Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners

Abstract

Background:

Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running.

Hypothesis:

Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy.

Results:

A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively.

Conclusion:

Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery.

Clinical Relevance:

Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Running as a sport and fitness activity has a wide range of health benefits and is growing in popularity.^10,15,28,36 Nevertheless, runners also have a relatively high incidence of associated pathologic musculoskeletal conditions. While advances in training, technique, and running gear have continued to emerge and evolve, the incidence of such conditions in running athletes ranges from 28% to 79%.^15,33 While a wide range of health professionals care for injuries in the running population, chronic exertional compartment syndrome (CECS) of the legs is a relatively rare but potentially debilitating condition associated with running that is seen and treated by orthopaedic surgeons.⁹

Caused by an activity-related increase in pressure within the fascial compartments of the legs, CECS involves compression of vessels, nerves, and muscle tissue, which leads to the primary symptom of diffuse leg pain, as well as paresthesias, hypoesthesias, and/or paraparesis in a subset of patients. CECS is most commonly seen in the lower extremities of athletes and military recruits who are frequently involved in running-related activities. Sugimoto et al²⁷ noted that female runners with a diagnosis of bilateral CECS demonstrated altered running mechanics, which include a greater overstride and increased ankle dorsiflexion angles, when compared with asymptomatic runners. Another biomechanical study noted that affected runners demonstrated a more upright posture and greater step length without any differences in muscle activity in the lower legs.²⁰

The diagnosis of CECS is typically made based on patient history and physical examination, as well as through measurement of intracompartmental pressures obtained before, during, and after exercise—usually in the form of running on a treadmill—which are compared with normative criteria defined by Pedowitz et al.¹⁹ Though not widely used, magnetic resonance imaging and near-infrared spectroscopy have also been described as confirmatory tests in the diagnosis of CECS.^19,31,32

Treatment of CECS may involve physical therapy, gait retraining, and other therapeutic modalities, but little evidence has emerged to support the effectiveness of nonoperative measures for the condition.⁶ While results of a recent study suggested that injections of botulinum toxin may reduce intracompartmental pressure and episodes of pain with CECS,¹³ the clinical application of this concept remains in its infancy. Instead, fasciotomy of the involved compartments has been increasingly utilized, with significant improvement in pain²⁹ and overall satisfaction rates ranging from 75% to 90%.^{4,5,9,12,17,25} Despite relatively high satisfaction, good to excellent postoperative functional outcome measures have been reported in as few as 33% and as high as 98% of patients, based on several small series and subgroups.^{5,16,17,26,30} Notably, few of these studies have clearly defined the activity level or athletic pursuits of the cohorts treated. As the diagnosis is generally made based on the presence of signs and symptoms that arise during running, and runners comprise the athletic subpopulation most commonly affected, the results of fasciotomy specifically in runners may be of interest to clinicians who treat CECS.

The purpose of this study was therefore to evaluate the postoperative activity level, pain, patient satisfaction, and rate of return to running in runners with CECS treated with fasciotomy.

Methods

A departmental database at a large, metropolitan, tertiary-care referral center was queried for cases of fasciotomy performed for a diagnosis of CECS between and including the years 1993 through 2010. With an institutional review board–approved protocol, patients’ medical records were reviewed for demographic data (including age at the time of surgery, sex, body mass index, and sports activity), as well as preoperative and postoperative clinical data. This included the date of onset of symptoms, laterality, number and location of compartments involved, pressure measurements in mm Hg for each compartment, concomitant injuries and conditions, past medical history, postoperative reoperations, and any associated complications.

Initial inclusion criteria consisted of a diagnosis of CECS for which a fasciotomy was performed at least 1 year prior to the time of the database query and participation in running in track, cross-country, or road racing as the patients self-identified primary preoperative athletic activity. The final inclusion criteria were based on completion of a mailed questionnaire to assess outcomes. While a variety of additional sports require significant amounts of running, to improve consistency and remove bias from variability, we excluded those patients who identified a sport other than those listed above as their primary sport. The diagnosis of CECS was made by the combination of 1 or more symptoms, including leg pain, weakness, paresthesias, and/or hypoesthesias as well as abnormally elevated intracompartmental pressure of at least 1 lower leg compartment, as measured per the protocol described by Pedowitz et al.¹⁹ However, in 2 cases, elevated/abnormal/pathologic compartment pressures and symptoms were referenced by the treating physician, but the precise pressure values and specific compartments involved were not listed in the medical record. Exclusion criteria consisted of cases of fasciotomy for posttraumatic or acute compartment syndrome or a reported diagnosis of any concomitant preoperative lower extremity condition or injury that contributed to the patient’s symptoms or prevented running. Insufficient retrospective clinical data, based on a meticulous review of each medical record, was also among the exclusion criteria.

