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research-article2013

FAIXXX10.1177/1071100713514390Foot & Ankle InternationalFinestone et al

Article Foot & Ankle International® 2014, Vol. 35(3) 285­–292 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100713514390 fai.sagepub.com

Management of Chronic Exertional Compartment Syndrome and Fascial Hernias in the Anterior Lower Leg With the Forefoot Rise Test and Limited Fasciotomy

Aharon S. Finestone, MD, MHA1,2, Matityahu Noff, MD1,2, Yussuf Nassar, MD1, Shlomo Moshe, MD2,3, Gabriel Agar, MD1,2, and Eran Tamir, MD1,2

Abstract Background: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart. Methods: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years. Results: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation). Conclusion: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg. Level of Evidence: Level IV, retrospective case series. Keywords: leg pain, percutaneous surgery, minimal invasive surgery, overuse injury, sports injury, muscle hernia Chronic exertional compartment syndrome is characterized by exertional pain in the anterolateral aspect of the lower leg, sometimes accompanied by numbness.29 It occurs during exercise in athletes and soldiers (referred to as athletes in this article), but most subjects are not symptomatic if they do not exercise.3 The mechanism is similar to that of the acute syndrome, but the pain usually prevents progression to tissue damage, a rare but grave consequence, mainly reported in the military.5,22 Chronic exertional compartment syndrome has been diagnosed with increasing frequency over the last decades, possibly due to increases in sports participation.3,9,32 Chronic exertional compartment syndrome is in the differential diagnosis when one is evaluating an athlete with pain in the lower leg. It is commonly accepted that chronic exertional compartment syndrome has 2 clinical presentations: most commonly exertional pain and less frequently

anterolateral muscle hernia of the lower leg.9,17 The hernia, often of the extensor hallucis longus,18 is usually at the natural fascial defect at the anterolateral aspect of the lower third of the leg, where the superficial peroneal nerve (mainly the medial dorsal cutaneous nerve, but sometimes the intermediate dorsal cutaneous nerve) exits the fascia. 1

Department of Orthopaedics, Assaf Harofeh Medical Center, Zerifin, Israel 2 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 3 Maccabi Healthcare Services, Occupational Medicine Department, Holon, Israel Corresponding Author: Aharon S. Finestone, MD, MHA, Assaf Harofeh Medical Center, POB 1424, Reut 71799, Israel. Email: [email protected]

286 An athlete with chronic exertional compartment syndrome or a muscle hernia has 2 possibilities. The first is modifying his or her training so as not to create painful pressure (an option probably adopted by many, even without gaining medical advice). If the athlete wants to continue training without decreasing training levels, there is no proven nonoperative treatment (even though nonoperative treatment should be attempted11), and fasciotomy is usually recommended.29 Since there are several diagnostic and therapeutic decisions in managing pain in the anterior lower leg, over the years we have created a management flowchart (Figure 1). The purpose of this study was to evaluate our clinical results using this flowchart. We hypothesized that using a simplified measurement of dynamic compartment pressure and a limited operative technique would achieve results at least as good as those published by other groups.

Methods We reviewed the files of all patients who underwent elective anterior compartment fasciotomy during the period 1996 to 2007 in the orthopaedic foot and ankle unit at our tertiary referral hospital. All patients were contacted by phone and invited to our outpatient clinic for the study (at no charge). Those not able or not willing to come were interviewed by phone. Data collected included demographics, military status, symptoms and exercise before and after surgery, and satisfaction (whether patient would have had surgery for the results he or she obtained). Pain was graded on a scale from 0 (none) to 4 (unbearable). Activity level was categorized as 1, nonactive; 2, moderate; 3 good; 4, excellent. The study was approved by the Assaf Harofeh Medical Center Institutional Review Board as a follow-up study including outpatient recall and telephone questionnaire.

Subjects During the 12-year period of the study, we operated on 36 patients (34 males). We interviewed 35 of them (9 at the clinic and 26 by phone). Patient age ranged from 16 to 54 years (mean, 24 years; median, 21 years; interquartile range, 19.7-23.6 years) reflecting the fact that 25 (69%) of the study subjects were conscripts in compulsory army service. All were healthy and active with no notable comorbidities. Median follow-up was 26 months (range, 4-120 months; interquartile range, 13-40 months).

