The amount of exercise required to bring on pain varies greatly between individuals. Usually for an individual the amount of exercise required to provoke symptoms is constant. The pain of CCS usually forces the individual to stop. The pain is usually well-localised,

Figure 4: Superficial fasciotomy of the anterior compartment

but it may radiate down the foot or be associated with paraesthesia. In these cases, the pain is probably due to neural compression. Wiley et al. describe the location of pain associated with individual compartments (19). It is evident that there is no “usual” location of pain, as there are large variations in the description and site of pain.

Figure 5: Danger of wound dehiscence and infection when a long incision is performed during a fasciectomy

but is extremely variable. Detmer et al., in his series of 100 consecutive patients, described the following symptoms and their prevalence (11): n consistent history of pain with exercise n progressive worsening with continuing exercise (94%) n reduction/cessation of exercise reduced the pain (85%) n aching pain (85%) n tightness/cramps (81%) n bilateral symptoms (82%).

Pain from CCS is not present at

rest and is rarely provoked by walking, except in severe cases, where pain may occur on walking or even at rest.

SURGERY (FASCIOTOMY AND FASCIECTOMY) PROVIDES THE ONLY EFFECTIVE TREATMENT FOR THIS CONDITION

20

IT IS GENERALLY ACCEPTED THAT

CLINICAL SIGNS ON EXAMINATION Passive examination is essential, even though physical examination is unlikely to be helpful. The examination may reveal bulky muscles, tense muscle compartment(s), a fascial defect or hernia, and sometimes bruising. Physical examination following provocative exercise may reveal tenderness over the affected muscle compartment, but this is variable. As there are few signs associated with the condition, negative findings are definitely the most useful. However, some authors have reported the following: n slight oedema and thickening of the subcutaneous border of the tibia n highly developed musculature and tension over the associated compartment n small fascial defects and muscle hernias (incidence 20–60%) n neurological symptoms, with occasional pain and weakness on passive stretch of the muscles involved n vascular disturbances (rare).

Summary of clinical symptoms and signs Clinical findings are considered by some to be the most important feature, but others challenge their reliability. Amendola and Webster- Bogaert correlated clinical features with pressure measurements and discovered that the most important criteria for CCS were (20): n age under 30 years n reproducible pain with exercise n no tenderness on palpation n bilateral symptoms n activity profile such as running,

where there is repetitive loading of the lower extremity. Wiley et al. used clinical criteria to select 16 patients for fasciotomy and reported good results in 14 of them (19). Several studies, however, have shown that not all patients suspected of having CCS entirely on clinical grounds have elevated ICPs.

In nearly all cases, the findings of

physical examination are decidedly unimpressive and unlikely to be helpful. History may be helpful but investigations are necessary for two main reasons: n to carry out a differential diagnosis n to confirm the diagnosis of CCS objectively.

INVESTIGATIONS Intracompartment pressure measurement

Intracompartment pressure (ICP) measurement remains the mainstay of objective diagnosis of CCS. Several methods of direct measurement of ICP have been developed. Styf neatly classifies them as follows (21): n Injection technique: French and Price were the first to measure ICP on two patients using the needle manometer technique (22). There was criticism of this technique: it was highlighted that the ICP could not be determined during active muscle contraction and that long-term continuous monitoring was impossible. This is the main disadvantage and limitation of this technique when dynamic monitoring is required. n Infusion technique: this technique is suitable for recording both the dynamic and the resting pressures. This method reduces the problem of catheter blockage, but care has to be taken to reduce infusion of saline below 3 ml/h in order to prevent a local rise in tissue pressure. A multi-holed Teflon™ catheter allows infusion rates as low as 0.2 ml/h. n Non-infusion technique: this technique is ideal, but it is not readily available. The occlusion of the catheter by muscle fibres and blood clots remains a problem but can be alleviated by using Rorabeck™ slit catheters and repeated flushing with 0.1 ml of heparinised saline. The technique involves cannulating a slit catheter that is primed with heparinised saline via a 17g Medicut™ needle. The catheter is linked to a pressure transducer (Fig. 2)

sportEX medicine 2009;40(Apr):16-22