The fascia surrounding the posterior tibialis muscle is theorized to form a 5th compartment.Įlevation of IMP is believed to occur in response to physiologic and pathologic changes, including muscle hypertrophy, intracompartmental fluid, and fascial thickening, whose effect is enhanced by a 20% muscle volume increase during strenuous physical activity. The anterior and deep posterior compartments contain the anterior tibial and posterior tibial artery and vein, respectively. Each consists of specific muscles and nerves contained within non-compliant fascial and osseous boundaries. The lower leg is divided into 4 main compartments: anterior, lateral, superficial posterior and deep posterior. 10 This should be considered and assessed via a similar diagnostic pathway, though there are few studies into the diagnostic criteria, testing modalities, and therapeutic interventions. CECS of the foot has been reported and is likely under-recognized. 9 Most common associated activities were running then soccer.Ĭhronic exertional compartment syndrome predominantly affects the lower leg, although CECS may also present in the upper extremity and rarely in the upper leg.
In the pediatric population, one study has suggested that females are at highest risk of LLECS with a peak age incidence of 16 years-old. 5 New research has also questioned if sex may influence the diagnostic testing criteria for CECS. Most recently, a large study has found equal prevalence of CECS in males and females, however, males were more likely to receive a diagnosis of CECS they also noted that findings of a higher prevalence of CECS in males in other studies may have limitations for interpretation due to selection bias of those enrolled. While there are conflicting reports, there is no clear sex bias. The Army had the highest prevalence of LLCES. 7,8 Amongst this group, women and Caucasian ancestry were found to be independent risk factors. The United States military is considered a high-risk cohort with an adjusted annual incidence of up to 0.33-0.5 cases per 1000 person-years. The deep posterior compartment is more often affected in soccer players, while the anterior compartment is associated with speed skating and non-sports activities. Location of LLECS can be sport or activity-dependent. 5 Risk factors include jumping, cutting, and skating sports. 5,6 The presence of unilateral symptoms is associated with prior trauma and vasculopathy. 5 Bilateral lower extremity involvement occurs in 85-95% of cases with a predilection for the anterior and deep compartments.
LLECS has a median age of onset of 20 years old, and the prevalence decreases with age, though it has been suggested that there is an underdiagnosed population within older adults, plateauing around age 50. 3,4 A vast majority (87%) of patients with LLECS participate in sports, with running accounting for 69%. In fact, this may be under-appreciated secondary to poor awareness among medical providers and the public, as illustrated by an average of 22 months from symptom onset to treatment. The incidence of LLECS in the general population is unknown, although some estimate that it accounts for 14-27% of previously undiagnosed exercise-induced leg pain.
Epidemiology including risk factors and primary prevention 2 Functional muscular compression and associated occlusion of vasculature has been proposed to create elevated hydrostatic pressures and fluid accumulation within the compartments, thereby explaining the elevated IMPs and common findings on imaging modalities. 1 It has been recently suggested that venous outflow occlusion may play a significant role in increased compartment pressures and symptom development. There are several proposed contributing factors, which vary from noncompliant anatomical tissues to deviations of anatomical features and build-up of metabolic byproducts. The exact mechanism by which this occurs remains unclear. The increased intra-compartmental pressures are thought to impede tissue perfusion, create a relative oxygen debt, and result in symptom onset. The exact mechanism that causes exertional compartment syndrome is unknown. Symptoms are absent at rest, occur at a well-defined distance, duration or intensity of exercise, and only subside by discontinuation of provoking activity once elicited. Lower limb exertional compartment syndrome (LLECS), also known as chronic exertional compartment syndrome (CECS), is an overuse syndrome characterized by exercise-induced elevation of intramuscular pressures (IMP) that results in reproducible transient pain, paresthesias, and neuromuscular dysfunction.
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