Clinical Journal of Sport Medicine, 10:176–184
© 2000 Lippincott Williams & Wilkins, Inc., Philadelphia
Evaluation of Outcomes in Patients Following Surgical
Treatment of Chronic Exertional Compartment Syndrome in
the Leg
*†James L. Howard, BSc, *†Nicholas G. H. Mohtadi, MD, MSc, FRCS(C), and
†J. Preston Wiley, MD, MPE, CCFP
*Faculty of Medicine, Department of Surgery; and †Faculty of Kinesiology, University of Calgary Sport Medicine Centre,
University of Calgary, Calgary, Alberta, Canada
Objective: To evaluate outcomes in patients who had a fas-
ciotomy performed on their leg(s) for chronic exertional com-
partment syndrome (CECS).
Design: A retrospective descriptive cohort study.
Setting: Tertiary care sport medicine referral practice.
Patients: A consecutive series of 62 patients surgically
treated for CECS from January 1991 to December 1997.
Main Outcome Measures: A questionnaire was designed
and developed to assess pain (using a 100 mm visual analogue
scale), level of improvement, level of maximum activity, sat-
isfaction level, and the occurrence of reoperations.
Results: Fifty patients had anterior/lateral compartment in-
volvement, 8 patients had deep posterior compartment involve-
ment, and 4 patients had anterior/lateral/deep posterior com-
partment involvement. The demographics of the 39 respondents
and 23 nonrespondents were similar. The mean percent pain
relief of respondents was 68% (95% CI [confidence interval]
⳱ 54% to 82%). There was no relationship between percent
pain relief and the documented immediate post exercise com-
partment pressures. A clinically significant improvement was
reported by 26 of 32 (81%) anterior/lateral compartment pa-
tients and 3 of 6 (50%) patients with deep posterior compart-
ment involvement. Patient level of activity after fasciotomy
was classified as equal to or higher than before the operation
with a lesser degree of pain by 28 of 36 (78%) patients, while
8 of 36 (22%) patients reported lower activity levels than be-
INTRODUCTION
A compartment syndrome is defined as a condition in
which increased pressure within a limited space compro-
mises the circulation to the tissues in the area and limits
their function.1 Compartment syndromes can be divided
into acute and chronic varieties. Acute compartment syn-
dromes are most often seen in nonathletes and occur with
fractures, crush injuries, burns, drug overdoses, and,
rarely, excessive exercise.2 Acute compartment syn-
Received June 14, 1999; accepted April 14, 2000.
Address correspondence and reprint requests to Nicholas G. H.
Mohtadi, MD, University of Calgary Sport Medicine Centre, 2500
University Dr. NW, Calgary, Alberta, T2N 1N4, Canada.
176
fore the operation. Of the patients reporting lower activity,
seven were due to exercise related pain in the post operative
leg(s) and one was due to lifestyle changes. Thirty of 38 pa-
tients (79%) were satisfied with the outcome of the operation.
Four of 62 patients (6%) failed the initial surgical procedure
and required revision surgery for exercise-induced pain. In ad-
dition, one of these individuals also had a sympathectomy and
another had a neurolysis performed at the time of revision
surgery. Three of the 62 (5%) patients had subsequent opera-
tions for exercise-induced pain on different compartments than
the initial surgical procedure. One individual had an unsuccess-
ful operative repair of a posttraumatic neuroma. Postoperative
complications were reported by 5 of 39 (13%) patients in the
additional comments section of the questionnaire.
Conclusions: The majority of patients surgically treated for
CECS experience a high level of pain relief and are satisfied
with the results of their operation. The level of pain relief
experienced by patients is not related to the magnitude of the
immediate post exercise compartment pressures. Despite the
possibility that some patients have less favorable outcomes,
experience complications, or need subsequent operations, fas-
ciotomy is recommended for patients with CECS as there is no
other treatment for this condition.
Key Words: Chronic exertional compartment syndrome,
outcomes—Leg—Fasciotomy—Compartment pressures.
