CLINICALLY SPEAKING
Exertional Compartment Syndrome of the Medial Foot Compartment—Diagnosis and Treatment A Case Report Faye E. Izadi, DPM* Douglas H. Richie, Jr, DPM† Exertional compartment syndrome in the foot is rarely reported and often confused with plantar fasciitis as a cause of arch pain in the running athlete. We describe a case involving a 19-year-old competitive collegiate runner who developed a chronic case of bilateral medial arch pain during training, which was initially diagnosed as plantar fasciitis but failed to respond to conventional treatment. After symptoms began to suggest exertional compartment syndrome, the diagnosis was confirmed by measuring an elevated resting pressure in the medial compartment of both feet. The patient underwent a bilateral medial compartment fasciotomy, which allowed a full return to activity, and has remained pain free after a 1-year follow-up. (J Am Podiatr Med Assoc 104(4): 417-421, 2014)
Exertional compartment syndrome (ECS) is a condition caused by increased pressure in a closed myofascial compartment, which occurs secondary to repetitive load or exertional activity.1 Its occurrence following exercise is thought to be related to the fact that during strenuous exercise, muscle fibers can swell up to 20 times their resting size and lead to a 20% increase in muscle volume.2 When the fascial envelope of the muscle compartment fails to expand during exercise, pressure will increase, leading to ischemia and nerve impingement. Failure to return to normal resting intracompartmental pressures after periods of exertional activity is diagnostic of ECS. Exertional compartment syndrome most commonly involves the lower extremities and is rarely documented in the foot. When this condition does occur in the foot, the medial plantar compartment is the most common location.2-4 The medial plantar foot compartment contains the abductor hallucis; flexor hallucis brevis; flexor digitorum longus tendon; peroneus longus tendon; and the medial plantar nerve, artery, and vein.3,5-7 Exertional compartment syndrome of the medial foot compartment can present with symptoms that include pain, cramping, paresthesia, swelling, burning, or tight*Lakewood Regional Medical Center, Lakewood, CA. †Alamitos Seal Beach Podiatry Group, Seal Beach, CA. Corresponding author: Faye E. Izadi, DPM, Lakewood Regional Medical Center, 3700 E. South St, Lakewood, CA 90712. (E-mail: [email protected])
ness of the medial plantar arch.1,3,7 Symptoms typically occur only during activity and are relieved after a variable period of rest.6,7 Although there is usually no history of direct trauma or injury, individuals who typically present with ECS are often involved in endurance activities that require a repetitive load on the lower extremities. There has been some correlation described in the literature between duration and intensity of activity, with length and severity of symptoms.1,7 Exertional compartment syndrome in the foot is often overlooked in the differential diagnosis of exercise-related arch pain because its symptoms closely mimic that of more common conditions, such as plantar fasciitis, tarsal tunnel syndrome, or posterior tibial tendon dysfunction.7 Exertional compartment syndrome is most frequently misdiagnosed as plantar fasciitis due to its common anatomic location of symptoms and due to the high prevalence of plantar fasciitis in runners.8,9 In the clinical setting, the diagnosis of ECS should be considered in cases of recalcitrant plantar arch pain that fails to respond to traditional treatments for plantar fasciitis, such as taping, orthoses, corticosteroid injections, or physical therapy. Clinical diagnosis of ECS can often be made based on symptoms and history; however, measurement of intracompartmental pressures offers a more definitive method for diagnosis. Although there is some lack of agreement in the literature regarding normal pre- and postexercise intracompartmental
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pressures, it is generally accepted that a delay of return to normal pressure after exertion is pathologic,4 with a normal resting intracompartment pressure believed to be between 0 and 8 mmHg.1 Reports in the literature suggest that resting pressures greater than 10 to 15 mm Hg or postexertional pressures greater than 20 to 25 mm Hg are diagnostic of ECS.1,4 Left untreated, chronic ECS can lead to ischemic changes, resulting in irreversible muscle and nerve damage, as well as other long-term sequelae.1-3,5-7,10 Therefore, we describe this case history to further support the notion that running athletes with exercise-induced plantar arch pain should be evaluated and considered for the possibility of ECS in one of the plantar arch muscular compartments. From this single case experience, we hope to provide clinicians with an awareness for correctly diagnosing and treating exertional compartment syndrome of the foot.
