Early Warning Signs of Chronic Exertional Compartment Syndrome (CECS): What Every Athlete Should Know

Chronic Exertional Compartment Syndrome (CECS) is a debilitating condition that causes pain and swelling in a specific muscle compartment during exercise or repetitive physical activity. It is most commonly seen in athletes, runners, and individuals engaging in activities that involve repetitive leg or arm movements. CECS commonly occurs in the lower extremity but can also affect the upper extremity and trunk.

Predictors of CECS include:

• Age under 25
• Participation in running and skating activities
• Bilateral symptoms
• Painful palpation of affected compartments

 

Cause of Chronic Exertional Compartment Syndrome

• Vascular compromise
• Microtrauma
• Myopathies
• Fascia-related compliance
• Nerve dysfunction
• Muscle hypertrophy

 

Clinical Presentation of Chronic Exertional Compartment Syndrome

Symptoms of a patient with CESC worsen progressively with exercise intensity and duration. They typically last about 15 minutes after stopping exercise but may persist for several hours depending on severity.

Anterior Compartment CECS:

• Presents with anterolateral pain during exertion.
• Paresthesia in the first web space.
• Often affects both lower extremities.

Deep Posterior Compartment CECS:

• Pain and tenderness in the medial calf region.
• Distal symptoms like weakness or pins and needles in the plantar region may indicate tibial nerve compression.
• Small muscle hernias can appear near the medial or anterior tibial borders post-exercise.
• Sudden onset of symptoms after trauma may indicate acute compartment syndrome, requiring immediate medical attention.

Lateral Compartment CECS:

• Pain is palpated anterior to the fibula.
• Paresthesia is felt over the dorsum of the foot.

 

Diagnosing Chronic Exertional Compartment Syndrome (CECS)

Diagnosing Chronic Exertional Compartment Syndrome (CECS) as a physiotherapist involves a comprehensive assessment of the patient's symptoms, activity history, and clinical examination findings. While the definitive diagnosis of CECS often requires invasive compartment pressure testing (typically done by a physician), the physiotherapist plays a crucial role in identifying the condition and ruling out other causes of exercise-induced pain.

Patient History

• Ask about pain patterns that correlate with specific physical activities (e.g., running, cycling, or walking). Symptoms of CECS often occur predictably after a set period of activity.
• Identify the compartment(s) affected (e.g., anterior, lateral, or posterior compartments in the leg). Pain often localizes to a specific compartment.
• Symptoms are often repeatable with the same type of activity and at the same intensity or duration.
• Identify if the patient has recently increased training volume or intensity, which could contribute to the onset of pain.

 

Physical Examination

A comprehensive physical examination should be conducted both before and after the exertional activity causing symptoms.

Physical Examination Protocol  Table

Palpation of Posterior Compartment:

• Mild tenderness along the medial tibia.
• Palpable tightness is less noticeable than in anterior or lateral compartments due to the depth of the deep posterior compartment.
• Experienced clinicians may distinguish tightness in the deep compartment from fascial thickening associated with medial tibial stress syndrome.
• Be cautious of other causes of calf pain, such as popliteal artery entrapment syndrome.

Anterior Compartment

• Plantar flexors tightness, mainly soleus and gastrocnemius is noticed.
• Muscle herniation often occurs 5-7 cm proximally to the distal tip of the fibula, where the superficial peroneal nerve penetrates the fascia.

 

Functional Testing (Provocation Tests)

Exercise Provocation:

If CECS is suspected, ask the patient to perform the activity that triggers their symptoms (e.g., running on a treadmill, cycling, or repetitive jumping). This can help recreate symptoms.

Post-Exercise Evaluation:

Re-assess the affected compartments immediately after the activity to check for increased muscle tightness, pain, and restricted motion. Palpate for firmness or swelling in the compartment.

 

Referral for Compartment Pressure Testing

If your clinical findings strongly suggest CECS, refer the patient to a physician or specialist for compartment pressure testing, which is the gold standard for confirming the diagnosis. This involves inserting a catheter or needle into the muscle compartment to measure pressure before and after exercise.

 

Imaging (to Rule Out Other Pathologies)

Magnetic Resonance Imaging (MRI):

• Captures water content in muscle tissue post-exertional activity. In healthy individuals, water content dissipates after exercise, while in CECS patients, it remains longer.

Near-Infrared Spectrometry (NIRS):

• A noninvasive option estimating muscle tissue oxygenation (StO2) using light transmission and hemoglobin/myoglobin absorption.
• Conducted at rest and immediately post-exercise. CECS patients had peak StO2 of ≥55% and a percent change in StO2 of ≥35%. NIRS is a better predictor of decreased neuromuscular function compared to elevated compartment pressures.

