Authors: Ricardo Catumbela, Ryan Linn, Aminah Amer, Faraz Sethi, Russel stocker, Dr Irfan Ahmed

What is chronic exertion compartment syndrome?

Vitamin D deficiency (see Supplementary Table 1) and hypophosphatemia, hypocalcaemia, or osteopenia are treatable medical risk factors that require screening. In athletes at risk for RED-S (Relative Energy Deficiency in Sport), bone stress injuries (BSI) should be considered and managed through a comprehensive approach that includes exercise, metabolic health, and strategies to enhance bone health. (9) Furthermore, Chronic Exertional Compartment Syndrome (CECS) may exhibit symptoms that resemble the initial phases of the Bone Stress Injury (BSI) spectrum, including periostitis and Medial Tibial Stress Syndrome (MTSS).

Table 5 – Differentials of exercise-induced leg pain. (10,11)

Aetiology	Common differentials	Clinical Signs on Examination	Risk Factors
Vascular	Peripheral Vascular Disease (Atherosclerosis) Peripheral artery dissection Popliteal Artery AneurysmFunctional Popliteal Artery Entrapment Syndrome Deep Venous Thrombosis Venous insufficiency	Absent peripheral pulses Ankle Brachial Pulse Index (ABPI) after exercise: <0.5 – severe arterial disease 0.5-0.8 – arterial disease or mixed arterial and venous diseasePain on the posterior compartment during passive dorsiflexion of the foot with the knee extended	Smoking history, Obesity, Diabetes, Hyperlipidaemia, Hypertension, Ischemic Heart Disease, Cerebral Vascular Accidents, IV Drug Use History
Muscular	Fascial Herniation Myopathy Tendinopathy Symptomatic accessory soleus muscle Myofascitis McArdle Disease Tumour	Bruising or haematomas Blisters Lumps or visual deformities	History of recent trauma, sprain, crush injury (excessive force or pressure) Recent viral infection
Bone	Bone stress injury Bone stress fracture Periostitis (Medial Tibial Stress Syndrome) Osteomyelitis Tumour	Pain on bone palpation. Pain on the “bone squeeze test”	Low Serum Vit D, Hypocalcaemia Hypophosphatemia, Eating disorders, Malabsorption, Female Gender, Performing artist
Spine	Vertebral Fractures Spinal Cord Compression Cauda Equina Syndrome RadiculopathyDisc prolapse Discitis Tumour	Lower motor neuron signs Upper motor neuron signs Pain worsening on straight leg raise with “big toe” dorsiflexion or during the slump test Spinal tenderness or deformity	Older age (>50 years old), History of back pain or disc disease, Previous spinal interventions, Previous spinal trauma, Bacteraemia or presence of implanted devices (i.e. heart valve, pacemakers, etc.)
Superficial/Peripheral nerve impingement	Neuropathy of Lateral Cutaneous nerve, Superficial Peroneal Nerve, Common Peroneal Nerve or Sural Nerve (Diabetic amyotrophy, Entrapment)	Lower motor neuron signs with relevant myotomal/dermatomal distribution. Tinel’s sign positive: – worsening pain on percussion of the affected nerve Hyperglycaemia and/or Raised HbA1C	Diabetes, Hypothyroidism, Hepatic or Renal failure, ETOH overuse, Autoimmune diseases (Sjogren, Lupus, RA, GBS, CIDP, Vasculitis), Infections (Shingles, EBV, Hep B and C, Leprosy, Lyme disease, diphtheria, botulism, HIV), Low serum B1, B3, B6, B12, E vitamins, Lead and Mercury intoxication
Other neurogenic causes	Myasthenia Gravis	Slurred speech, dysphagia, generalised weakness (including facial nerves), shortness of breath	Autoimmune diseases, History of a Thymoma
Medication-related	Statins, Beta blockers, Beta-2 agonists, Diuretics (esp. thiazides, loop diuretics), ACEi, ARBs, Antipsychotics		Medication history

 

Figure 2 – Differentials of exercise-induced leg pain. (10,11)

Primary care focussed assessment for chronic exertion compartment syndrome

The physical examination of patients with CECS is often unremarkable when undertaken at rest, as symptoms typically emerge only during particular physical activities. Given that the increase in intra-compartmental pressure is specific to exercise, the assessment should be carried out during or after the patient’s symptom-inducing exercise.