Case Report A healthy 19-year-old female presented to Alamitos Seal Beach Podiatry Group (Seal Beach, California) via referral from her running coach who was concerned about the patient’s failure to improve after 4 months of treatment for persistent bilateral medial arch pain. The patient, who is a competitive cross-country and track runner at the collegiate level, began having severe pain, tightness, and swelling in the proximal medial longitudinal arches after starting her indoor track season. The symptoms evolved slowly over a period of 8 months, but reached a level of severity that forced the patient to terminate running altogether. Her symptoms were described as pain localized to the proximal medial arches of both feet, which on occasion radiated distally. In addition, she related occasional episodes of numbness and burning into digits 3, 4, and 5, bilaterally. Symptoms would commence after long periods of standing or after a few minutes of running, and were relieved after some period of rest. The patient had been treated by her school athletic trainers using standard interventions for plantar arch strain or fasciitis, which included arch taping, anti-inflammatory medications, physical therapy, custom orthoses, and changes in shoe gear. On initial clinical examination, the patient was noted to have a moderate cavus deformity with mild tenderness in the medial arch and central band of the plantar aponeurosis. Neurologic testing revealed no abnormalities in the lower extremities and feet.
418
Percussion of the tarsal tunnel demonstrated no radiation of symptoms. A Stryker intra-compartmental pressure monitor was used to measure the medial foot compartment, which revealed a resting pressure of 28 mm Hg. This finding, along with the presenting symptoms provided strong support for a diagnosis of chronic exertional compartment syndrome. Given the failure of the condition to respond to conservative treatment, a plantar medial arch compartment fasciotomy was recommended. Because of a short time frame before the patient was scheduled to return to school, bilateral fasciotomies were performed in the same operative setting. Surgical Technique Prior to administration of anesthesia, the sites of maximal tenderness were palpated and marked. This area was located immediately medial to the central band of the plantar aponeurosis, overlying the mid-portion of the abductor hallucis muscle in identical locations in both feet. The surgery was performed using a posterior tibial nerve block under monitored anesthesia care. A 5-cm linear longitudinal incision was made at the proximal plantar medial arch, overlying the point of maximal tenderness (Fig. 1). Dissection was deepened to the level of the deep fascia envelope of the medial foot compartment. The deep fascial layer was then sharply incised across the length of the incision and carried 0.5 cm further both proximal and distal (Fig. 2). Thus, an approximate 6-cm length fasciotomy was performed. Next, the underlying abductor hallucis muscle belly was visualized and was bluntly dissected away from its adhered fascia. No bulging of the muscle belly was noted and thus it was decided to not perform a debulking procedure (Fig. 3). The deep fascia was left open while the superficial fascia and skin incisions were approximated with Vicryl (Ethicon, Inc, Blue Ash, Ohio) and nylon suture, respectively. A bulky dressing with moderate compression to the plantar arch was applied bilaterally. Postsurgical Follow-Up The patient was restricted to bilateral nonweightbearing for the first 2 weeks postoperatively, which required restriction to a wheelchair. Partial crutchassisted weightbearing commenced after week 2 for a limited period of time. We recommended the wearing of athletic shoes and compressive stockings after week 2 to minimize edema and reduce tension on the plantar skin incisions. Active and
July/August 2014 Vol 104 No 4 Journal of the American Podiatric Medical Association
Figure 1. Incision placement is shown by the linear hash marks. Points of tenderness were marked preoperatively with the maximal point of tenderness just lateral to the incision.
passive range of motion exercises for the toe flexors and calf musculature began at week 2 and continued for 2 months postoperatively. Return to full weightbearing as tolerated commenced at week 4. Physical therapy exercises were then expanded to include weightbearing strengthening, range of motion, and balance training. At postoperative week 8, the patient began a gradual walk-run exercise program supervised by her coach and the athletic training staff. With each week the patient increased her level of running activity as tolerated. At 3 months postoperative, the patient could tolerate running for 2 to 3 miles without pain. At 5 months postoperative, the patient returned to full-time training for competitive track and field, tolerating training at distances more than 25 miles per week. At 9 months postoperative, she reported running her first 5K race with no pain in her feet.
