Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome (CECS) is a painful condition of the legs. It’s characteristic signs are elevated pressure within the compartments of the legs, which causes pain and often disrupts normal neuromuscular function. When the pain and dysfunction become severe, surgery to relieve the pressure may be an option. The current thinking is that pressure builds within the compartments because the muscle mass and fluid within the compartment is simply greater than the compartment space allows. For a better understanding of what these compartments are all about, see the illustrations below. As always, please excuse me for being more of a Piccaso than a Leonardo when it comes to drawing and labeling graphic representations.






The above illustration is a cross section of the leg about midway between the knee and ankle. All the “stuff” (muscles, vessels, nerves, etc) have been left out so you can see the distinct compartments. Each compartment houses sets of muscles and, although in reality the muscles work together to provide movement and stability, each set of muscles has their own orientation. The lateral compartment is a sack that holds muscles that generally provide lateral stabilization, the anterior compartment is a sack that hold muscles that generally provide dorsi flexion and the posterior compartment is a sack that holds muscles that provide plantar flexion. These compartments are walled by the septa, the deep fascia of the leg and the interosseous membrane. If all the structures within the compartments fit just right, there is enough pressure to push the blood back up through the vein when the muscles of that compartment contact. Too tight a fit, fluid has trouble getting out; too loose a fit, the muscle have to work harder to push blood up the vessels and may need help. The most common and most dangerous scenario is too tight a fit. Check out the illustration below. It shows the compartments with all their contents. It doesn’t take much imagination to see how conditions in the legs can be tight and uncomfortable, even in normal health legs. No wonder it feels good (and is a good practice!) to put our legs up after a long day!





Anterior Compartment
TA - tibialis anterior
EDL - extensor digitorum longus
EHL - extensor hallucis longus

Lateral Compartment
fibularis longus
fibularis brevis

Deep Posterior Compartment
TP - tibialis posterior
FDL - flexor digitorum longus
FHL - flexor hallucis longus

Superficial Posterior Compartment
soleus
gastrocnemius

Special mention has to be made here of the name of the condition we are addressing. You’ll usually hear people refer to it as just “compartment syndrome” rather than give the full name of chronic exertional compartment syndrome (CECS). This understandable, because CECS is a mouthful, but it is somewhat a misnomer. Compartment syndrome can be either chronic or acute. Acute compartment syndrome (ACS) is brought on by trauma to the leg and is an emergency situation that needs to be addressed immediately. Requisites for determining if the pain in the legs is CECS include anatomical location (as discussed above, in one of the compartment), results from tests that there is increased pressure in the compartments, decreased circulation in the legs, and neuromuscular dysfunction in the structures within the compartments. The “gold standard” for determining pressure in the compartments is to actually insert at probe into the compartment to measure the pressure, although less invasive neurogical tests have recently shown some promise in determining if CECS is the cause of the patient’s pain and dysfunction.

If a diagnosis of CECS is returned, then a decompressive fasciotomy may be an option to relieve the pain and dysfunction. This procedure cuts open the walls of the compartments relieving the pressure on the structures inside. There are several different approaches to the procedure, but the basic procedure is the same. The illustrations below presents one approach where two incisions are made on the lateral aspect of the leg (yes, that illustration is supposed to be a leg!) and the epidermis and subcutaneous adipose is retracted to expose the deep fascia of the leg. Figure 1 clearly illustrates the anterior compartment and the lateral compartments. The darker line that separates them is the anterior intermuscular septum (see the first illustration above for clarity). Note the superficial peroneal nerve where it emerges from the deep fascia of the leg – it is important for both the surgeons performing the procedure and the therapists working with the patient/client to identify it. In figure 2, I have removed the hooks to make it easier to see where incisions have been made in the anterior and lateral compartments.




A similar procedure is execute on the medial side of the leg for the deep posterior compartment, but is complicated by the orientation of the soleus muscle where it attaches to the tibia and must be detached and retracted to expose the deep posterior compartment (see the second illustration for a better visual of why this is necessary). On the medial side, it is the saphenous nerve and vein that must be carefully worked around.

