/
Chronic Exertional Compartment Syndrome Chronic Exertional Compartment Syndrome

Chronic Exertional Compartment Syndrome - PowerPoint Presentation

phoebe-click
phoebe-click . @phoebe-click
Follow
435 views
Uploaded On 2017-04-01

Chronic Exertional Compartment Syndrome - PPT Presentation

Sathish Rajasekaran MD Clinical Assistant Professor Division of PMampR University of Alberta None Disclosures Introduction Anatomy Pathophysiology History and Physical Exam Diagnostic Evaluation ID: 532321

syndrome compartment exertional chronic compartment syndrome chronic exertional journal medicine leg sports pain treatment american surgery dec cecs clinical rajasekaran 2012 anterior

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Chronic Exertional Compartment Syndrome" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

Slide1

Chronic Exertional Compartment Syndrome

Sathish Rajasekaran, MD, Clinical Assistant Professor, Division of PM&R, University of AlbertaSlide2

None

DisclosuresSlide3

Introduction

Anatomy

Pathophysiology

History and Physical Exam

Diagnostic EvaluationTreatment

Outline

Have an approach to adding CECS to your differential diagnosis based on history and physical examinationOutline an approach to ordering the appropriate tests for patients where CECS is on the differential diagnosisOutline conservative and surgical treatment options for CECSOutline return to play guidelines for CECS

Objectives

Choric Exertional Compartment Syndrome (CECS)Slide4

Clinical Case

24 year old female – J.M.

History:

Classical symptoms?

Physical ExaminationAt rest vs. post-exertionDiagnostic TestingCompartment pressure testing vs. other imaging modalitiesOther studies to exclude other diagnosesTreatment optionsConservative (rehabilitation) vs. interventional options vs. surgerySlide5
Slide6

Epidemiology

Incidence

2,3

General population (unknown)

Undiagnosed leg pain (14-27%)Age4-8Potential bimodal distribution (20 [before 30] vs. 48 years)Association with sports4,9Involved in sports (87%)Running (69%)Diabetic patients with exertional leg pain and normal vascular studies (90%)Slide7

Location

Can present in various regions of the body

10

Lower leg, thigh, foot, and forearm

Lower leg most common region affected (95%)

10

Bilateral lower leg involvement (82%)4Slide8

Anatomy

40-60%

4,5

32-60%

4,5

12-35%

4,5

2-20%

4,5

Rajasekaran

S,

Kvinlaug

K,

Finnoff

JT. Exertional leg pain in the athlete. PM &

R.

Dec 2012;4(12):985-1000.Slide9

Pathophysiology

↓Compliance → ↑Compartment pressure?Slide10

Pathophysiology

Reduced microcirculatory capacity

Vascular congestion as a result of decreased venous returnSlide11

Pathophysiology

Abstract presented at AMSSM 2013 (Rajasekaran and

Aly

)Slide12

PathophysiologySlide13

History and Physical Examination

Pain with exertion

Dull → sharp pain

Neurological symptoms

Worsening over timePain with passive stretching of muscles in involved compartmentSlide14

Diagnostic Evaluation

Pressure testing

Pre-exercise (15 mm Hg), 1 min post-exercise (≥30 mm Hg), 5 min post-exercise (≥20 mm Hg)Slide15

Diagnostic Evaluation (Imaging)Slide16

Diagnostic Evaluation - Imaging

Bresler

M, Mar W,

Toman

J. Diagnostic imaging in the evaluation of leg pain in athletes. Clinics in sports medicine. Apr 2012;31(2):217-245

.Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol. Skeletal radiology. Nov 2007;36(11):1067-1075.Slide17

Diagnostic Evaluation - Imaging

Tib

Fib

TP

ATMG

Rajasekaran

S, Beavis C,

Aly

AR,

Leswick

D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2013;23(4):305-311.Slide18

Treatment

Conservative

Interventional

SurgerySlide19

Treatment – ConservativeSlide20

Treatment – InterventionalSlide21

Treatment - InterventionalSlide22

Treatment – Surgery

Single incision (open) technique

One or two incision (subcutaneous) technique with or without endoscopic assistance with the removal of a strip of fasciaSlide23
Slide24

Treatment - Surgery

24Slide25

Treatment - Surgery

Complications (11-16%)

28,29

Infection

Nerve or vascular injuryDeep vein thrombosisWound dehiscenceComplex regional pain syndromeScar hypersensitivitySeroma/hematoma formationSlide26

Treatment - Surgery

POD 1-2

Gentle active and passive range-of-motion, weight bearing as tolerated,

edema

control measures, basic activities of daily living, protect the healing incision at all times

POD 3-4

Achieve independence with activities of daily living, and begin unassisted ambulationWeeks 1-4Add stair climbing and increase walking distanceWeeks 4-6Begin non-impact lower extremity aerobic exerciseWeeks 6+

Initiate unrestricted impact lower extremity activitiesRajasekaran S, Kvinlaug K, Finnoff JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000.Slide27

Clinical Case

24 year old female – J.M.

