Chronic exertional compartment syndrome (CECS)

Exercise related lower leg pain is one of the more common presentations faced by practitioners in a sports medicine setting and can often present difficult diagnostic and management challenges.

From adolescent populations through to the exercising elderly, there are numerous potential causes for exertional calf or shin pain and not infrequently – an overlap of two or more inputs exists.

Chronic exertional compartment syndrome (CECS) is a condition affecting any of the four main muscle groups of the lower leg and can present as calf pain, shin pain or a combination of the two.

Each muscle group or ‘compartment’ (anterior, lateral, superficial and deep posterior) are surrounded by thick fibrous tissue called fascia.

With exercise, muscle volume generally increases by 20%, in turn increasing pressure within the muscle group.

In symptomatic individuals, this pressure is too high and can affect the supply and function of nerve and blood vessels within the compartments – resulting in pain and/or symptoms of nerve irritation (e.g. pins and needles) or vascular compromise (e.g. colour changes).

CECS is classically only exercise related, is more common in younger adult runners or those performing repetitive impact exercise.

It is often present in both legs at the time of diagnosis.

The condition can also affect other muscle groups such as the forearms and less commonly the feet.

Despite key features in the history, CECS is often misdiagnosed and under-recognised and the dreaded condition can literally stop runners in their tracks.

Though not always the case, pain classically commences consistently at the same time, duration and intensity once exercise has begun, and will worsen  (crescendo pain) the further you exercise.

Pain does not typically subside and indeed will often force you to stop exercising.

Some will notice rapid improvement on stopping, others requiring 15-20 minutes for pain to subside.

Over time however, the time required for recovery may increase between bouts of exercise, and symptoms may commence earlier in activity.

Pain is often described as a tightness or pressure in the affected limb(s) and there may also be a feeling of burning or cramping.

Some cases may have associated tingling or pins and needles, colour change or swelling in the affected leg(s) and in extreme cases there may be a feeling of foot or leg weakness or even foot-drop.

Whilst taking a break from exercise often brings with it an improvement in your symptoms, unfortunately most cases recur on resumption of the offending activity.

This can be very frustrating for athletes and all recreational exercisers alike.

Often examination for CECS is normal and your practitioner may wish to re-examine you before and after a run or exercise when you have your symptoms and pain, in particular to feel for abnormal muscle pressures.

They may also assess for pulses including listening for murmurs behind the knee that may be suggestive of a less common cause of exertional calf pain known as popliteal artery entrapment syndrome (PAES).

Effective treatment for your leg pain requires the correct diagnosis to be made first of all, and the experienced clinician will detect critical components in your history and examination to help in decision-making.

Medical imaging such as x-rays or MRI are often not required, but may be ordered more so to exclude other more common causes of your leg pain such as stress fractures or medial tibial stress syndrome (often also called shin splints).

The mainstay of treatment for CECS is massage, dry needling and stretching to improve flexibility and reduce tightness in the affected muscle compartment(s) combined with load modification/reduction in exercise, attendance to biomechanical issues that may be identified during your examination and consideration of footwear changes or orthotics.

Occasionally a video running assessment might be recommended and changes can be made to your running style and/or foot strike.

Unfortunately sometimes ongoing and compliant conservative treatment still fails to resolve pain and surgical treatment may then be contemplated.

In such cases, or when the diagnosis is perhaps unclear or complex, you may be recommended to undergo compartment pressure testing (CPT) – the gold standard investigation to confirm the diagnosis of CECS.

CPT involves the insertion of needles into the affected muscle compartment(s) under local anaesthetic, and is performed immediately once your pain and symptoms have been reproduced with exercise (e.g. treadmill or run in nearby park).

Abnormally elevated pressures within the muscle compartments make the diagnosis.

Most surgeons will require confirmation of the diagnosis of CECS by means of CPT prior to undertaking surgery, as the surgery itself is not without risk.

Bleeding and nerve damage are the main concerns.

The surgery itself involves the release and or partial removal of the investing fascia, and this procedure is called a fasciotomy or fasciectomy.

Dr Trefor James has performed CPT for many years now and like all our specialist sport and exercise physicians, is experienced in the assessment, diagnosis and optimal management of exercise related lower leg pain including CECS.

Lifecare Prahran Sports Medicine is close to suburbs including Malvern, South Yarra, Toorak, Armadale, St Kilda East, Caulfield, Richmond and Hawthorn, and has early and late appointments for all your sports medicine and physiotherapy needs.