Therapeutic Considerations
Although most decompressive fasciotomies are successful in relieving the pain and dysfunction, allowing the athlete to return to their sport, they will likely need to maintain a regiment of self care in which circulatory massage and cross-fiber friction can play an important role. As with any surgery, massage therapy can help decrease adhesion around scar tissue. With the septa cut and the resistance to muscle contraction reduced, regular circulatory massage can also help maintain the health of the tissues by influencing venous flow. Care must be taken in the areas of scar tissue near nerves, particularly the superficial peroneal nerve.

References:

Williams, E.H, Detmer, D.E., Guyton, G.P., Dellon, A. L. (2009) Non-invasive neurosensory testing used to diagnose and confirm successful surgical management of lower extremity deep distal posterior compartment syndrome. Journal of Brachial Plexus and Peripheral Nerve Injury,4(4)

Rorabeck, C.H., Bourne, R.B., Fowler, P.J., (1983) The surgical treatment of exertional compartment syndrome in athletes. The Journal of Bone and Joint Surgery, 65: 1245-1251

www.mayoclinic.com/health/chronic-exertional-compartment-syndrome/DS00789/DSECTION=treatments-and-drugs

Houglum, Peggy. “Therapeutic Exercise for Musculoskeletal Injuries, 2nd Edition.” Primary and Secondary Healing. Ed. David H. Perrin. Champaign, IL, Human Kinetics, 2005.

Netter, Frank. “The Atlas of Human Anatomy”
Phiadelphia, PA, Saunders-Elsevier, 2003

Iliotibial Band Syndrome

Spring has sprung early and beautifully this year. We can’t have the yin without the yang it seems, so along with early warmth, blue skies, and breathtaking buds comes allergies, knee, hip, and low back conditions. Just like allergies, musculoskeletal conditions come any time of year, but each season seems to bring more of one than the other. Spring and summer see a lot of knee conditions, but iliotibial band syndrome (ITB) is the unquestioned champion of Soarbody Therapeutics at this time of year.

A syndrome is distinct from a disease or specific condition in that is defined by the presence of a number of symptoms that characterize a condition and its usually ongoing, that is, it doesn’t run a specific course with an outcome. Generally, ITB syndrome is an overuse syndrome whose main symptom, pain at the lateral aspect of the knee, is caused by friction between the lateral epicondyle of the femur and the iliotibial band. So let’s step back and see what that means.

The iliotibial band is a tough band of connective tissue connects two muscles whose origin are on the ilium (gluteus maximus and tensor fasciae latae, TFL) to the anterior of the tibia, specifically to a lump on the more anterior aspect of the tibia called Gerdy’s Tubercle. Because of the way the ITB has to angle past the knee to get to the anterolateral aspect of the Tibia, it has to pass by the lateral epicondyle of the femur. When running, as gluteus maximus and TFL are engaged during heel strike phase to stabilize the leg and ready the hip for extension and the knee for flexion, great pressure is felt along the ITB. The ITB has to pass over the lateral epicondyle as the knee moves from being fully extended into flexion while still under great stress from gluteus maximus and TFL. It’s believed that that most of the friction takes place around 30 degrees of knee flexion. Although by no means restricted to runners, this scenario is played out most dramatically in distance runners.

So why don’t all runners experience this syndrome? Because there are a number of variables involved in how forcefully the ITB snaps over the lateral epicondyle. Training errors (scheduling too much distance, too much downhill too soon) are certainly one cause. Certain inherent traits are also factors (Q – angle, arch design and mechanics in the foot). The most frequent cause of stubborn cases of ITB syndrome in this therapist’s experience, however, is simply the over use of the muscles recruited to perform the athletes’ main action combined with the under utilization of other muscles that are usually used to provide stability in gait. This overuse may be due to training error or compensational patterns due to previous injuries.