Assessment of Intracompartmental Pressure on Exertion Preoperative resting and exercise anterior intracompartmental pressures were evaluated with a commercially available pressure monitor (Stryker 295-2 Quick Pressure,

Foot & Ankle International 35(3) Stryker Instruments, Kalamazoo, MI), with the side-ported, noncoring needle.6,9,29 We marked a crosshair on the center of the anterior compartment of the leg with a pen, and the skin and muscle were infiltrated with 5 mL of lidocaine 1.5% without epinephrine (Figure 2). If both legs were symptomatic, only the less symptomatic side was measured, and if the pressure was normal, the other side was measured. If only 1 leg was symptomatic, both were measured. The patient stood bearing weight equally on both feet (with a staff member close by, in case of fainting), and the resting intracompartmental pressure was measured and the needle immediately removed. The patient was then instructed to dorsiflex both feet, raising the forefeet from the floor while maintaining full weight bearing on both heels, and lowering them back to plantigrade repeatedly for 5 minutes or until the patient’s characteristic symptoms developed (usually pain in the anterior compartment, usually after 1-2 minutes). As soon as the patient stopped exercising, the needle was reinserted and the intracompartmental pressure measurement repeated. Intracompartmental pressure was not measured in 9 patients (25%, 8 patients with a clearly diagnosable muscle hernia on physical examination, and 1 with a clinical diagnosis of chronic exertional compartment syndrome who came to the preoperative clinic on a day when the monitor was out of order). In 8 patients we also measured the intracompartmental pressure a third time after the patient recovered from the exercise. This was performed after 10 to 15 minutes of resting supine, again with the patient standing. Our cutoff points based on intracompartmental pressure for diagnosis were resting pressure greater than 40 mm Hg and exercise pressure greater than 60 mm Hg, although other clinical factors were taken into account in the final decision on surgery. The diagnosis of a hernia was made clinically by performing the repeated forefoot rise test and palpating a defect in the fascia of the anterolateral aspect of the distal leg through which muscle bulged.17

Operative Technique Surgery was performed under local anesthesia (10 mL 1% lidocaine without epinephrine + 10 mL 0.5% bupivacaine per leg). Percutaneous fasciotomy of the middle and proximal lower leg was performed through a 40-mm longitudinal incision over the middle of the anterior compartment, 15 mm lateral to the tibial crest, the distal end at the center between the head of the fibula and the lateral malleolus (Figure 3). After performing blunt dissection down to the fascia and making a slight slit in it, the surgeon passed a long pair of closed gynecological scissors over and under the fascia, taking care to point the curve of the scissors upward (superficially) both distally and proximally. The fasciotomy was then performed by opening the scissors about 5 mm and pushing them blindly through the fascia in

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Figure 1.  Flowchart for management of lower leg pain. CRPS, complex regional pain syndrome; S/P, status post.

the direction of the fibers distally and proximally, taking care that the curved tip pointed toward the tibial crest, and not going distal into the lower third of the lower leg where there would be danger of injuring a branch of the superficial

peroneal nerve (and beyond which there was almost no tibialis anterior muscle). Adequate release was assessed by digital palpation. In cases that needed distal fasciotomy (cases of hernias), the distal fasciotomy was performed

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Figure 2.  Forefoot rise test. With the patient supine, the crosshair was marked in the center of the anterior compartment (halfway between the medial malleolus prominence and the tibial tuberosity, 25 mm lateral to the tibial crest) and local anesthesia administered to the center of the crosshair. The patient then stood, with assistance, and the pressure monitor was introduced at the same spot. After the resting pressure was documented, the monitor was removed for the exercise. Immediately following exercise cessation, the pressure was measured again, with the patient still standing.

openly so as to have direct vision of the medial branches of the superficial peroneal nerve, making the incision over the distal part about 70 mm long. Only the anterior compartment was opened in all cases.

Data Analysis Statistical analysis used paired t tests for pre–post analysis and Student’s t test and chi-square test for comparing subgroups.

Results During the 12-year period, we operated on 36 patients (67 legs). We interviewed 35 patients (9 at the clinic and 26 by

Foot & Ankle International 35(3) phone). One patient had died (cause unknown, but from the conversation with his mother, it appeared that the cause was not related to the surgery). Of the 36 patients, 20 had bilateral surgery at 1 session, 11 were unilateral (9 right and left) with 5 staged (1 side and then the other). The indications for surgery were documented high intracompartmental pressure in 27 patients (75%), muscle herniation in 6 patients (17%), and pain after an attempted fascial repair in 1 patient (at another institution, the procedure we performed was a percutaneous fasciotomy). One patient was operated on for suspected high pressure without pressure evaluation due to equipment failure. One medical file could not be located. The mean intracompartmental pressures are presented in Table 1. Of these patients, 25 (71%) reported that they would have undergone surgery had they known their results, and the rest would have declined surgery. Changes in pain scores, activity level, and distance the subjects were able to walk and run are presented in Table 2. Complications included injury to the superficial peroneal nerve in 3 legs in 3 patients (operated on percutaneously), with 1 patient requiring unilateral reoperation (neurectomy). None of the patients had undergone further surgery for inadequate pressure relief. Patients operated on in 2 sessions (each leg separately, usually a few weeks between sessions) improved less than those operated on in 1 session (pain decreased 0.4 ± 1.5 vs 1.8 ± 1.2, P = .02). There were no significant differences between patients operated for high pressure or for hernias (Table 3). There was no significant difference between soldiers and civilians in pain improvement or activity level (soldiers’ pain decreased 1.4 ± 1.4 vs civilians’ 2.0 ± 1.3, and activity level increased 0.9 ± 1.0 vs 1.6 ± 0.9, respectively.

