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 Chronic exertional compartment syndrome

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PostSubject: Chronic exertional compartment syndrome   Chronic exertional compartment syndrome EmptyThu Jan 20, 2011 3:09 pm

Chronic exertional compartment syndrome
Filed under: Boomer's Health
Chronic exertional compartment syndrome is an uncommon, exercise-induced
neuromuscular condition that causes pain, swelling and sometimes even
disability in affected muscles of your legs or arms.

Anyone can develop chronic exertional compartment syndrome, but it's
more common in athletes who participate in sports that involve
repetitive movements, such as running, fast walking, biking and
swimming. Chronic exertional compartment syndrome is sometimes called
chronic compartment syndrome or exercise-induced compartment syndrome.

Conservative treatments typically don't help with chronic exertional
compartment syndrome. However, surgery is usually successful, allowing
you — whether you're a recreational or serious athlete — to return to
your sport.

©
Symptoms

The pain and other symptoms associated with chronic exertional compartment syndrome may be characterized by:

* Aching, burning or cramping pain in the affected limb — usually
the lower leg, but sometimes the thigh, upper arm, forearm or hand
* Tightness in the affected limb
* Numbness or tingling in the affected limb
* Weakness of the affected limb
* Foot drop, in severe cases, if nerves in your legs are affected
* Occasionally, swelling or bulging as a result of a muscle hernia

Pain due to chronic exertional compartment syndrome typically follows this pattern:

* Begins soon after you start exercising the affected limb
* Progressively worsens as long as you exercise
* Stops 15 to 30 minutes after the affected limb comes to rest
* Over time, may begin to persist longer after exercise, possibly lingering for a day or two

Taking a complete break from exercise may relieve your symptoms, but
usually only temporarily. Once you take up running again, for instance,
those familiar symptoms usually come back.

When to see a doctor
If you experience unusual pain, swelling, weakness, loss of sensation,
or soreness related to exercise or sports activities, talk to your
doctor because these symptoms may be associated with conditions that
require emergency medical treatment. Don't try to exercise through the
pain, as that may lead to permanent muscle or nerve damage — and
jeopardize continued participation in your favorite sports.

Sometimes chronic exertional compartment syndrome is mistaken for shin
splints. If you think you have shin splints but they don't get better
with self-care, talk to your doctor.

©
Causes

Your arms and legs have several groupings, or compartments, of muscles,
blood vessels and nerves. Each of these compartments is encased by a
thick layer of connective tissue called fascia (FASH-ee-uh), which
supports the compartments and holds the tissues within each compartment
in place. The fascia is inelastic, which means it has little ability to
stretch.

In chronic exertional compartment syndrome, exercise or even repetitive
muscle contraction causes the tissue pressure within a compartment to
increase to an abnormally high level. But because the fascia can't
stretch, the tissues in that compartment aren't able to expand
sufficiently under the increased pressure. Imagine shaking up a soda
bottle but leaving the cap on — an enormous amount of pressure builds
up.

As the pressure builds up within one of your muscle compartments, with
no outlet for release, nerves and blood vessels are compressed. Blood
flow may then decrease, causing tissues to get inadequate amounts of
oxygen-rich blood, a condition known as ischemia (is-KE-me-uh). Nerves
and muscles may sustain damage.

Experts aren't sure why exercise or muscle contraction creates this
excessive pressure in some people, leading to chronic exertional
compartment syndrome. Some experts suggest that biomechanics — how you
move, such as landing styles when you jog — may have a role. Other
causes may include having enlarged muscles, an especially thick or
inelastic fascia, or high pressure within your veins (venous
hypertension).

©
Risk factors

The condition is most common in athletes under 40, although people of
any age can develop chronic exertional compartment syndrome.

People most at risk of developing chronic exertional compartment
syndrome are those who engage in exercise that involves repetitive
motions or activity. Young female athletes may be at particular risk,
for reasons unknown.

Risk factors include engaging in such sports, exercises and activities as:

* Running
* Football
* Soccer
* Biking
* Tennis
* Gymnastics

Overuse of your muscles or overtraining — that is, working out too
intensely or too frequently — also can raise your risk of chronic
exertional compartment syndrome.

©
Complications

Chronic exertional compartment syndrome isn't a life-threatening
condition and usually doesn't cause any lasting or permanent damage if
you seek appropriate treatment. However, if you continue to exercise
despite pain, the repeated increases in compartment pressure can lead to
muscle, nerve and blood vessel damage. As a result, you may develop
permanent numbness or weakness in affected muscles.

Perhaps the biggest complication of untreated chronic exertional
compartment syndrome is its impact on participation in your favorite
sports — the pain may prevent you from being active.

©
Preparing for your appointment

You're likely to start by first seeing your family doctor or a general
practitioner. He or she may refer you to a doctor who specializes in
sports medicine or orthopedic surgery.

Because appointments can be brief, and because there's often a lot of
ground to cover, it's a good idea to be well prepared for your
appointment. Here's some information to help you get ready for your
appointment, and what to expect from your doctor.

