Chronic exertional compartment syndrome

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

This athlete experiences severe pain in the lower legs, predominantly on the left, when exercising. He was referred to a vascular surgeon with 'intermittent claudication.' There were no risk factors of peripheral vascular disease. The clinical suspicion was that of exercise-induced compartment syndrome.

Patient Data

Age: 25 years old
Gender: Male
MRI

MRI pre-exercise

Axial T1 and STIR of both lower legs show normal structures bilaterally without evidence of muscle oedema, interstitial fluid or focal abnormality.

The patient was asked to run up and down the stairs between ground floor and second floor where the MRI scanner is located, and to promptly report to the radiographers upon onset of pain in the lower legs.

MRI

MRI post exercise

The patient was scanned immediately after onset of pain.

While the muscles of the right calf appear normal on the postexercise imaging, there is a definite interval change in the signal intensity of the muscles in the left extensor and peroneal compartments manifesting as increased signal on STIR and consistent with muscle oedema. 
MRI

Side-by-side comparison of pre- and post exercise MRI STIR

Following exercise, there has been an interval increase in signal intensity in the anterior and lateral compartments of the left lower leg, involving tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus longus and peroneus brevis muscles. The appearances are therefore consistent with exercise induced compartment syndrome.

Case Discussion

Chronic exertional compartment syndrome usually occurs in competitive athletes, long distance runners, skiers, basketball and soccer players. It is characterized by pain induced during exercise, most typical occurring at a specific distance or time (i.e. predictable by the patient).

Although previously thought to be a form of shin splints, it is now recognised as a completely different entity.

In this case, the patient was made to exercise outside the scanner until pain occurred, and then was immediately scanned. 

There are also in-scanner exercise protocols where the patient's feet get strapped to a custom-made resistance plate, allowing continuous plantar- and dorsiflexion against resistance with little motion of the lower legs otherwise (legs in a birdcage-type transmit-receive coil).1

See also

Achnowledgements

Thanks to Dr E Heffernan, Consultant Radiologist at St. Vincent's University Hospital, Dublin

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Case information

rID: 22179
Case created: 17th Mar 2013
Last edited: 19th Feb 2016
Inclusion in quiz mode: Included

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