Discussion This patient had initially been diagnosed with bilateral plantar fasciitis, which is the most common cause of mid-arch pain in the running athlete.8,9 However, conventional treatments for plantar fasciitis failed, while the patient’s symptoms progressed and became debilitating. With patients in whom arch pain continues, despite receiving treat-
Figure 2. Incision of the deep fascia decompressing the medial compartment. The abductor hallucis muscle belly is seen just deep to this incision.
ments that are usually successful, further investigation should be undertaken to determine if elevated muscular compartmental pressure might be the underlying pathology. There are several key features that distinguish plantar fasciitis from exertional compartment syndrome of the foot. Most important are the description of symptoms and the timing of onset during activity. Patients with ECS will describe pain during exercise, but other symptoms are often present such as burning, cramping, tightness, tingling, and numbness. These symptoms are usually not seen in plantar fasciitis. The symptoms of ECS are often symmetrical and bilateral, which are not as common with plantar fasciitis. In addition, patients with ECS will tend to have pain diffusely through the medial arch area of the foot while plantar fasciitis is more localized to the central band of the plantar aponeurosis in a more proximal location of the foot. In regards to onset of pain, there are key differences between the two pathologies. The classic symptom of first-step morning pain associated with plantar fasciitis is not commonly seen with ECS. Instead, ECS will predictably occur at a certain point of training runs, each and every attempt. Plantar fasciitis symptoms often subside during the run; ECS causes pain that builds in severity during exercise and gradually resolves with rest over a period of several hours. We have found that efforts to support the medial
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419
Figure 3. Single linear incision placement for medial compartment fasciotomy of the left (A) and right (B) foot. Upon decompression of the fascia, the abductor hallucis muscle belly was visualized with no noted bulging or hypertrophy.
arch of the foot will generally relieve symptoms of plantar fasciitis but will often exacerbate the symptoms of ECS. Our assumption is that arch taping and foot orthoses may actually increase external pressure against the medial arch compartment and increase the severity of symptoms of ECS. In our experience, arch taping can be used as a diagnostic tool to help differentiate ECS from plantar fasciitis. Several surgical approaches have been described in the literature for decompression of a medial foot compartment ECS. These include a straight medial incision, a medial and dorsal incision, two dorsal incisions, and medial parallel oblique incisions.1,2,6,10 It has been shown that a single linear medial incision is sufficient to decompress the medial compartment; incisions as long as 8 cm have been described.1,6,10 Our surgical technique involved a minimal 5-cm medial skin incision at the proximal plantar medial arch, with successful results. We prefer this location because it is distal to the porta pedis area of the abductor hallucis and avoids risk of injury to the medial plantar nerve. After a thorough review of the literature, we conclude that there is still no concrete evidence that links foot structure to a predisposition toward developing exertional compartment syndrome. For our patient, she was noted to exhibit a moderately cavus foot type with normal ankle, subtalar, first ray, and first metatarsophalangeal joint range of
420
motion. In the few previously published case reports on exertional compartment sydrome in the foot, there is no discussion regarding patient foot type; therefore, a comparative analysis would be difficult to ascertain at this time. Also, there are no published reports on footstrike or running style and associated risk for ECS. Therefore, any discussion about our patient’s foot type and running style as a causative factor for this condition would be purely speculative. Further research evaluating the correlation between foot structure and incidence of developing ECS is needed. Exertional compartment syndrome in the foot is not commonly diagnosed in practice, and this may be in part due to a lack of awareness and misdiagnosis. As reports of this condition increase in number, perhaps a future study may evaluate the relationship between gait patterns, foot structure, and predisposition toward development of ECS.
Conclusions We present a case of a young athlete who developed bilateral exertional medial foot compartment syndrome confirmed by intracompartmental pressure testing. The patient underwent a bilateral medial compartment fasciotomy with successful results. A careful review of symptoms described by the patient, which are subtly different from plantar
July/August 2014 Vol 104 No 4 Journal of the American Podiatric Medical Association
fasciitis, will suggest the presence of exertional compartment syndrome. The possibility of exertional compartment syndrome must always be considered when treating running athletes who fail to respond to conventional treatment for exerciseinduced arch pain in the feet.