Over the 18-year period queried (January 1993 to December 2010), 149 patients underwent fasciotomy for a diagnosis of CECS, 56 (38%) of whom were identified as primarily running athletes. Fasciotomy of only the symptomatic compartments (defined by both elevated pressures on testing and clinical symptoms) was performed by a senior orthopaedic sports medicine surgeon. As 13 patients had either insufficient documentation of their clinical course or insufficient follow-up, 43 runners (77% of runners, 29% of fasciotomy patients) met inclusion criteria and were sent a questionnaire (see the Appendix, available in the online version of this article), which was adapted from Howard et al¹¹ and modified to better adhere to the current study purpose. The survey was completed postoperatively and was designed to collect information regarding preoperative and postoperative visual analog scale (VAS) scores for pain, sports activity level (defined as recreational, local competitive, regional competitive, and national/elite), return to running or other sports postoperatively, reasons for any sport activity change, effect of pain on performance, miles run per week, perceived improvement, and overall satisfaction. A total of 32 runners completed and returned the questionnaire (response rate, 74%) and were included in separate outcomes analyses.

Data were recorded in Microsoft Excel (Version 14; Microsoft Office 2010) and imported into SPSS (IBM Corp) software for statistical analysis. Descriptive statistics were used to present overall population characteristics and overall rate of return to play. Multivariate logistic regression analysis was used to identify potential risk factors for failure of fasciotomy. Paired t tests were used to compare preoperative and postoperative pain levels among patients who were and were not able to return to running and those with >3 or ≤3 months of preoperative symptoms.

Results

A total of 43 (77%) patients met inclusion criteria, and this study cohort was assessed through descriptive statistics. There were 34 (79%) female and 9 male (21%) participants. The mean age at index surgery was 19.42 years (range, 12.9-35.0 years). Mean duration of symptoms prior to fasciotomy was 17 months (range, 1-36 months). There were 83 extremities included in this initial phase of study, of which 79 (95%) had available data on compartment pressure testing. In those 79 extremities, elevated pressures were identified in varied combinations of compartments: 2 (2.5%) involved the anterior compartment only, 1 (1.2%) the lateral compartment only, 28 (34.6%) both the anterior and the lateral compartments, 8 (9.9%) superficial posterior compartment only, 4 (4.9%) with both deep and superficial posterior compartments, 4 (4.9%) with anterior and posterior compartment, and 32 (39.5%) with anterior, lateral, and posterior compartments.

Of the 32 runners who provided responses to the prospective patient outreach, there were 27 females (84%) and 5 males (16%). In this subpopulation, the mean age at index surgery was 20 years (range, 13.2-35.9 years; median age, 18.6 years). Thirty (94%) patients had bilateral involvement. The median duration of symptoms prior to fasciotomy was 10.6 months (interquartile range [IQR], 19.7 months; mean ± SD, 18 ± 19.8 months; range, 1-95 months). The median follow-up was 50 months (IQR, 75 months; mean ± SD, 66 ± 50.7 months; range, 12.4-220.0 months).

Of the 62 legs included in the subpopulation study, adequate records were available for 60 legs (97%) regarding compartment pressure testing. Only a single compartment demonstrated elevated pressures in 13 legs (22%): 2 (3%) anterior compartment, 1 (2%) lateral compartment, and 10 (17%) posterior compartment. The majority of cases (47/60; 78%) involved positive readings in multiple compartments: 21 (35%) anterior + lateral, 4 (7%) anterior + posterior, and 22 (37%) anterior + lateral + posterior compartments. The mean 1-minute postexercise compartment pressure was 34.0 mm Hg (95% CI, 31.1-36.9 mm Hg; SD, 10.7 mm Hg; range, 18.0-56.0 mm Hg; median, 33.5 mm Hg; IQR, 17.8 mm Hg). There was no difference in the mean values between compartments.

The data collected from the mailed surveys are summarized in Figure 1. Twenty-five patients (78%) indicated being satisfied with the results of their fasciotomy. On questioning related to pain, 7 patients (22%) reported being pain-free, 17 (53%) had significantly improved but were still having some pain, and 8 patients (25%) indicated that they had slightly improved (n = 5), did not improve (n = 2), or felt worse than before the surgery (n = 1). The overall pain level, as assessed using the VAS for pain (minimum, 0; maximum, 10), decreased significantly. The mean preoperative reported level of pain, as recollected or projected by patients retrospectively, was 7.9 (range, 3.0-10.0; SD, 1.72; median, 8.4; IQR, 2.5). Postoperatively, at the time of the questionnaire, the mean reported level of pain was 1.7 (range, 0.0-7.6; SD, 2.1; median, 1.0; IQR, 2.9) (P < 0.001, Wilcoxon signed-ranks test).

