CECS of the lower leg is a condition of pain induced by exercise. CECS accounts for 14-33% of
lower leg pain in athletes, evenly divided among males and females. Symptoms are described as
a tight, cramp like ache that occurs at a well-defined and reproducible point in the exercise
bout and increases if the training persists. Relief of symptoms typically occurs within 30
minutes of ending the activity.
The anterior compartment is most commonly affected, followed by the deep posterior, the
lateral and the superficial posterior compartment. Often more than one compartment in the
same leg is involved, and the condition is reported bilateral in up to 95% of affected
athletes.
The pathophysiology of CECS is not fully understood. It is, however, generally agreed that
exercise induces abnormal elevation in ICP, which interferes with tissue perfusion and cause
painful ischemia affecting the nerves and impairing muscle function. A noncompliant muscle
compartment, which is unresponsive to the expansion of muscle volume that occurs with
exercise, offer a possible pathophysiological explanation for CECS. However, this view is
challenged by a study reporting no difference in fascial thickness and stiffness between CECS
patients and healthy controls. Furthermore, the thickness of the anterior compartment
increased more with exercise in CECS patients relative to controls, questioning decreased
compliance as the main pathophysiology in CECS. The definition of a pathologically elevated
ICP during exercise is important for the diagnosis of CECS and is currently debated. The
criteria suggested by Pedowitz is used as standard by most clinicians for the diagnosis of
CECS: 1) a pre-exercise pressure of 15 mmHg or greater, and/or 2) a 1-minute post-exercise
pressure of 30 mmHg or greater, and/or 3) a 5-minute post-exercise pressure of 20 mmHg or
greater. The precision and diagnostic value of these commonly used criteria is debated, due
to a reported overlap in ICP readings between patients and healthy controls at certain time
points. Interestingly, in a small cohort of asymptomatic rollerskiers ICP was elevated,
according to the Pedowitz criteria, in 100% of participants after 20 minutes of exercise.
Despite these uncertainties, it is suggested that ICP measured 1-minute after ceasing
exercise has the highest diagnostic value, as it most consistently display higher values in
patients with CECS symptoms relative to healthy controls. The different types of catheters
(slid catheter, side-port, straight-needle) also clearly influence the absolute values of the
measurements and the catheter tip can be wrongfully placed outside the compartment by
experienced health professionals in up to 21% of cases when positioned without ultrasound
guidance.
Non-invasive modalities such as magnetic resonance imaging (MRI), near infrared spectroscopy
(NIRS) and ultrasound measurements have been suggested as future adjuncts or alternatives for
diagnosing CECS, but their diagnostic value remains to be established.
In summary, it is generally agreed that ICP measurements are important for diagnosing CECS,
but several studies question current practice including the mentioned criteria and
particularly the use of non-ultrasound guided catheter positioning.
Both conservative and surgical treatment options are suggested in the literature.
Conservative treatment, including physiotherapy, has been attempted with varying success and
is generally believed by many to be insufficient for the long-term treatment of CECS.
However, inducing muscle hypotrophy via injection of botulinum toxin, was efficient in
reducing exercise induced pain in CECS patients, but also resulted in decreased muscle
strength, although without measurable functional consequences. Interestingly, changing the
gait pattern in order to achieve a forefoot/midfoot strike during running, which potentially
decrease pressure in the anterior compartment and eccentric load of the anterior compartment
muscles has proven successful for treatment of anterior CECS. These studies suggest a role
for non-operative treatment of CECS, but to our knowledge, no randomized controlled studies
exist regarding the effect of physiotherapy or other non-surgical interventions.
Surgical fasciotomy, with release of the compartment(s) with elevated intra-compartmental
pressure, has been shown by many investigators to be effective using both open, mini-open and
endoscopically assisted techniques. There are, however, considerable variations in the
reported outcomes of surgery. In a large cohort, 45% had symptom recurrence after surgery and
16% experienced surgical complications including infection, neurological damage, and
hematoma. Moreover, the need for revision surgery can be as high as 11%. Other groups report
more successful outcome of surgery with patient satisfaction of 60 to 90%, including a
retrospective follow-up study, in which operation was successful in 81% of patients and
non-operative treatment successful in only 41% of patients.
CECS is a common condition in athletes and although disagreements exist, the diagnosis is
typically made based on a history of pain in the calf muscles during exercise that resolves
within 30 minutes of ending the activity as well as a positive ICP reading. Typically the
patients are offered fasciotomy if the symptoms persist.
No studies have compared the effect of fasciotomy to any non-surgical treatment strategies in
a randomized controlled setting. Moreover, correlation between symptom severity, ICP
measurements, muscle compartment compliance and perfusion, and effect of treatment is not
fully elucidated. Finally, the possible effect of changing the landing pattern in combination
with physical therapy has not been attempted in a randomized setting.
It is hypothesized that physiotherapy including a change in running landing pattern and
surgical fasciotomy are equally good as treatment options for chronic exertional compartment
syndrome (CECS) of the anterior compartment of the lower leg.
The endpoints/outcomes are:
Change from week 0 (start of study) to week 12 (completion of intervention) in: patient
reported outcome measure (PROM) (Exercise induced leg pain Questionnaire (EILP)).
Secondary outcomes are: Visual Analogue Scale (VAS) score after an "exercise provocation
test": Change in intracompartmental pressure (ICP)Change in muscle compartment compliance.
Change in Global Rating of Change Score/Scale (GRC). Change in Single Assessment Numeric
Evaluation (SANE)
The study is important because:
Results from recent studies suggest that physiotherapy represents a valid alternative to
surgery for the treatment of CECS. Surgery is currently standard treatment and a change
towards physiotherapy as primary treatment could potentially reduce both complication
rates and costs.
Intracompartmental pressure (ICP) is gold standard for diagnosing CECS. However, the
association between ICP and symptoms of CECS, both before and after physiotherapeutic
and surgical treatment, muscle compartment compliance and intracompartmental perfusion,
has not been thoroughly investigated.