Trialed forefoot running technique

Symptoms resolved

Repeat pressures were not donePatient continues to be asymptomatic (7 months)Slide28

Rajasekaran

S,

Kvinlaug

K,

Finnoff

JT. Exertional leg pain in the athlete. PM & R. Dec 2012;4(12):985-1000.Slide29

Introduction

Anatomy and

Pathophysiology

History and Physical Exam

Diagnostic EvaluationTreatmentReturn-to-Play Guidelines

Outline

Have an approach to adding CECS to your differential diagnosis based on history and physical examinationOutline an approach to ordering the appropriate tests for patients where CECS is on the differential diagnosisOutline conservative and surgical treatment options for CECSOutline return to play guidelines for CECS

Objectives

Choric Exertional Compartment Syndrome (CECS)Slide30

References

Horn

C. Acute

ischaemia

of the anterior tibial muscle and the long extensor muscles of the toes. J Bone Joint Surg Am. 1945;27(4):615-622.Qvarfordt P, Christenson JT, Eklof B, Ohlin P, Saltin B. Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clinical orthopaedics and related research. Oct 1983(179):284-290.

Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. The American journal of sports medicine. Mar-Apr 1988;16(2):165-169.

Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. The American journal of sports medicine. May-Jun 1985;13(3):162-170.Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. The American journal of sports medicine. Jan-Feb 1990;18(1):35-40.Slide31

References

Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. The Journal of bone and joint surgery. American volume. Dec 1983;65(9):1245-1251.

Wallensten

R. Results of fasciotomy in patients with medial tibial syndrome or chronic anterior-compartment syndrome. The Journal of bone and joint surgery. American volume. Dec 1983;65(9):1252-1255.Styf JR, Korner LM. Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. The Journal of bone and joint surgery. American volume. Dec 1986;68(9):1338-1347.

Edmundsson D, Toolanen

G. Chronic exertional compartment syndrome in diabetes mellitus. Diabetic medicine : a journal of the British Diabetic Association. Jan 2011;28(1):81-85.Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med. Mar 1997;31(1):21-27.Slide32

References

Rajasekaran S,

Kvinlaug

K,

Finnoff JT. Exertional leg pain in the athlete. PM & R : the journal of injury, function, and rehabilitation. Dec 2012;4(12):985-1000.Hurschler C, Vanderby R, Jr., Martinez DA, Vailas AC, Turnipseed WD. Mechanical and biochemical analyses of tibial compartment fascia in chronic compartment syndrome. Annals of biomedical engineering. May-Jun 1994;22(3):272-279.

Dahl M, Hansen P, Stal P, Edmundsson

D, Magnusson SP. Stiffness and Thickness of Fascia Do Not Explain Chronic Exertional Compartment Syndrome. Clinical orthopaedics and related research. Sep 24 2011.Edmundsson D, Toolanen G, Thornell LE, Stal P. Evidence for low muscle capillary supply as a pathogenic factor in chronic compartment syndrome. Scandinavian journal of medicine & science in sports. Dec 2010;20(6):805-813.Birtles DB, Rayson MP, Casey A, Jones DA, Newham DJ. Venous obstruction in healthy limbs: a model for chronic compartment syndrome? Medicine and science in sports and exercise. Oct 2003;35(10):1638-1644.Slide33

References

Aweid O, Del

Buono

A,

Malliaras P, et al. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2012;22(4):356-370.Roberts A, Franklyn-Miller A. The validity of the diagnostic criteria used in chronic exertional compartment syndrome: A systematic review. Scandinavian journal of medicine & science in sports. Sep 13 2011.

McDonald S, Bearcroft P. Compartment syndromes. Seminars in musculoskeletal radiology. Jun 2010;14(2):236-244.

Bresler M, Mar W, Toman J. Diagnostic imaging in the evaluation of leg pain in athletes. Clinics in sports medicine. Apr 2012;31(2):217-245.Litwiller DV, Amrami KK, Dahm DL, et al. Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol. Skeletal radiology. Nov 2007;36(11):1067-1075.Slide34

References

Rajasekaran S, Beavis C,

Aly

AR,

Leswick D. The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Jul 2013;23(4):305-311.Kirby RL, McDermott AG. Anterior tibial compartment pressures during running with rearfoot and forefoot landing styles. Archives of physical medicine and rehabilitation. Jul 1983;64(7):296-299.

Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. International journal of sports physical therapy. Dec 2011;6(4):312-321.

Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome. The American journal of sports medicine. Mar 16 2012.Isner-Horobeti ME, Dufour SP, Blaes C, Lecocq J. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study. The American journal of sports medicine. Nov 2013;41(11):2558-2566.Slide35

References

Wittstein J, Moorman CT, 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. The American journal of sports medicine. Aug 2010;38(8):1661-1666.

Packer

JD, Day MS, Nguyen JT, Hobart SJ,

Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. The American journal of sports medicine. Feb 2013;41(2):430-436.Waterman BR, Laughlin M,

Kilcoyne K, Cameron KL, Owens BD. Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. The Journal of bone and joint surgery. American volume. Apr 3 2013;95(7):592-596.

Brennan FH, Jr., Kane SF. Diagnosis, treatment options, and rehabilitation of chronic lower leg exertional compartment syndrome. Current sports medicine reports. Oct 2003;2(5):247-250.Slide36

Acknowledgments

Dr. Jonathan Finnoff