Discussion In our series we used a clinical management flowchart that offered surgery less frequently than most other published protocols, and our surgery was more minimal. We found that 80% of our patients’ pain decreased following surgery, together with an increase in the ability for most of them to walk and run, a result comparable to the findings of others.9,28,31 Lower leg pain is extremely frequent among athletes,25,26 making its management somewhat challenging because of the wide differential diagnosis. Most clinicians are aware of acute anterior compartment syndrome and its management, which includes aggressive surgery based on a quick clinical decision. Because missing the diagnosis or inadequate release of all compartments can have such devastating results, minor complications can be accepted. Chronic exertional compartment syndrome is a completely different issue. It affects athletes who seek the best performance from their body, and even a minor complication can

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Figure 3.  Operative technique. Incision from 15 mm lateral to tibial crest, halfway between fibular head and the lateral malleolus, 40 mm proximally. The curved tip of the scissors should point superficially when the fascia is separated from overlying and underlying tissue and should point toward the tibia when the fascia is incised. The tip of the scissors should never go distal to the lower one-third mark.

Table 1.  Mean Exertional Intracompartmental Pressurea. No. of Patients Resting (preexercise) Exercise Recovery

8 27 8

Intracompartmental Pressure, mm Hg 55 ± 21 (11-80) 86 ± 24 (55-150) 40 ± 27 (5-88)

a Intracompartmental pressure is presented as mean ± SD (min to max). Recovery: 10 to 15 minutes following the exercise.

result in a performance decline and be seen as a major setback to the athlete. For this reason, a clear staged scheme for diagnosis and management is necessary, and surgery must be contemplated carefully. There is ample literature on the technique of measuring the intracompartmental pressure and on the pressure cutoff points for diagnosis,3 but there is little discussion on the exercise protocol for creating the pressure, and thus standards need to be set, both in the exercise protocol and in intracompartmental pressure cutoff points.2,10,19 Most centers create the stress by having the subject run on a treadmill or outside, so that the test requires a special setup and/or continuous pressure monitoring. The subject runs until classic complaints arise possibly preventing further running, and this can take half an hour or longer. The test we use (lifting the forefoot to the standing on heel position) is a modification of a test described to demonstrate a muscle hernia. The fact that the test was originally reported for muscle hernia diagnosis further stresses the close connection between the diagnoses of chronic exertional compartment syndrome and fascial hernias. Assessment of the

intracompartmental pressure must be done during or within seconds of ceasing the exercise,4 as the pressure drops rapidly in some patients. The technique we use has several advantages: its ease of application (no equipment necessary beyond the commercially available pressure monitor with the side-ported, noncoring needle), the fact that the needle may be reinserted within less than 5 seconds after ceasing exercise, and the fact that almost all patients develop symptoms within less than 5 minutes, limiting the complete consultation and test to 15 to 20 minutes. The lower cutoff points published for deciding to perform fasciotomy are 1 of 3: preexercise pressure 15 mm Hg or greater, 1 minute postexercise pressure 30 mm Hg or greater, or a recovery pressure (10 to 15 minutes) 20 mm Hg or greater.27 The pressures we measured and our cutoff points for diagnosis (resting >40, exercise >60) are considerably higher than most reports. The nearest report to ours demonstrated exercise pressures of 48 ± 7 mm Hg (range, 31-138 mm Hg), curiously also in a predominantly military population. Our limited data show that recovery pressures are unreliable for determining surgery, as has been shown by others,4 and we have stopped measuring them. This problem with recovery pressures is supported by electromyographic data showing that muscles may remain contracted at rest following the exercise34: that is, there can be great variability. We do not routinely measure pressure bilaterally because the decision to perform surgery is a clinical one, and the pressure measurement is only a decision-supporting test. If the clinical picture is of chronic exertional compartment syndrome and the patient’s complaints are bilateral, unilateral high pressure is enough to justify bilateral surgery.

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Table 2.  Means for Reported Parameters Before and After Surgery (± SD).

a

Pain Activity levelb Walking distance, km Running distance, km

No. of Patients

Preoperative

Postoperative

P

35 33 27 29

2.9 ± 0.9 1.9 ± 0.5   9 ± 20 1.3 ± 1.6

1.3 ± 1.3 3.1 ± 0.9 21 ± 30 4.0 ± 3.4

Management of chronic exertional compartment syndrome and fascial hernias in the anterior lower leg with the forefoot rise test and limited fasciotomy.

Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier...
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