Shear Wave Elastography (SWE):

• An emerging diagnostic tool using ultrasound to measure tissue elastic properties. Tissue stiffness is reported as shear wave velocity or shear modulus (kPa). A study found a correlation between increased shear modulus and high intramuscular pressure in healthy individuals.
• SWE showed significant changes in lower leg compartments before and after running. SWE may serve as an additional, noninvasive diagnostic tool for CECS.

 

Differential Diagnosis

• Shin Splints (Medial Tibial Stress Syndrome)
• Stress Fractures
• Tendinopathies (e.g., Achilles Tendinopathy)
• Popliteal Artery Entrapment Syndrome
• Nerve Entrapment Syndromes (e.g., Peroneal Nerve Entrapment)
• Deep Vein Thrombosis (DVT)
• Peripheral Arterial Disease (PAD)
• Muscle Strain
• Lumbar Radiculopathy
• Fascial Defects
• Chronic Muscle Tear
• Fibular Stress Reaction

 

Physiotherapy management of Chronic Exertional Compartment Syndrome

Physiotherapy management of Chronic Exertional Compartment Syndrome (CECS) focuses on symptom relief, correcting biomechanical issues, and guiding patients through conservative treatment options. While surgical intervention (fasciotomy) may be required in some cases, physiotherapy can be an effective conservative approach, especially for mild to moderate cases.

Patient Education

• Encourage the patient to track symptoms, noting the specific activities, duration and intensity that provoke symptoms.
• Advise them to reduce the intensity and duration of aggravating activities and to stop or modify exercise as soon as symptoms start.

 

Biomechanical Correction

Adjustments in running technique may reduce the stress on the affected compartments and correct any biomechanical faults such as overpronation, supination or improper running form.

Running Gait Retraining:

It is used in isolation or combined with other treatments to help athletes return to activity.

Goals include:

• Reducing vertical ground reaction forces.
• Reducing muscle activity in the symptomatic compartment.
• Reducing stride length and vertical displacement.

Techniques to achieve these goals:

• Change ground contact from rearfoot to forefoot strike.
• Increase cadence to 180 steps per minute (gradually by 5% to 10%).
• Maintain an upright posture.

Footwear Assessment

• Recommend proper footwear that supports the arches and reduces abnormal stresses on the lower leg. In some cases, orthotics may be beneficial to correct foot alignment issues (e.g., flat feet or high arches).
• Lowering heel height in footwear or using orthotics may reduce anterior muscle load and alleviate pain
• Advise the patient to avoid hard surfaces and switch to softer surfaces like grass or dirt trails to reduce impact forces.

 

Strengthening and Conditioning

Focus on strengthening the muscles in the lower leg, especially the anterior tibialis, gastrocnemius, soleus and peroneals, to improve endurance and reduce compartment strain. Examples of exercises include:

• heel raises
• toe raises
• resisted ankle dorsiflexion
• calf raises

 

Stretching and Mobility

Encourage regular stretching of the muscles in the affected compartment to relieve tightness and improve flexibility. Dynamic and static stretching can be incorporated into warm-ups and cool-downs regimen.

Key stretches include: 

• gastrocnemius stretch
• soleus stretches
• hamstring stretches
• anterior tibialis stretch

 

Manual Therapy Techniques

Soft Tissue Mobilization is performed to reduce muscle tightness and improve blood flow to the affected area.

• Sustained myofascial tension techniques combined with passive and active plantarflexion to restore fascial flexibility in anterior compartment.
• Tightness in the posterior compartment is adressed with sustained myofascial tension and dorsiflexion exercises.

If there are mobility restrictions in the ankle or foot, joint mobilizations may help restore proper range of motion and reduce stress on the muscles.

 

Dry Needling or Acupuncture

These techniques can help relieve muscular tension, reduce pain and promote healing in tight or restricted compartments. Physiotherapist can treat focal muscular thickening with transverse friction or dry needling

 

Neuromuscular Re-education

Incorporate exercises that challenge balance and coordination to improve neuromuscular control and reduce the risk of overloading the affected compartments. Examples include:

• single-leg balancing 
• BOSU ball exercises
• agility drills

Low-impact aerobic exercises like cycling or swimming, along with aquatic therapy, help maintain fitness while reducing stress on affected compartments. Gradually reintroduce sport-specific activities using graded exposure and interval training. Self-management, including massage, home exercises and cryotherapy, supports recovery. If symptoms persist, refer to an orthopedic surgeon. Regular monitoring and reassessment ensure effective treatment adjustments.