1. Chronic Exertional Compartment Syndrome

2. Normal Anatomy Lower leg divided into 4 compartments Anterior Deep peroneal nerve Tibialis anterior Long toe extensors Anterior tibial artery and vein Lateral Peroneus longus and brevis Superficial peroneal nerve Superficial posterior Gastrocnemius Soleus Distal segment of the sural nerve Deep posterior Tibialis posterior Long toe flexors Posterior Tibial artery and vein Posterior Tibial nerve Muscle volume can increase up to 20% of its resting size during exercise

3. Pathology Muscle volume increases with exercise As volume increases within a fascial and osseous boundary it increases the internal pressure Blood flow becomes insufficient for metabolic requirements Symptoms occur bilaterally in 70-80% of people

4. Mechanism of Injury Insidious Excessive loading through lower limb Poor biomechanics Excess training volume Sudden changes in loading Excess training time Hopping, running, jumping sports Changing environment Changing footwear

5. N.B Acute Compartment Syndrome from trauma is a medical emergency

6. Classification Anterior Compartment (deep peroneal nerve) Loss of sensation first web space Weakness dorsiflexion and toe extension

7. Classification Lateral Compartment (superficial peroneal nerve) Loss of sensation dorsum of the foot Weakness of foot eversion

8. Classification Superficial Posterior Compartment (distal segment of the sural nerve) Loss of sensation lateral foot and distal calf

9. Classification Deep Posterior Compartment (posterior tibial nerve) Loss of sensation plantar aspect of the foot Weakness of plantar flexion

10. Subjective Examination Leg pain with prolonged use Gets better upon cessation of activity Described as pain/tightness/discomfort/burning/pressure Occurs a similar time/distance/intensity of exercise Numbness or tingling in peripheral nerve distribution Weakness of affected muscles

11. Objective Examination Usually normal at rest Examination after exercise is useful Pain on palpation of involved muscles Pain with passive stretching Firmness of compartment Sensation and Motor changes relevant to specific compartment Muscle herniation through fascia (40-60% of people) Biomechanics Anterior Compartment Prolonged ankle dorsiflexion and reduced ankle plantarflexion Audible “Slapping” during heel strike Posterior Compartment Increased forefoot running

12. Further Investigation Measurement of intracompartment pressure MRI Near – infrared spectroscopy

13. Management Only definitive treatment is fasciotomy Conservative management focused on altering the load during running External Factors Reduce training time/distance/environment/intensity Internal Factors Decrease stride length Biomechanics Muscle length/strength

14. Conservative Reduce pain and inflammation Massage Ice NSAID’s Orthotics Appropriate loading Reduce stride length Restore Normal Range of Movement Ankle, Knee and Foot Soft tissue massage Foam rolling Stretching Dry needling Joint mobilisations Joint manipulations Restore Normal Muscle Activation Tibialis Anterior Plantarflexors Invertors and Everters Hip External Rotators and abductors Restore Dynamic Stability Proprioceptive work Return to sport/activity specific exercise Gait re-education – forefoot running and decrease stride length Gradually increasing running time/distance

15. Plan B Fasciotomy

16. References Flautt, W. and J. Miller (2013). "Post-surgical rehabilitation following fasciotomies for bilateral chronic exertional compartment syndrome in a special forces soldier: a case report." Int J Sports Phys Ther 8(5): 701-715. Franklyn-Miller, A., A. Roberts, D. Hulse and J. Foster (2014). "Biomechanical overload syndrome: defining a new diagnosis." Br J Sports Med 48(6): 415-416. George, C. A. and M. R. Hutchinson (2012). "Chronic exertional compartment syndrome." Clin Sports Med 31(2): 307-319. Helmhout, P. H., A. R. Diebal, L. van der Kaaden, C. C. Harts, A. Beutler and W. O. Zimmermann (2015). "The Effectiveness of a 6-Week Intervention Program Aimed at Modifying Running Style in Patients With Chronic Exertional Compartment Syndrome: Results From a Series of Case Studies." Orthopaedic Journal of Sports Medicine 3(3). Hutchinson, M. (2011). "Chronic exertional compartment syndrome." Br J Sports Med 45(12): 952-953. Tucker, A. K. (2010). Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med. New York. 3: 32-37.