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DIAGNOSIS CHRONIC COMPARTMENT SYNDROME
and a recording system, which displays online information (Fig. 3). The main advantage of this technique is that it allows the ICP to be measured in the patient’s physical activity that provokes the symptoms and, often, the rise in ICP is exercise-specific (23). n Micro-tip transducer technique: this is the latest development in recording pressures utilising solid-state intracompartment transducers (STIC).
Recent advances in technology
have led to a quest for alternative methods that are non-invasive or less invasive than ICP studies.
Magnetic resonance imaging Magnetic resonance imaging (MRI) provides a non-invasive method of investigation that has been adapted mainly for research purposes in CCS. Proton-density MRI scans have shown specific changes after exercise, and these are believed to be due to increased extracellular water content, which correlates with previous histochemical studies. At this stage, MRI remains a
research technique and its role in clinical diagnosis is yet to be established.
Nuclear magnetic resonance spectroscopy Phosphorous-31 nuclear magnetic resonance (NMR) spectroscopy provides a method to assess the physiological and metabolic characteristics of exercising skeletal muscle without ionising radiation or an invasive procedure. The initial studies were performed
on the dog models of ACS and involved arterial occlusion for 6–8 hours. These methods involved assessment of the ratio of phosphocreatine to one of its metabolic products (inorganic phosphate) and muscle pH, which represents the commencement of anaerobic metabolic in response to inadequate oxygenation. NMR spectroscopy presents
exciting opportunities to understand the pathophysiological processes involved in CCS. Its role in clinical diagnosis, however, is severely limited by cost and availability.
Nuclear medicine
Nuclear medicine proposes techniques to assess local blood flow using
133-xenon or 99-technetium-MIBI, but its application in CCS is very much in its early stages. Styf et al., using 133-xenon,
found that the decreased blood flow during exercise correlated well with the pathological increase of muscle relaxation pressure in symptomatic legs and suggested that blood flow may be impeded at intramuscular pressures between 30 mmHg and 50 mmHg (24).
In Amendola et al.’s MRI study, an
assessment of blood flow was made using nuclear medical techniques (99-Tc-MIBI) (25). There was evidence to suggest a direct correlation with local blood flow; however, no consistent ischaemic changes were found, despite pressure and MRI changes. Preliminary studies with a similar
technique have shown some changes in CCS, but the most dramatic result has been shown by Jenner in a case of popliteal artery entrapment syndrome (26).
Quantitative hardness Palpatation has long been part of the clinician’s armamentarium, and hardness of the anterior compartment post-exercise has been described by some authors as a sign in chronic compartment syndrome. A recent study proposes a technique similar to ophthalmic tonometry, which assesses pressure in the anterior chamber of the eye, developed by Von Graefe in 1862. An experimental piston probe indents the muscle compartment by an amount called “quantitative hardness”, and this is correlated with ICP.
Preliminary laboratory studies
show a promising correlation. The main attraction is that the technique is simple and non-invasive. Further studies are required, however, to establish its reliability and role in diagnosing CCS.
Ultrasound
Ultrasound has a great advantage in imaging soft tissue structures. It is dynamic and inexpensive, gives rapid online assessment, is radiation-free, and maintains high resolution. The use of ultrasound in sports medicine practice has a great potential as experience with its application increases.
Recently ultrasound has been used as a technique to examine the cross- sectional area of muscle compartments
(27,28). Its use is limited by the fact that CCS is a dynamic condition and that patients are usually examined while resting on a couch.
TREATMENT Surgery Once the diagnosis of CCS is confirmed with dynamic intracompartment pressure study, it is generally accepted that surgery (fasciotomy and fasciectomy) provides the only effective treatment for the condition. The main aim of the fasciotomy (Fig. 4) is to increase the compartment volume by dividing the entire length of the fascia through a short skin incision. The outcome of surgery is usually very good, but it varies between surgeons and compartments decompressed. Abramowitz and Schepsis (29) found that, in their series, patients with anterior compartment decompression had a better outcome than patients with deep posterior compartment decompression.
Fasciectomy (removing a ribbon of fascia) is usually performed as an open procedure and requires a longer incision. It is usually performed when fasciotomy has failed. Turnispeed and Detmer carried out decompression in 209 patients (100 fasciotomy, 109 fasciectomy) and found a higher success rate with fasciectomy (98%) compared with fasciotomy (89%) (30). This was partly because better decompression is achieved by direct visualisation, but this requires a longer incision, which increases the risk of infection and dehiscence (Fig. 5). The success of surgery also depends on postoperative rehabilitation. It is generally agreed that patients should be weight-bearing as soon as possible in order to keep the compartment open and bigger. Surgery carries the usual risk factors, such as neuropraxia, infection, dehiscence, haematoma, deep vein thrombosis (DVT), and arterial and venous damage.
Conservative treatment The condition is self-limiting, as pain occurs mainly with exercise and is better with rest, so giving up the activity that causes the pain is an effective treatment. This is usually not acceptable to most athletes, however, and is not the advice that clinicians should offer. Various conservative treatment
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