Compartment Pressure Testing

If you have been experiencing:

• Pain in both shins, perhaps with one side worse than the other, that;
• Improves with rest, and;
• Appears as cramping, contracting, piercing, aching, tightness or a squeezing sensation

You may be suffering from Chronic Exertional Compartment Syndrome (CECS) and require Compartment Pressure Testing.

What is Chronic Exertional Compartment Syndrome (CECS)?
Chronic Exertional Compartment Syndrome is one of the less common causes of exertion-related leg discomfort and occasionally upper limb pain.

The pain tends to involve both shins, although one side may be worse than the other, and it improves with rest. This is different to so-called “shin splints”, when the exertion-related pain worsens after exercise. To confuse matters, some people suffer both CECS and shin splints at the same time, making diagnosis somewhat challenging.

As noted above, the pain of a CECS has been described as cramping, contracting, piercing, aching, tightness or a squeezing sensation. The anterior compartment (shin muscles) are most often affected and, in severe cases, exertion may cause “pins and needles” (less commonly) over the top of the foot, “foot slapping” or a foot drop, and sometimes ankle weakness or fatigue. The calves may also be affected by CECS (less often) and may present as chronic tightness or recurrent tears. The condition may appear alongside the more common Chronic Anterior Compartment Syndrome.

Physical examination of athletes with CECS is generally inconclusive, with few visible clues as to the underlying problem. However if you are symptomatic at the time of seeing a professional, there may be tenderness when touching the affected area. Small muscle hernias or “bumps”, especially over the shin area, may be seen in around 40% of cases.

What causes CECS?
The causes of the pain and tightness of CECS are still not fully understood, but notable research has indicated that reduced blood flow through the arteries into the muscles is probably the main cause. This occurs because of pressures which develop in the muscle compartments during exercise. The reduced blood flow means reduced oxygen for the muscles, leading to pain.

Another possible cause of pain that has been put forth recently is reduced return of blood through the veins from the legs back into the central circulation. With this in mind, the use of running tights or support stockings by many athletes who are told they might help minimise “shin splints”, may also help improve circulation in cases of exertion-related leg pain.

Diagnosing CECS using Compartment Pressure Testing
At the Sports Injury Diagnosis Clinic, you will be given a consultation with an expert practitioner who can establish on clinical grounds whether you are suffering from CECS, using a highly effective specialist method known as Compartment Pressure Testing.

We usually require patients to continue to exercise in the days before diagnosis so that they are symptomatic on the day of testing. We then measure intramuscular pressure using the special Kodiag Pressure Transducer System, a minimally invasive device we use in muscles after you have exercised to induce your pain. We perform Compartment Pressure Testing under local anaesthetic, so you won’t experience much discomfort during the procedure itself.

The test often involves brisk walking or running on a treadmill for 10-15 minutes in order to reproduce your pain. A small catheter is inserted into the area being tested. Pressure readings (measured in mmHg, as in blood pressure recordings) are then taken using the Kodiag device while you rest. Positive readings are in the region of 30 mmHg or more after a minute of rest, but the main finding in many cases is a delayed return to normal pressures (5-8 mmHg) within the minute. The higher the pressure readings after exercise (60 mmHg or more) and the greater the delay in returning to normal resting pressures, the more indicative of CECS the test has been.

Sometimes patients may have no pain during or after the test and pressure readings might be “borderline”, making diagnosis more challenging. In such cases a retest may be arranged, or alternatively other tests such as MRI or vascular scans, blood tests (e.g. to rule out Iron Deficiency Anaemia) may be necessary.

Treatment
Many patients with CECS find it has gone unnoticed for years, but the good news is that something can actually be done about it.

Modified rest and a change in running style represent conservative treatments which may be worthwhile in those who are “heel strikers”, as some may overuse their shin muscles whilst running. However, rest itself is obviously somewhat problematic for athletes, especially as symptoms may simply recur when they return to their normal exercise routine.

With that in mind, treatment tends to involve a surgical procedure known as Fasciotomy. A Fasciotomy is a surgical cut of the internal fascia (tissue that is often very tight or tough and covers the muscles affected).

This surgery involves long-term success rates in the region of 80-90%, with very low rates of problem recurrence. Many patients return to sports within 6-8 weeks after surgery and have no further trouble.