5.
6.
Financial Disclosure: None reported. Conflict of Interest: None reported.
7.
References
8.
1. BLACKLIDGE DK, KUREK JB, RESTO SOTO AD, ET AL: Acute exertional compartment syndrome of the medial foot. J Foot Ankle Surg 35: 19, 1996. 2. JOWETT A, BIRKS C, BLACKNEY M: Chronic exertional compartment syndrome in the medial compartment of the foot. Foot Ankle Int 29: 838, 2008. 3. FINNOFF JT, HENNING PT, CEDERHOLM SK, ET AL: Accuracy of medial foot compartment pressure testing: A comparison of two techniques. Foot Ankle Int 31: 1001, 2010. 4. MOLLICA MB, DUYSHART SC: Analysis of pre- and postex-
9.
10.
ercise compartment pressures in the medial compartment of the foot. Am J Sports Med 30: 268, 2002. CHAMBERS L, HAME SL, LEVINE B: Acute exertional medial compartment syndrome of the foot after playing basketball. Skeletal Radiol 40: 931, 2011. MIOZZARI HH, GERARD R, STERN R, ET AL: Acute, exertional medial compartment syndrome of the foot in a highlevel athlete. Am J Sports Med 36: 983, 2008. PADHIAR N, ALLEN M, KING JB: Chronic exertional compartment syndrome of the foot. Sports Med Arthrosc Rev 17: 198, 2009. RIBIERO AP, TROMBINI-SOUZA F, TESSUTTI V, ET AL: The effects of plantar fasciitis and pain on plantar pressure distribution of recreational runners. Clin Biomech 26: 194, 2011. TAUNTON JE, RYAN MB, CLEMENT DB, ET AL: A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 36: 95, 2002. RICHTER J, SCHULZE W, KLAAS A, ET AL: Compartment syndrome of the foot: An experimental approach to pressure measurement and release. Arch Orthop Trauma Surg 128: 199, 2008.
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Exertional Compartment Syndrome of the Medial Foot Compartment—Diagnosis and Treatment A Case Report Faye E. Izadi, DPM* Douglas H. Richie, Jr, DPM† Exertional compartment syndrome in the foot is rarely reported and often confused with plantar fasciitis as a cause of arch pain in the running athlete. We describe a case involving a 19-year-old competitive collegiate runner who developed a chronic case of bilateral medial arch pain during training, which was initially diagnosed as plantar fasciitis but failed to respond to conventional treatment. After symptoms began to suggest exertional compartment syndrome, the diagnosis was confirmed by measuring an elevated resting pressure in the medial compartment of both feet. The patient underwent a bilateral medial compartment fasciotomy, which allowed a full return to activity, and has remained pain free after a 1-year follow-up. (J Am Podiatr Med Assoc 104(4): 417-421, 2014)
Exertional compartment syndrome (ECS) is a condition caused by increased pressure in a closed myofascial compartment, which occurs secondary to repetitive load or exertional activity.1 Its occurrence following exercise is thought to be related to the fact that during strenuous exercise, muscle fibers can swell up to 20 times their resting size and lead to a 20% increase in muscle volume.2 When the fascial envelope of the muscle compartment fails to expand during exercise, pressure will increase, leading to ischemia and nerve impingement. Failure to return to normal resting intracompartmental pressures after periods of exertional activity is diagnostic of ECS. Exertional compartment syndrome most commonly involves the lower extremities and is rarely documented in the foot. When this condition does occur in the foot, the medial plantar compartment is the most common location.2-4 The medial plantar foot compartment contains the abductor hallucis; flexor hallucis brevis; flexor digitorum longus tendon; peroneus longus tendon; and the medial plantar nerve, artery, and vein.3,5-7 Exertional compartment syndrome of the medial foot compartment can present with symptoms that include pain, cramping, paresthesia, swelling, burning, or tight*Lakewood Regional Medical Center, Lakewood, CA. †Alamitos Seal Beach Podiatry Group, Seal Beach, CA. Corresponding author: Faye E. Izadi, DPM, Lakewood Regional Medical Center, 3700 E. South St, Lakewood, CA 90712. (E-mail: [email protected])
