrome, you have to go the extra mile, literally. Video recording your athletes running or playing their sport can reproduce their symptoms. That may mean going to the track, the hospital gym, or like I do, having soldiers run the hallways and stairwells in the hospital. You have to see what they are feeling firsthand and examine these patients before and after exercise. In my experience, one is far more likely to catch a muscle herniation, a subluxing peroneal tendon, or anterior tibial tendon weakness after exercise. More infrequently, one may even diagnose a neurologic condition like Charcot Marie Tooth or disc herniation after exercise than before.

When Should One Pursue Testing For Exercise-Induced Compartment Syndrome?

Once you isolate the affected compartments, then and only then do I feel compartment testing is a consideration. Here is where the controversy starts. I never jump to compartment testing. Instead, I bring the patient back for another appointment to simply discuss their long-term career outlook as an athlete or soldier in light of this condition. I paint a bleak picture for the patient. If we perform compartment testing and find elevation, in my experience, we are medically and legally obligated to pursue surgery. I stress that if we perform compartment releases, that statistically the likelihood of resuming their sport is very low and gets worse with each compartment released.

With my soldiers, in my experience, the likelihood of medical discharge for failing to resume full duty is 50 percent or higher. And, if all four compartments are released, the likelihood of medical discharge approaches 100 percent. That stat has never improved during my 30-year career for my colleagues and me. So the success rate of getting athletes back to their sport is very poor.

I then pull out the needle and show them the Wicks catheter. If they are still sitting in the exam room, I ask, “Are you paid to run? Is your livelihood contingent on you playing this sport?” If any answer is a “yes,” then and only then do I pursue testing before and after exercise. Otherwise, I find the best treatment is no treatment and ceasing the inciting sport.

At this time, people start fantasizing that there must be other ways to diagnose and treat compartment syndrome. Of course, many surgeons will look at bone scans, MRIs, ultrasound, or other modalities, but pressure is pressure. By all means, I encourage surgeons to stall testing because there is no turning back. We are obligated to stress that to our patients. When testing, it must always conclude with surgery if pressures are abnormal. And in many cases, these patients will not only have high pressures with exercise but also present with abnormally high resting pressures. Sure, you don’t see a vast delta change between pre- and post-exercise, but having a resting pressure of 35 mmHg is abnormal. I’m aware of numerous studies that use higher normal values in military versus civilian cohorts. I routinely use 30 mmHg as my benchmark, despite some studies declaring anything above 15 mmHg as abnormal.

Packer and Beck, in 2019, concluded that so many studies showed that patients who had lower resting pressures had far worse results than those with higher resting pressures regardless of their post-exercise pressures.⁴ Thus, it is so critical not to operate on patients who are NOT on the lower end of “abnormal.” Thus, I tend to focus on 30mmHg values regardless of the resting and post-exercise change.

In 2008, Baltopoulos and team performed a study on asymptomatic 5000 m runners, testing compartment pressures before, during, and after running, finding asymptomatic exercise pressures between 18 and 27mmHg.⁵ Based on those numbers, many of those patients’ pressures would have been considered abnormal. The key is, five minutes after exercise, the majority returned to 17 mmHg. With symptomatic patients, not only will the pre- and post-exercise pressures be higher, but the return to more normal levels will take much longer than five minutes in symptomatic patients. This study clearly shows that pressures can and will rise with exercise, but should return to normal afterward. However, symptomatic patients may take hours, or even days to resolve those pressures, having continued symptoms throughout their recovery. This is why it is so critical to utilize greater than 30 mmHg as the benchmark.    

One telling story is about a recent soldier on whom I did perform compartment releases. A different army base measured her compartment pressures in 2018. One compartment revealed a resting pressure of 45 mmHg and exercise pressure of 50 mmHg. Two different surgeons argued whether the difference between resting and exercise was significant. In my experience, the difference is important, but far too often, clinicians focus on the delta, and not the fact that her resting pressure was already abnormally high. We can argue what is normal, but pain daily with all activity, plus any pressure above 30 mmHg is significant. Three years later, she presented to our practice, still with constant leg pain. I tried my best to talk her out of re-testing and simply encouraged her to get out of the Army. Since that initial testing, she had seen three different podiatrists and four orthopedists, all giving her inserts and NSAIDs. No one offered to re-test, discussed medical discharge, or suggested that she stop running. She deployed two different times and struggled in pain each time. She has since had compartment releases on one leg, and will on the other by the time this article is published. Ultimately, I believe she will never run pain-free again. Her one leg is significantly better, but the writing is on the wall for a medical discharge.

Final Thoughts

Whether or not we treat compartment syndrome, we have to be familiar with the signs and symptoms. Having a complete understanding of the anatomy and what structures can exhibit symptoms is crucial (see table on page 28).  We, as podiatrists, are too often consulted for specific symptom(s) that almost always link with compartment syndrome. We must not jump to shin splints or peroneal tendonitis, and instead look out for the big picture. We need to advocate for our patients because other specialties may not put it all together. We need to be prepared to present the harsh reality to our athletes that perhaps their sport or activity is not something they should struggle to do.

Telling a soldier that their career is over is no fun. Telling a high school cross-country runner to stop is easier, I find, because they have so little time invested and often are simply not very fast. Dealing with a collegiate basketball player who has undergone tibial nailing and struggled to play games but couldn’t practice due to ongoing leg pain is also difficult. Shouldn’t we intervene?

No, in my observation, it is simply time to stop playing all together regardless of talent. It is very hard to accept and convey this concept, and we see many high-profile players end their careers due to chronic leg pain. However, it is even worse to see a soldier convert exercise-induced compartment syndrome into an acute compartment syndrome after a 20-mile ruck march trying to complete the final phase of Ranger School or Special Forces training. Emergent compartment releases with full-scale muscle death is an awful situation I have seen far too often. Debriding dead muscle is the most horrible surgical experience I have ever had to deal with, far worse than dealing with landmine injuries, in my opinion, simply because compartment syndromes are avoidable! 

Dr. Spitalny is a staff podiatrist at General Leonard Wood Army Community Hospital and Adjunct Faculty of the SSM Depaul Podiatry Residency Program in St. Louis, Mo.

References

1. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med. 2010;3(1-4):32–37.

2. Vogels S, Ritchie ED, van Dongen TTCF, Scheltinga MRM, Zimmerman WO, Hoencamp R.  Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg. Scand J Med Sci Sports. 2020;30(10):1827–1845.

3. Salzler M, Maguire K, Heyworth BE, Nasreddine AY, Micheli LJ, Kocher MS. Outcomes of surgically treated chronic exertional compartment syndrome in runners. Sports Health. 2020;12(3):304–309.

4. Buerba RA, Fretes NF, Devana SK, Beck JJ. Chronic exertional compartment syndrome: current management strategies. Open Access J Sports Med. 2019;10:71–79.

5. Baltopoulos P, Papadakou E, Tsironi M, Karagounis P, Prionas G. Pre, during, and post exercise anterior tibial compartment pressures in long distance runners. J Sports Sci Med. 2008;7(1):96–100.