4/3/2023 0 Comments Lower extremity compartmentsWithin this compartment lies the superficial fibular (peroneal) nerve at the anterior apex. It is bound anteriorly by the extensor digitorum longus muscle, medially by the fibula, and posteriorly by the edges of the flexor hallucis longus and soleus muscles. The lateral compartment contains the fibularis (peroneus) longus and brevis muscles. Symptomatic involvement may present as a mild foot drop, weakness with dorsiflexion, or paresthesias over the dorsum of the foot with the exception of the webspace between the first and the second digit and the far lateral aspect of the foot. At the posterior medial border of the compartment lie the deep fibular (peroneal) nerve and the anterior tibial artery and veins. The compartment is bound medially by the tibia, posteriorly by the interosseous membrane, and laterally by the fibularis (peroneus) muscles. The anterior compartment contains the tibialis anterior, extensor hallucis longus, and the extensor digitorum longus muscles. Figure 1:Ĭross-sectional anatomy of the left lower extremity compartments. Understanding the anatomy of the lower leg aids in localizing which compartment is affected based on the history and also guides catheter placement when measuring ICP (Fig. The lower leg contains four separate compartments, each bound by fascia and containing nerves and/or arteries and veins. This avoids unnecessary testing and, more importantly, subsequent referral for and even execution of surgical treatment ( 18,33). If the history is not entirely convincing for CECS, it may be worthwhile to have the patient perform the exercise/exercise challenge that typically provokes the patient’s symptoms to determine whether their pain is consistent with CECS ( 14). Currently there are no universally accepted diagnostic criteria for pathologic ICP values ( 1,29). It is important that only patients with historical clues suggestive of CECS have compartment testing performed. Patients evaluated directly after exertion may demonstrate edema and neurologic dysfunction on physical exam ( 5,6,9,27,31,37). As ICP rises and nerves are compressed, patients may experience paresthesias or even progress to paresis manifested often by a “foot drop.” The physical exam in the clinical setting will almost inevitably by normal as the syndrome is, by definition, exertional. Pain is brought on by exertion and relieved with rest. Patients report typical symptoms of an aching pain in the affected limb, often with location specifically reflecting the affected compartment, the most common being the anterior compartment ( 4). This article only discusses CECS in the lower extremity. There are many compartments within the body that can be affected by CECS. The actual pain experienced is hypothesized to be related to direct muscular pressure increases, ischemia, and compression of local sensory nerves ( 2,22,34,36). Studies examining fascial thickness and stiffness suggest that an overly noncompliant fascial sheath does not play a significant role in pathogenesis ( 8). This may be due to abnormally increased blood flow and edema exacerbated by poor muscular microcirculation ( 10,20,31,32,37,39). An expanding compartment within a fixed fascial sheath eventually generates an increased pressure that limits blood flow and compresses nerves. The compartments of the leg are defined as groups of muscles surrounded by fascia. PathophysiologyĬECS has existed in the literature for more than 50 years and yet the pathophysiology is not fully understood ( 10,20,31,39). The standard treatment for CECS is surgical fasciotomy. Newer research and standardization of diagnosis is required to more accurately describe the current epidemiology. Various studies cite values of 10% to 60% in athletes depending on study methodology ( 7,27,31,33). The true incidence of the disease is difficult to determine because patients may simply modify their activity to decrease symptoms without ever seeking treatment ( 42). Typical historical elements combined with objective data from intracompartmental pressure (ICP) testing make the diagnosis. Chronic exertional compartment syndrome (CECS) in the lower extremity presents as pain in the leg worsened by activity and improved with rest. The differential diagnosis is broad and the most common ones include stress fracture, exertional compartment syndrome, and nerve and artery entrapment syndromes ( 5). Exertional leg pain is a common complaint, especially among athletes ( 27,33).
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