Figure 1.

Flowchart illustrating inclusion and exclusion criteria for study participants and subsequent outcomes.

In total, 27 (84%) participants reported return to sports. Of the 5 patients who did not return to sports, 2 (40%) reported failing to do so for reasons unrelated to lower extremity symptoms. Of patients who did return to sports, 18 (67%) returned to running. Of these patients who returned to running sports, the mean weekly distance decreased from 23.6 miles per week preoperatively to an average of 15.5 miles per week in the postoperative follow-up period. Among the 9 patients who returned to sports but did not return to running, 4 (44%) did so for reasons unrelated to symptoms (Figure 1). There was no correlation between patient satisfaction and preoperative pain or activity level.

Six (19%) patients developed recurrent symptoms for which they underwent revision fasciotomies during the study period, 4 (67%) of whom returned to sports and running specifically, and 2 (33%) of whom did not return to sports (Figure 2). The mean time to the revision surgery was 22 months (range, 2.8-57 months). Revision surgery for 4 of 6 patients involved releasing a compartment that was not released at initial surgery. One revision surgery required a repeat release of a compartment that had been previously released. The final revision surgery was a fasciectomy of the previously released compartments. Among the revision surgery cohort, 1 patient (17%) was pain-free, 3 (50%) were significantly improved, 1 (17%) reported being slightly better, and 1 (17%) reported being worse at the time of survey completion. Four (67%) of the 6 patients who underwent revision surgery indicated being satisfied with the results of their fasciotomies.

Figure 2.

Revision fasciotomy: indications and outcomes, including return to sport (RTS).

Based on the electronic medical record review, 5 (16%) patients developed complications. One patient treated with bilateral fasciotomy developed a postoperative sural nerve neuropraxia, treated with observation. Symptoms were resolving at the 1-year follow-up visit, and the symptoms did not impede her running. One patient developed a hematoma in the leg, diagnosed 1 week postoperatively, without frank cellulitis but which was treated with prophylactic oral antibiotic treatment for 1 week. One patient developed bilateral plantar foot pain, diagnosed as plantar fasciitis and bilateral tarsal tunnel syndrome, that resolved with revision bilateral fasciotomies of her superficial and deep posterior compartments. One patient was diagnosed with a suture abscess 1 month postoperatively, treated with oral antibiotics for 10 days.

Discussion

The current study investigated the long-term postoperative course and natural history of runners who underwent fasciotomy for limiting symptoms of CECS, with an emphasis on understanding degrees of symptom resolution, return to sports, and performance level in the subpopulation of competitive running athletes. Overall, 3 of 32 (9.4%) patients with outcomes data were unable to return to running due to pain, and an additional 5 of 32 (15.6%) changed their primary sport due to pain, yielding a rate of 1 in 4 whose running careers were permanently altered by CECS and the surgical treatment thereof. Given the age of the study population, which was frequently transitioning from high school competitive sports to college or from collegiate competitive sports to professional career phases, it is not surprising that 4 patients chose alternative sports and 2 patients did not return to sports for reasons other than pain. The rate of return to all sports (27/32; 84.4%) in the current series is actually higher than the 63% and 78% rates of return to activity reported by Pasic et al¹⁸ and Howard et al,¹¹ respectively, in series that use return to sports as an outcome. However, the rate of return specifically to running (18/32; 56.3%) is relatively low compared with other interventions in orthopaedic sports medicine, which may suggest that the goal of returning to running as a primary sport is more challenging than returning to other sports.

The overall patient satisfaction rate in the current series (78.1%) falls within the range described in other recent studies, such 84% by Campano et al,⁶ 76% by Micheli et al,¹⁶ 76% by Pasic et al,¹⁸ and 60% by Slimmon et al.²⁶ The mean percentage pain relief of 77.5% in the current series is similar to the 68% rate reported by Howard et al.¹¹ Abramowitz and Schepsis¹ have suggested that fasciotomies in the deep posterior compartment may not relieve pain, and this is supported by additional studies that have found better pain improvement after release of the anterior/lateral compartments compared with the deep posterior compartment.^11,21,22,24