In the case of ITB syndrome, over use of gluteus maximus and TFL and under utilization in the gluteus minimus and medius are often implicated as active structures in the hip to be addressed. However, keep in mind that imbalances to either side of the knee, proximal and distal, can present unbalanced stresses around the knee in gait. So a good therapist will be examining what is happening distal to the knee in the leg, ankle, and foot as well as what is occurring in the thigh and hip. Manual therapists, in fact, often neglect to address both the muscles of the leg (especially the peronials!) and adjustments to the ankle (be on the look-out for this error!).

Finally, be mindful of the stages of healing (see the last post). Chronic overuse injuries often come to those of us (myself included) who are crazed about having to do our sport. In fact, in all honesty, many of us get injured because we have been obsessively practicing our sport without giving our bodies a break to heal (no post season). You need to follow the therapist’s directives. No running means no running! You’ll survive, believe me. Cheating will just impede your progress. For those of you who are running to maintain your weight, there are better ways to do it (cardio is not the best, by the way) and a personal trainer or strength coach who can communicate with your therapist can help you maintain your ideal weight. If you are running to fight off depression, talk to a psychologist about other means of control while you are healing

The Musculotendinous Healing Process

A basic understanding of the soft tissue healing process is helpful – it provides insight into why it is important to address an injury (no matter how small) as soon as possible and gives us general bench marks for how well we are healing.
The process of healing itself is rather complex, but we can look at it in general terms to simplify things a bit. It makes sense that the more serious the lesion is, the more scar forms and the longer it will take to heal. If the lesion is small, or its parts are sutured together soon after the insult, cells from the two separated parts bridge the gap between, binding the ends of the lesion together. This is the fastest type of healing, results in the least scar tissue and is referred to as healing by primary intention. If the lesion is more serious (second degree, where larger amounts of tissue are separated by more space) without surgical intervention, tissue is produced from the bottom and the sides of the wound to fill up the gap. This takes more time, creates more scar tissue and is referred to as healing by secondary intention.

Regardless which type of healing occurs, the process is continuous and will run its course if allowed to so, that is, if we listen to our bodies and do the right thing. Although continuous in nature, we can break the process into three phases, whose signs and symptoms can be read by the therapist and client. This is a quick generalization and should give you a rough idea of what is going on with your lesion, but I urge you to study the process in more detail.


Inflammation

Onset up to day 5
Onset of injury–point tender; red, hot, swollen

Proliferation

Up to day 21
Scar tissue may be larger than normal due to edema

Remodeling

Up to 1 year
Scar tissues loses some of its water content,
scar density increases,
vascularity/redness decrease

(Houglum, 37-43)

During the inflammation stage, the focus needs to be on controlling the inflammation and stabilizing the area to prevent further injury. After that, your therapist will determine what type of therapy is appropriate depending on your injury and using well established guidelines.

There are also general time lines that we can expect for the healing of different types of tissues to regain nearly normal strength:

Ligaments – as long as 40 to 50 weeks
Tendons – as long as 40 to 50 weeks
Muscle – 6 weeks to 6 months
Cartilage – 6 months
Bone – 12 weeks
(Houglum, 48-51)

Keep in mind that these ranges are general and that we are resuming guided activity by the therapist well before the “normal strength” limit has been reached – in fact, the lesion won’t heal properly or fully unless we are active.
There are also general stages of rehabilitation your therapist will take you through that you must be patient with to facilitate the proper healing of the above tissues. You will need to progress from stability of the injured structure, to it’s flexibility, to it’s strengthening, to it’s ability to produce raw athletic power, and finally to full functionality in your sport. These stages will likely overlap each other to some degree. Focusing on preventing other systems and structures from becoming deconditioned in order to facilitate the healing of the lesion and maintaining your readiness to return to full functionality will also be part of your treatment plan.

Treatment will probably include both exercise prescription and modalities (massage therapy, ultrasound, etc). Both are important, but keep in mind, specifically for repetitive stress injuries, it was inefficient movement over a long period of time that caused the condition and that inefficient movement will need to be corrected and will take time to do so. Be patient - the exercises will not only facilitate the healing of the lesion but prevent it from returning. With respect to the modalities, some you won't feel at all and some can be quite painful. Suck it up – you’re an athlete! Learning what’s good pain and what’s bad pain is an important lesson. The realm of ultimate health, inner balance, peace, love, understanding, general feel good, etc. are noble goals, but lie further down the healing spectrum. Your goal is to heal that lesion and get back to kicking ass, not to lie around and feel your inner peace.