Figure 3 – Focussed physical exam, helpful in assessing ELP in primary care

When evaluating CECS patients, initial contact practitioners, such as physiotherapists or primary care physicians, should conduct a thorough physical examination and collect medical history before arranging targeted investigations. If a vascular issue is suspected, the Ankle Brachial Pulse Index is a straightforward primary care test that can be performed before and after exercise to assess for vascular compromise. Additionally, practitioners should also check for widespread pain syndromes that may mimic musculoskeletal pain.

Table 6 – Clinical examination findings in CECS

Clinical Examination	Signs
Inspection	Pallor Swelling Myofascial Herniations/Fasciculations/Deformity
Palpation	Firmness & tenderness along the myofascial compartment Faint or absent distal pulses in severe cases (i.e. Popliteal, Posterior Tibial Artery, Dorsalis Pedis Artery) Poikilothermic
Neurological	Localised reduced sensation (i.e. dorsum of the foot, 1st web space) Localised muscle weakness (i.e. foot drop)

Which patients should I refer on?

When managing patients with CECS, it is essential to consider their goals and needs. A conservative therapy trial lasting 6 to 12 weeks is generally recommended, with an effectiveness evaluation after 3 to 6 months. If conservative methods do not succeed, or if the patient experiences ongoing debilitating symptoms that hinder physical activity, they should be referred to a specialist in sports medicine or orthopaedics. 

Intra-compartmental pressure monitoring (ICP), post-exertion magnetic resonance imaging, and near-infrared spectroscopy are valuable tools for diagnosing chronic exertional compartment syndrome (CECS). Although a definitive consensus has not been reached, ICP continues to be the most widely used in clinical settings. Various exercise and procedural protocols exist for measuring ICP and collectively indicate that CECS patients experience higher resting pressures before and after exercise than control subjects. (4, 10)

Figure 4 – Infographic on the work up of ELP patients in primary care

What treatment options are available?

1. Conservative Management

Non-operative management typically begins with the cessation of the provoking exercise, although patients may resist this, as it could jeopardise their careers. Altered gait biomechanics and running style significantly contribute to the pathophysiology of CECS. (11) 

Gait re-training should ideally involve objectively assessing running and employing clinical cues to guide changes to alleviate symptoms.

Figure 5 – Conservative options for the management of CECS

Clinicians should concentrate on one aspect of gait re-training at a time, evaluate its effect on symptoms, and attempt an alternative strategy or combine techniques if no improvement is observed. Beginning with adjustments to cadence is frequently effective. (11)

Using a treadmill with video analysis may be helpful. It ensures consistent speed and incline throughout, reducing external variables. Cadence adjustments can be cued with online metronomes or mobile apps.

Table 7 – Examples of gait retraining strategies

Strategy	Assessment/Measurement	Aim	Clinical Cues/Performance
Cadence	Count steps taken during a timed 60 second test Treadmill helps to maintain consistent speed	165-180 steps per minute	Set metronome Maintain a consistent running speed Run to metronome beat without changing speed
Alter ground reaction forces	Listen to foot strike on treadmill, is it loud, is it equal?	Reduce forces on foot strike	Cues: Shorten step length Avoid over-striding (reaching the foot far out in front) Aim to land on the mid-foot Aim to land as softly as possible
Foot landing position	Video analysis – pause frame on foot strike Observe trainers for wear patterns	Mid to forefoot strike	Cue: Imagine lifting the heels 2-3cm higher than usual at heel off. Aim to land with weight on the middle of the foot.

 

Figure 6 – A stepwise approach to rehabilitating a CECS patient using conservative measures from deloading and gait retraining to strength and conditioning

Alternative non-surgical treatment options include non-steroidal anti-inflammatory drugs, chemo-denervation, extracorporeal shockwave therapy, orthotics, ultrasound-guided fascial fenestration, botulinum toxin A injections, and taping.

2. Surgical Management

It is advisable to explore all non-surgical options prior to considering operative management, based on the patient’s goals. The standard surgical intervention involves performing a fasciotomy on one or more compartments. This procedure can be carried out through open surgery, endoscopically, via a single small incision, percutaneously, or even with ultrasound guidance.