ness of the medial plantar arch.1,3,7 Symptoms typically occur only during activity and are relieved after a variable period of rest.6,7 Although there is usually no history of direct trauma or injury, individuals who typically present with ECS are often involved in endurance activities that require a repetitive load on the lower extremities. There has been some correlation described in the literature between duration and intensity of activity, with length and severity of symptoms.1,7 Exertional compartment syndrome in the foot is often overlooked in the differential diagnosis of exercise-related arch pain because its symptoms closely mimic that of more common conditions, such as plantar fasciitis, tarsal tunnel syndrome, or posterior tibial tendon dysfunction.7 Exertional compartment syndrome is most frequently misdiagnosed as plantar fasciitis due to its common anatomic location of symptoms and due to the high prevalence of plantar fasciitis in runners.8,9 In the clinical setting, the diagnosis of ECS should be considered in cases of recalcitrant plantar arch pain that fails to respond to traditional treatments for plantar fasciitis, such as taping, orthoses, corticosteroid injections, or physical therapy. Clinical diagnosis of ECS can often be made based on symptoms and history; however, measurement of intracompartmental pressures offers a more definitive method for diagnosis. Although there is some lack of agreement in the literature regarding normal pre- and postexercise intracompartmental
Journal of the American Podiatric Medical Association Vol 104 No 4 July/August 2014
417
pressures, it is generally accepted that a delay of return to normal pressure after exertion is pathologic,4 with a normal resting intracompartment pressure believed to be between 0 and 8 mmHg.1 Reports in the literature suggest that resting pressures greater than 10 to 15 mm Hg or postexertional pressures greater than 20 to 25 mm Hg are diagnostic of ECS.1,4 Left untreated, chronic ECS can lead to ischemic changes, resulting in irreversible muscle and nerve damage, as well as other long-term sequelae.1-3,5-7,10 Therefore, we describe this case history to further support the notion that running athletes with exercise-induced plantar arch pain should be evaluated and considered for the possibility of ECS in one of the plantar arch muscular compartments. From this single case experience, we hope to provide clinicians with an awareness for correctly diagnosing and treating exertional compartment syndrome of the foot.
Case Report A healthy 19-year-old female presented to Alamitos Seal Beach Podiatry Group (Seal Beach, California) via referral from her running coach who was concerned about the patient’s failure to improve after 4 months of treatment for persistent bilateral medial arch pain. The patient, who is a competitive cross-country and track runner at the collegiate level, began having severe pain, tightness, and swelling in the proximal medial longitudinal arches after starting her indoor track season. The symptoms evolved slowly over a period of 8 months, but reached a level of severity that forced the patient to terminate running altogether. Her symptoms were described as pain localized to the proximal medial arches of both feet, which on occasion radiated distally. In addition, she related occasional episodes of numbness and burning into digits 3, 4, and 5, bilaterally. Symptoms would commence after long periods of standing or after a few minutes of running, and were relieved after some period of rest. The patient had been treated by her school athletic trainers using standard interventions for plantar arch strain or fasciitis, which included arch taping, anti-inflammatory medications, physical therapy, custom orthoses, and changes in shoe gear. On initial clinical examination, the patient was noted to have a moderate cavus deformity with mild tenderness in the medial arch and central band of the plantar aponeurosis. Neurologic testing revealed no abnormalities in the lower extremities and feet.