So be patient, accept your pain, and work hard, and you’ll back on the field, on the track, on the court, or in the pool, as good as (if not better than!) ever.

References
Houglum, Peggy. “Therapeutic Exercise for Musculoskeletal Injuries, 2nd Edition.” Primary and Secondary Healing. Ed. David H. Perrin. Champaign, IL, Human Kinetics, 2005.

Anatomically Speaking

The mission of this blog is not to help the injured athlete self diagnose or self evaluate, but to gain an understanding on their challenges that provides them with direction in seeking help and the motivation to more fully recover.

This, however, takes a certain amount of understanding of musculoskeletal anatomy, at least basic anatomical orientation and the structures involved. Explaining injuries and conditions without this base of understanding leads to confusion and misunderstanding. Some terms you will want to know by heart are: anatomical position, anatomical planes (transverse, frontal, sagittal), medial, lateral, contralateral, ipsilateral, anterior, posterior, superior, inferior, proximal, distal, superficial (to), deep (to), cephalad, caudad, dorsal, ventral, palmar, plantar, flexion, extension, adduction, abduction, rotation, circumduction, pronation, supination, inversion, eversion

It is quite easy to find online definitions of these terms, although there is no substitute for a good, reputable anatomy atlas - it is your best source of reliable information and a great companion on the healing journey through life.

One clear, simple online reference that anyone can understand is:

www.becomehealthynow.com/article/anatom/704/

Good texts (definitely worth the investment)

Atlas of Human Anatomy by Dr. Frank Netter

Anatomy, A Regional Atlas of the Human Body by Carmine D. Clemente

Putting just a little time into understanding these definitions will empower you to heal more fully and get back in the game asap!

Self Assessing/Self Diagnosing Musculoskeletal Conditions

Three words: don’t do it!

With the advent of the internet, an avalanche of information has become available to the general public about medical conditions. This is good (if not always reliable) – the more information we have about a condition, the wiser the choice of treatment we can make. As we become more experienced with our bodies and accumulate more of this information, however, it is very tempting to try to self assess and self diagnose a problem. This is unwise for many, many reasons. Depth of understanding, experience, and objectivity are three of the most important reasons not to attempt this. The health professionals testing you have spent years studying the body within their scope of practice, most with graduate degrees focused on their specialty. Then they have had a great deal of experience interpreting what your history, signs, symptoms, and test results mean. Finally, they strive to be objective and their opinion is not tainted by personal feelings about the subject, which is unlikely we can do to ourselves, although many people think they can. Even the most learned and experience physician in a particular field will seek the opinion of another physician about his own conditions if they are wise.

Be wise. If you are experiencing pain, see the appropriate health care professional.

The Injured Athlete

Nobody wants to get over and past their injuries as much as an athlete. Much of their self esteem and joy in life is rooted in their athletic performance. Additionally, much of their self confidence and feeling of order and control comes from the fitness level they are required to maintain to perform competitively. Once injured, the dedicated athlete will do anything to get back into the game. The challenge for the therapist, in fact, is to keep the athlete from doing too much too soon.

This is the mission of Soarbody Therapeutics – to get the athlete hampered by chronic conditions and pain back on track as soon as possible. Manual therapy is employed to decrease pain and to begin resolve restrictions, while exercise is assigned to facilitate continued healing and reestablish the effective functional movement patterns necessary for the athlete to excel at their sport. Once these goals are met, athletes are referred out to strength coaches, personal trainers,
and massage therapists to help them achieve peak performance in their field.

The term athlete is used in the Soarbody mission statement for brevity and convenience. Many clients, of course, fit the above implied functional definition of athlete who are not involved in sports. Dedicated musicians are a prime example of this. Clearly, anyone who has the desire and drive to get over and past the chronic soft tissue roadblocks would be a candidate for treatment at Soarbody Therapeutics.

To learn more, please visit www.soarbody.com.