Figure 7 – Evolution of fasciotomy techniques: From traditional open methods to minimally invasive, ultrasound-guided procedures

Recovery rates, the ability to return to the same activity level, and symptom resolution vary across studies. Recurrence rates can reach 45% (12), with nearly 20% of patients requiring further surgeries. Therefore, it is essential to categorise risk factors for CECS, as mixed cases involving mechanical or metabolic factors are less likely to achieve complete recovery following surgical intervention. Surgical complications, which include scarring, nerve damage, infection, haemorrhage, vascular injury, and thromboembolism, occur in about 16% of cases (12).

References

1. George CA, Hutchinson MR. Chronic Exertional Compartment Syndrome. Clin Sports Med. 2012 Apr;31(2):307–19. 
2. Bonasia DE, Rosso F, Cottino U, Rossi R. Exercise-induced leg pain. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015 Jul;2(3):73–84. 
3. Schubert AG. Exertional compartment syndrome: review of the literature and proposed rehabilitation guidelines following surgical release. Int J Sports Phys Ther. 2011 Jun;6(2):126–41. 
4. Tzortziou V, Maffulli N, Padhiar N. Diagnosis and Management of Chronic Exertional Compartment Syndrome (CECS) in the United Kingdom. Clinical Journal of Sport Medicine. 2006 May;16(3):209–13. 
5. Velasco TO, Leggit JC. Chronic Exertional Compartment Syndrome: A Clinical Update. Curr Sports Med Rep. 2020 Sep;19(9):347–52. 
6. C. Ramanayake RPJ, K. Basnayake BMT. Evaluation of red flags minimizes missing serious diseases in primary care. J Family Med Prim Care. 2018;7(2):315. 
7. Di Pietro P, Izzo C, Carrizzo A. Editorial: The role of metabolic syndrome and disorders in cardiovascular disease. Front Endocrinol (Lausanne). 2023 Oct 31;14. 
8. Chen P, Miah MR, Aschner M. Metals and Neurodegeneration. F1000Res. 2016 Mar 17;5:366. 
9. Jasty NM, Dyrek P, Kaur J, Ackerman KE, Kraus E, Heyworth BE. Evidence-Based Treatment and Outcomes of Tibial Bone Stress Injuries. Journal of the Pediatric Orthopaedic Society of North America. 2021 Nov;3(4):372. 
10. Bosnina F, Padhiar N, Miller S, Girotra K, Massoura C, Morrissey D. Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review. J Foot Ankle Res. 2023 Jan 21;16(1). 
11. Padhiar N, Malliaropoulos N, Lohrer H. Exercise-induced leg pain in sport. Br J Sports Med. 2015 Dec 1;49(24):1546–7. 

Supplementary materials

Figure 8 – Vitamin D Treatment guidelines

The two primary sources of vitamin D are sunlight exposure and specific food groups. However, certain populations are at higher risk for vitamin D deficiency and require particular attention (table 8)

Table 8 – High-risk groups for vitamin D deficiency.

At risk populations:

Infants 0-3 years old

Pregnant and breast-feeding women

Adults aged over 65 years old

Housebound individuals

Individuals who cover their skin for cultural or religious reasons

South-Asian, African and African-Caribbean individuals, specially women and children

Patients in at-risk groups must be educated on the importance of lifelong vitamin D supplementation to ensure compliance. Clinicians should provide culturally sensitive advice, especially when discussing how darker skin and covering up relate to vitamin D deficiency. Some patients may avoid certain brands of cholecalciferol due to gelatine content, so alternatives should be offered. Mothers, pregnant, and breastfeeding women should be informed about Healthy Start supplements and how to access them at a reduced or waived cost.

Table 9 – Vitamin D replacement dosage according to age as per NICE CKS recommendations. Find more information on: https://cks.nice.org.uk/topics/vitamin-d-deficiency-in-adults/management/management/

Vitamin D Treatment – Loading and Maintenance Dosage according to age
Age	Loading	Maintenance
1-6 months	3000 IU cholecalciferol daily for 12 weeks	400-600 units daily all ages
6 months -12 years	6000 IU cholecalciferol daily for 12 weeks
12-18 years	10000 IU cholecalciferol daily for 12 weeks
Over 18 years	40000 IU per week for 7 weeks	800-2000 units daily after loading dose. Consider up to 4000 units per day for high-risk groups
*rule out chronic liver disease, chronic kidney disease and hypercalcaemia ** if using high dose loading treatment – re-check calcium 1 month after initiating treatment

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