418
Percussion of the tarsal tunnel demonstrated no radiation of symptoms. A Stryker intra-compartmental pressure monitor was used to measure the medial foot compartment, which revealed a resting pressure of 28 mm Hg. This finding, along with the presenting symptoms provided strong support for a diagnosis of chronic exertional compartment syndrome. Given the failure of the condition to respond to conservative treatment, a plantar medial arch compartment fasciotomy was recommended. Because of a short time frame before the patient was scheduled to return to school, bilateral fasciotomies were performed in the same operative setting. Surgical Technique Prior to administration of anesthesia, the sites of maximal tenderness were palpated and marked. This area was located immediately medial to the central band of the plantar aponeurosis, overlying the mid-portion of the abductor hallucis muscle in identical locations in both feet. The surgery was performed using a posterior tibial nerve block under monitored anesthesia care. A 5-cm linear longitudinal incision was made at the proximal plantar medial arch, overlying the point of maximal tenderness (Fig. 1). Dissection was deepened to the level of the deep fascia envelope of the medial foot compartment. The deep fascial layer was then sharply incised across the length of the incision and carried 0.5 cm further both proximal and distal (Fig. 2). Thus, an approximate 6-cm length fasciotomy was performed. Next, the underlying abductor hallucis muscle belly was visualized and was bluntly dissected away from its adhered fascia. No bulging of the muscle belly was noted and thus it was decided to not perform a debulking procedure (Fig. 3). The deep fascia was left open while the superficial fascia and skin incisions were approximated with Vicryl (Ethicon, Inc, Blue Ash, Ohio) and nylon suture, respectively. A bulky dressing with moderate compression to the plantar arch was applied bilaterally. Postsurgical Follow-Up The patient was restricted to bilateral nonweightbearing for the first 2 weeks postoperatively, which required restriction to a wheelchair. Partial crutchassisted weightbearing commenced after week 2 for a limited period of time. We recommended the wearing of athletic shoes and compressive stockings after week 2 to minimize edema and reduce tension on the plantar skin incisions. Active and
July/August 2014 Vol 104 No 4 Journal of the American Podiatric Medical Association
Figure 1. Incision placement is shown by the linear hash marks. Points of tenderness were marked preoperatively with the maximal point of tenderness just lateral to the incision.
passive range of motion exercises for the toe flexors and calf musculature began at week 2 and continued for 2 months postoperatively. Return to full weightbearing as tolerated commenced at week 4. Physical therapy exercises were then expanded to include weightbearing strengthening, range of motion, and balance training. At postoperative week 8, the patient began a gradual walk-run exercise program supervised by her coach and the athletic training staff. With each week the patient increased her level of running activity as tolerated. At 3 months postoperative, the patient could tolerate running for 2 to 3 miles without pain. At 5 months postoperative, the patient returned to full-time training for competitive track and field, tolerating training at distances more than 25 miles per week. At 9 months postoperative, she reported running her first 5K race with no pain in her feet.
Discussion This patient had initially been diagnosed with bilateral plantar fasciitis, which is the most common cause of mid-arch pain in the running athlete.8,9 However, conventional treatments for plantar fasciitis failed, while the patient’s symptoms progressed and became debilitating. With patients in whom arch pain continues, despite receiving treat-
Figure 2. Incision of the deep fascia decompressing the medial compartment. The abductor hallucis muscle belly is seen just deep to this incision.
ments that are usually successful, further investigation should be undertaken to determine if elevated muscular compartmental pressure might be the underlying pathology. There are several key features that distinguish plantar fasciitis from exertional compartment syndrome of the foot. Most important are the description of symptoms and the timing of onset during activity. Patients with ECS will describe pain during exercise, but other symptoms are often present such as burning, cramping, tightness, tingling, and numbness. These symptoms are usually not seen in plantar fasciitis. The symptoms of ECS are often symmetrical and bilateral, which are not as common with plantar fasciitis. In addition, patients with ECS will tend to have pain diffusely through the medial arch area of the foot while plantar fasciitis is more localized to the central band of the plantar aponeurosis in a more proximal location of the foot. In regards to onset of pain, there are key differences between the two pathologies. The classic symptom of first-step morning pain associated with plantar fasciitis is not commonly seen with ECS. Instead, ECS will predictably occur at a certain point of training runs, each and every attempt. Plantar fasciitis symptoms often subside during the run; ECS causes pain that builds in severity during exercise and gradually resolves with rest over a period of several hours. We have found that efforts to support the medial
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419
Figure 3. Single linear incision placement for medial compartment fasciotomy of the left (A) and right (B) foot. Upon decompression of the fascia, the abductor hallucis muscle belly was visualized with no noted bulging or hypertrophy.
