Chronic Exertional Compartment Syndrome: How Physical Therapy Can Help You Break Free From the Stranglehold on Your Leg
Imagine going for your daily run in your neighborhood. You are enjoying the outside air, burning calories, and improving your fitness. You’re 2 miles from your house because you planned on doing a “light 4 miles”. Then all of a sudden you get a “Charley Horse” cramp in the back of your leg and your entire workout comes to a halt. While this cramp may make you contemplate why you even went outside today, you take a couple minutes to rub it, stretch it, and take a swig of your Gatorade to get some electrolytes in you. Just like that you are back running like nothing happened. You may even run back home and drink pickle juice because you heard it was good for cramping. The moral of the story is that you were able to continue your run without that cramp coming back.
Now imagine if that “Charley Horse'' that made you rethink why you were running in the first place didn’t go away with rubbing it, stretching it, or with a swig of that Gatorade you packed. What would you do? Even better, what if this “Charley Horse” started at 0.10 miles into your run? To make it even more interesting … What if this “Charley Horse” happened every single time you decided to go for a run or workout and started to make your feet go numb in the process? If your answer to these questions is “I have no idea what I would do”, you are not alone. Because personally, I have no idea what I would do if I had to deal with this every time I wanted to workout. But unfortunately, there are athletes who have to answer these questions internally every single time they workout or participate in their sport.
Chronic Exertional Compartment Syndrome (CECS) is a condition where the muscles of the lower leg swell after the initiation of exercise, resulting in significant cramping, pain, numbness/tingling, and ischemia into the lower leg. In addition to the muscles swelling, it is also believed that the fascia in the lower leg is stiff and does not allow for adequate expansion of the muscles during exercise. The combination of muscle swelling and stiff fascia can ultimately lead to the compression of nerves, arteries, and veins which will result in the signs/symptoms mentioned previously. This phenomenon can happen in any of the four compartments of the lower leg (anterior, lateral, deep posterior, or superficial posterior), although 95% of CECS cases occur in the anterior compartment. CECS affects males and females at an equal rate, but is most common in patients who are in their 20’s. It is most commonly found in endurance runners and athletes who participate in running-dominant sports such as; soccer, lacrosse, basketball, and hockey. The hallmark sign of CECS is the fact that the patient’s reported symptoms subside with rest and cessation of the provoking activity.
CECS is typically diagnosed by a physician who performs the Compartment Pressure Test (CPT). In this test a needle is inserted into each of the four compartments of the lower leg prior to exercise and after the onset of symptoms. If it is found that the pressure in any of the compartments is raised between 15-30 mmHg after exercise, it is deemed the patient has CECS. Unfortunately, this test has many limitations and often provides no real value to the patient other than a number saying the pressure in their leg is higher. No information on prognosis, direction of treatment, or reasoning for why this is happening in the first place.
As Physical Therapist’s we are not allowed to perform the Compartment Pressure Test, but luckily we do not need that test to confidently diagnose a patient with CECS. Actively listening to a patient and providing a thorough physical examination should be enough to rule in/out CECS. It will also save the patient from unnecessary medical costs and delay in their treatment.
While it is well known what CECS is, how it is diagnosed, and who it affects, unfortunately very little is known about WHY this happens? Because of this, oftentimes patients who are dealing with CECS are forced to make a difficult decision between the surgical route or the conservative route with very little information to go off of.
The gold standard surgery for CECS is a Fasciotomy. This procedure involves a surgeon removing fascia in the lower leg to attempt to give the lower leg more area to swell during exercise. The hope is that with the removal of the fascia, the structures within the lower leg will no longer be compressed and the patient will have no report of symptoms when exercising. Unfortunately, that is not always the case. Satisfaction rates from this surgery are reported to be as low as 48%. The reasoning for it being so low is that the recurrence of symptoms is very high and patients sometimes get no relief from the surgery. If this is the case, the is the stiff fascia really the main issue? On top of the recurrence of symptoms, complications from this surgery can also result in nerve injury, hematoma, and DVT’s. Doesn’t sound too appealing right? A coin flip to see if pain and symptoms will be improved at all.
On the other hand, the conservative route to manage CECS is to do just that … manage. Often patients who have Chronic Exertional Compartment Syndrome figure out methods to relieve their symptoms through intermittent breaks during activity, massage, or compression to the lower leg. While this may be a decent strategy to manage the flare-ups, this doesn’t tackle the main issue of what is driving this increase in pressure in the lower leg.
Unfortunately, there are not many high-quality research studies on the management/treatment of Chronic Exertional Compartment Syndrome and patients lack confidence in making the decision to pursue the surgical route or manage on their own.
Luckily, PT’s are well-versed in diagnosing and treating musculoskeletal conditions and can utilize thorough examination techniques to create an impairment-based treatment program to help patients with Chronic Exertional Compartment Syndrome improve their overall function and participation in sport/exercise. Through the correction of LE biomechanics, targeted strengthening, stretching, gait retraining, neurodynamics, and joint mobilization/manipulation PT’s can address any impairments that may be contributing to the onset of the patient's symptoms. In addition to impairment-based interventions, PT’s can also work with CECS patients to develop strategies to reduce the severity and frequency of exacerbations when they are outside of the clinic. Attacking CECS with a full-body approach and actively listening to the patient’s experience is essential to a successful PT outcome.
While Chronic Exertional Compartment Syndrome may not be fully understood at this current moment in time, PT’s are able to work with these patients to address their impairments and improve their participation in the activities they love. Additionally, PT’s are able to listen to these patient’s experiences, empathize with what they are going through, and help kickstart a plan to break free from the stranglehold of their leg.
Written by: AJ Peña, SPT