Regarding surgical technique, Maher et al¹⁴ noted that patients achieve greater postoperative satisfaction and higher rates of return to sport (91% vs 66%) when all 4 compartments are released versus individual compartments. Beck et al³ similarly noted that pediatric patients with isolated compartment release had higher rates of failure and reoperation than those with 4-compartment releases. van Zantvoort et al³⁴ evaluated resumption of sport activity specifically after isolated release of the lateral compartment for CECS and found that, of those who completed a questionnaire at 4 years postsurgery, 73% had returned to presurgery activity. Of those who returned, approximately 40% were at their presurgical level, while the remaining 60% were at a lower level of sport.³⁴ Gatenby et al⁸ similarly investigated outcomes after isolated anterolateral compartment release and reported that 90% of patients return to sports at the same or higher level postoperatively. This study similarly notes that patients who required revision surgery were often returning to the operating room to release compartments previously not released.

Other studies of fasciotomy for CECS have examined potential prognostic factors associated with outcomes such as compartment(s) involved, duration of symptoms prior to fasciotomy, sex, and maximal preoperative compartment pressure.^7,11,16,26 Slimmon et al²⁶ also found better relief after anterior/lateral compartment release; they also noted that fewer than 12 months of symptoms prior to treatment was associated with a better prognosis after anterior/lateral compartment release, whereas duration of symptoms was not associated with prognosis with posterior compartment release. Micheli et al¹⁶ evaluated 47 women and found that, compared with studies that reported on both males and females, women may have poorer outcomes than men. Finally, multiple studies have found no prognostic value in maximal preoperative compartment pressure.^7,11 Of the 5 patients who were unable to return to running due to pain and the 3 patients who were unable to return to sports at all due to pain, we were unable to define any statistically significant prognostic factors.

There are several weaknesses of the current study. The lengthy follow-up period of 5.4 years was designed to capture as many possible recurrences as might have occurred and may be a good proxy for long-term results. However, as previously described, many patients likely chose to alter their desired activity level (6 of 32) due to lifestyle changes rather than leg symptoms. A shorter follow-up would likely yield better matched pre- and postoperative activity and activity level, but it would not have captured all recurrences. Another limitation of the current study is that postsurgical compartment pressures were not obtained. Six (19%) of our patients underwent a revision compartment release within an average of 21 months. Postsurgical compartment pressures may have provided insight into whether the recurrent releases were necessitated by incomplete releases, recurrence of CECS, or another factor. Of those 6 patients, the satisfaction rate (83%) and return to running (4 of 6, with 1 additional patient switching sports for reasons other than pain), are similar to results of the overall cohort. Additionally, the questionnaire was mailed out to participants after surgery; therefore, assessment of preoperative pain and functional scores may be biased due to recall.

The time to recurrence of 21 months is similar to that in the series of revision fasciotomies for recurrent exertional compartment syndrome described by Schepsis et al,²³ who also reported a similar satisfaction rate of 72%. The overall 74% response rate for the questionnaire represents another weakness. Since the mean age at surgery was 19.4 years, with a mean follow-up of 4.2 years, many of the patients had moved from their original address without forwarding information available. Though we cannot make this claim with certainty, we do not have reason to believe that the nonresponders we were unable to contact or who declined to participate would differ from the responders in their rate of return to play. Other studies involving the outcomes of CECS release have had similar or lower response rates.^11,26

Recall bias also represents a clear limitation in the current study, as this bias can be encountered when using questionnaires. The responders’ preoperative pain scores and level of activity are subject to recall bias, which may affect their improvements in pain levels and return to specific levels of activity. However, the primary outcome, return to running, should be relatively unaffected by recall bias, as the survey captures patients’ current levels of activity.

Future studies on fasciotomy for CECS may be able to better elucidate prognostic factors associated with return to running. The literature consists of small series of patients gathered over years because fasciotomy for CECS for athletes in any sport is an uncommon procedure. Furthermore, nearly all of the literature to date, including this study, consists of retrospective cohort studies.^7,11,16,26 The most recent systematic review of the literature was performed by Barnes² in 1997, and a new review or meta-analysis may be helpful in retrospectively obtaining larger numbers for determining prognostic factors. The only prospective series, performed in 2004 by Verleisdonk et al,³⁵ uses reduction in complaints as an outcome after anterior compartment releases and does not address prognostic factors or return to sport.

Conclusion

This study examines the rate of return to sport specifically in competitive runners after fasciotomy for CECS. Since running is considered the primary inciting activity for pain in all sports where athletes experience pain related to CECS, the return to activity results had the potential to be poorer than in other sports. Based on this group of runners, surgeons can inform runners that they are very likely to be able to return to running and to be satisfied with the outcome.