arch of the foot will generally relieve symptoms of plantar fasciitis but will often exacerbate the symptoms of ECS. Our assumption is that arch taping and foot orthoses may actually increase external pressure against the medial arch compartment and increase the severity of symptoms of ECS. In our experience, arch taping can be used as a diagnostic tool to help differentiate ECS from plantar fasciitis. Several surgical approaches have been described in the literature for decompression of a medial foot compartment ECS. These include a straight medial incision, a medial and dorsal incision, two dorsal incisions, and medial parallel oblique incisions.1,2,6,10 It has been shown that a single linear medial incision is sufficient to decompress the medial compartment; incisions as long as 8 cm have been described.1,6,10 Our surgical technique involved a minimal 5-cm medial skin incision at the proximal plantar medial arch, with successful results. We prefer this location because it is distal to the porta pedis area of the abductor hallucis and avoids risk of injury to the medial plantar nerve. After a thorough review of the literature, we conclude that there is still no concrete evidence that links foot structure to a predisposition toward developing exertional compartment syndrome. For our patient, she was noted to exhibit a moderately cavus foot type with normal ankle, subtalar, first ray, and first metatarsophalangeal joint range of
420
motion. In the few previously published case reports on exertional compartment sydrome in the foot, there is no discussion regarding patient foot type; therefore, a comparative analysis would be difficult to ascertain at this time. Also, there are no published reports on footstrike or running style and associated risk for ECS. Therefore, any discussion about our patient’s foot type and running style as a causative factor for this condition would be purely speculative. Further research evaluating the correlation between foot structure and incidence of developing ECS is needed. Exertional compartment syndrome in the foot is not commonly diagnosed in practice, and this may be in part due to a lack of awareness and misdiagnosis. As reports of this condition increase in number, perhaps a future study may evaluate the relationship between gait patterns, foot structure, and predisposition toward development of ECS.
Conclusions We present a case of a young athlete who developed bilateral exertional medial foot compartment syndrome confirmed by intracompartmental pressure testing. The patient underwent a bilateral medial compartment fasciotomy with successful results. A careful review of symptoms described by the patient, which are subtly different from plantar
July/August 2014 Vol 104 No 4 Journal of the American Podiatric Medical Association
fasciitis, will suggest the presence of exertional compartment syndrome. The possibility of exertional compartment syndrome must always be considered when treating running athletes who fail to respond to conventional treatment for exerciseinduced arch pain in the feet.
5.
6.
Financial Disclosure: None reported. Conflict of Interest: None reported.
7.
References
8.
1. BLACKLIDGE DK, KUREK JB, RESTO SOTO AD, ET AL: Acute exertional compartment syndrome of the medial foot. J Foot Ankle Surg 35: 19, 1996. 2. JOWETT A, BIRKS C, BLACKNEY M: Chronic exertional compartment syndrome in the medial compartment of the foot. Foot Ankle Int 29: 838, 2008. 3. FINNOFF JT, HENNING PT, CEDERHOLM SK, ET AL: Accuracy of medial foot compartment pressure testing: A comparison of two techniques. Foot Ankle Int 31: 1001, 2010. 4. MOLLICA MB, DUYSHART SC: Analysis of pre- and postex-
9.
10.
ercise compartment pressures in the medial compartment of the foot. Am J Sports Med 30: 268, 2002. CHAMBERS L, HAME SL, LEVINE B: Acute exertional medial compartment syndrome of the foot after playing basketball. Skeletal Radiol 40: 931, 2011. MIOZZARI HH, GERARD R, STERN R, ET AL: Acute, exertional medial compartment syndrome of the foot in a highlevel athlete. Am J Sports Med 36: 983, 2008. PADHIAR N, ALLEN M, KING JB: Chronic exertional compartment syndrome of the foot. Sports Med Arthrosc Rev 17: 198, 2009. RIBIERO AP, TROMBINI-SOUZA F, TESSUTTI V, ET AL: The effects of plantar fasciitis and pain on plantar pressure distribution of recreational runners. Clin Biomech 26: 194, 2011. TAUNTON JE, RYAN MB, CLEMENT DB, ET AL: A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 36: 95, 2002. RICHTER J, SCHULZE W, KLAAS A, ET AL: Compartment syndrome of the foot: An experimental approach to pressure measurement and release. Arch Orthop Trauma Surg 128: 199, 2008.
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