What you can do

* Write down any symptoms you're experiencing, including any that
may seem unrelated to the reason for which you scheduled the
appointment.
* Write down key personal information, including any major stresses or recent life changes.
* Make a list of all medications, as well as any vitamins or supplements, that you're taking.
* Get copies of any imaging tests you've had done, if possible. Ask
your doctor's staff how you can get these forwarded to your doctor
before the appointment.
* Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions
will help you make the most of your time together. List your questions
from most important to least important in case time runs out. For
chronic exertional compartment syndrome, some basic questions to ask
your doctor include:

* What's causing my symptoms?
* Are there any other possible causes for my symptoms?
* What kinds of tests do I need?
* Is my condition likely temporary or chronic?
* What treatment do you recommend?
* What are the risks involved with surgery?
* What might happen if I don't have surgery?
* Are there alternatives to the primary approach that you're suggesting?
* Are there any restrictions that I need to follow, such as avoiding
certain activities or limiting the amount of physical activity I
participate in?
* Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
* Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor,
don't hesitate to ask questions anytime you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to
answer them may reserve time to go over any points you want to spend
more time on. Your doctor may ask:

* When did you first begin experiencing symptoms?
* Have your symptoms been continuous or occasional?
* How severe are your symptoms?
* What, if anything, seems to improve your symptoms?
* What, if anything, appears to worsen your symptoms?
* How soon do your symptoms start after you begin your activity?
* How quickly do your symptoms resolve after you stop your activity?
* Do you notice any weakness in the legs or foot slapping associated with your symptoms?
* Do you experience any numbness or tingling?

What you can do in the meantime
Don't try to exercise through your pain. Limit your physical activities
to those that don't cause pain. For example, if running bothers your
legs, you may be able to swim. Use ice or take acetaminophen (Tylenol,
others) or nonsteroidal anti-inflammatory medications, such as aspirin
or ibuprofen (Advil, Motrin, others), to reduce pain until you can see
your doctor.

©
Tests and diagnosis

Pain is common in athletes of all levels. It can have many causes, which
can make diagnosis challenging. In fact, for many people with chronic
exertional compartment syndrome, establishing the diagnosis may take
many weeks to months.

Because other exercise-related problems are more common than chronic
exertional compartment syndrome, your doctor may first try to determine
if you have shin splints or stress fractures, for instance. As the more
common problems are ruled out, your doctor will begin to focus on the
less common potential causes, along with more specialized testing.

Medical history and physical exam
A diagnosis begins with an overview of your current and past medical
problems. Your doctor will discuss your symptoms with you. The history
of your symptoms and their pattern of occurrence may offer valuable
clues in making a diagnosis.

Your doctor will also examine the areas where you experience pain, such
as your arms or legs. Sometimes your doctor may notice a muscle bulge,
or herniation, if you have chronic exertional compartment syndrome. Less
commonly, your doctor may discover areas of swelling or tightness
around a muscle. But one problem that makes diagnosing chronic
exertional compartment syndrome challenging is that the physical exam is
usually completely normal.

Imaging studies
Your doctor may suggest that you have imaging studies done. These
studies are obtained to detect abnormalities in your bones, muscles or
blood vessels. They may include X-rays, computerized tomography (CT),
ultrasound and Doppler ultrasound.

In addition, some medical centers are researching the use of a
specialized magnetic resonance imaging (MRI) test to detect chronic
exertional compartment syndrome. While you're lying down in the MRI
machine, you contract muscles to bring on your symptoms. The MRI can
detect changes that are characteristic of chronic exertional compartment
syndrome, which can be helpful in making the diagnosis. But further
evaluation to measure your compartment pressures is still necessary to
provide a definitive diagnosis and to determine if you would benefit
from surgery.

Compartment pressure testing
A physical exam or imaging studies can't definitively point to a
diagnosis of chronic exertional compartment syndrome, but they can
identify or rule out other problems. If you've undergone those tests and
still haven't gotten a diagnosis, your doctor may suggest measuring the
pressure within your muscle compartments.

This test, often called compartment pressure measurement, is the gold
standard for diagnosing chronic exertional compartment syndrome. Because
it's an invasive test, involving insertion of needles into your
muscles, and can be mildly painful, compartment pressure measurement
usually isn't performed unless your medical history and other tests
strongly suggest you may have this condition.

©
Treatments and drugs

Options to treat chronic exertional compartment syndrome include both
conservative and surgical methods. However, conservative measures have
proved to be much less effective.

Conservative options
Your doctor may initially recommend pain medications, stretching or
strengthening regimens, orthotics, massage, a break from exercise, or
the use of different biomechanical techniques, such as changing how you
land when you jog. However, these kinds of conservative options
typically don't provide lasting benefit for true chronic exertional
compartment syndrome.

You can also consider switching to a different sport. For instance, if your symptoms are related to jogging, try biking instead.

Surgical options
Surgery is the main treatment of chronic exertional compartment
syndrome, and the most effective. Surgery involves operating on the
fascia — that inelastic tissue encasing each muscle compartment.
Surgical methods include either cutting open the fascia of each affected
compartment (fasciotomy) or actually removing part of the fascia
(fasciectomy). In either case, this release or decompression means the
compartment is no longer trapped by the unyielding fascia, giving it
room to expand when pressure increases.

Although surgery is highly effective for most people, it's not without
risk. Complications of the surgery can include infection, permanent
nerve damage, numbness and scarring. In addition, since your muscles
will no longer be encased by fascia, they may bulge out during exercise,
creating a cosmetic concern.

There also are different ways to perform each type of surgery. For
instance, surgery that involves smaller incisions may leave smaller
scars but could make it more difficult for your surgeon to navigate
through the internal tissues — muscles, nerves and blood vessels —
leading to a higher risk of complications. In addition, some surgeons
prefer making just one incision, while others prefer two.

Be sure to talk to your doctor about the method that's best for you and
about how long you will need to wait before returning to exercise and
activity. Be sure to follow post-surgical instructions your doctor will
give you to ensure a smooth return to your sport.

©
Prevention

There aren't any self-care measures that will specifically help prevent
or treat chronic exertional compartment syndrome. But following basic
sports and fitness guidelines can help protect your health and safety
during exercise:

* Warm up before starting exercise.
* Cool down when you're done exercising.
* Stop if you're in pain.
* Check with your doctor before starting a new exercise program if you have any health issues.
* Eat a healthy, balanced diet.
* Stay hydrated.
* Engage in a variety of physical activities.

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