Clin J Sport Med 2000;10:176–184.
dromes are potentially limb-threatening problems and re-
quire emergency treatment. Chronic compartment syn-
dromes are most often seen in athletes. Unlike acute
compartment syndromes, the chronic variety are almost
always the result of exercise and overuse and are thus
often termed chronic exertional compartment syndrome
(CECS).3
The majority (95%) of chronic exertional compart-
ment syndromes occur in the lower leg.2 This is because
of the anatomy of the region and is due to the fact that the
leg is used in virtually all sports. In the traditional view
there are four lower leg compartments in which the syn-
drome can occur; the anterior, lateral, superficial poste-
rior, and deep posterior. Some researchers have chal-
 PATIENT OUTCOMES FOLLOWING SURGICAL TREATMENT OF CECS
lenged this traditional view by proposing that there are
more than four compartments in the lower leg.4–6 In this
study, we considered the anterior, lateral, deep posterior,
and posterior tibial compartments.
Chronic exertional compartment syndromes often
have a typical clinical presentation.2,3,7 The patient often
complains of aching or tightness in the leg, which de-
velops with exercise and fades with rest. The problem
usually has progressively become more severe over time.
These symptoms can pose a significant problem for ath-
letes who cannot exercise due to the associated pain.
Because CECS symptoms subside with rest, many pa-
tients likely modify their activities to avoid exercise that
causes pain.2 Two general approaches to the treatment of
patients presenting with chronic exertional compartment
syndrome have been suggested. First, conservative treat-
ment options such as antiinflammatory drugs, stretching,
prolonged rest, diuretics, and physiotherapy are open to
patients. However, there has been no documented case of
conservative treatment successfully achieving long-term
pain relief.8–11 The only documented successful treat-
ment for chronic exertional compartment syndrome is
fasciotomy.3,4,8,12–15 Fasciotomies can be used to divide
the restrictive fascia and increase the size of the com-
partment into which the muscle can expand.
The purpose of this study was to evaluate outcomes in
patients who had a fasciotomy performed on their leg(s)
for chronic exertional compartment syndrome. In addi-
tion, the immediate post exercise compartment pressures
were compared with patient outcomes to see if a rela-
tionship existed between the two.
METHODS
The study design was that of a retrospective descrip-
tive cohort evaluating outcomes using a subjective pa-
tient questionnaire. The Conjoint Scientific Review
Committee and the Conjoint Medical Ethics Research
Board of the University of Calgary Faculty of Medicine
approved this design of this study. The questionnaire was
modified from the one used in the study by Schepsis et
al.14 (Appendix 1). The questionnaire was designed and
developed (multiple choice and short answer response)
to assess pain (using a 100 mm visual analogue scale),
level of improvement, level of maximum activity, satis-
faction level, and the occurrence of subsequent opera-
tions. Before it was used in the study, the questionnaire
was pretested on five patients outside of the treatment
series scheduled for fasciotomy for CECS in the leg.
These patients were interviewed individually and asked
to identify any problems with the wording or meaning of
the questionnaire. Based on their feedback, the question-
naire was modified accordingly.
The patient population consisted of all patients in a
tertiary care sport medicine referral practice who were
surgically treated for CECS from January 1991 to De-
cember 1997. Patients were identified through the Uni-
versity of Calgary Sport Medicine Centre and hospital
records. Once identified, the compartment(s) involved,
the post exercise compartment pressures, and the demo-
177
graphic information of the patients were recorded from
hospital/clinic charts. Three rounds of questionnaire
mailings were performed in 1998. The data from the 39
returned questionnaires was then entered into a database
along with the information from the patient’s charts and
analyzed using frequency distributions, correlation coef-
ficients, and descriptive statistics.
Results from the 39 returned questionnaires were
evaluated as a whole and on an anatomic basis. For
evaluation on an anatomic basis, patients with deep pos-
terior compartment involvement were grouped sepa-
rately from patients with only anterior/lateral compart-
ment involvement. From the questionnaire, patient
symptom improvement was classified as clinically sig-
nificant improvement or little improvement/worsening of
symptoms. Percent pain relief was calculated using pre-
and postoperative visual analogue scale (VAS) values.
Both of these VAS values were retrospective responses
since all patients received their questionnaire in 1998,
regardless of when their surgery had been done.
Percent pain relief ⳱ 100(VAS pre-op − VAS
post-op)/VAS pre-op
Pressure Measurements
Serial compartment pressure measurements for the an-
terior compartment were recorded and performed in the
following manner. First the local tissue was anesthetized
with 3–4 ml of 1% lidocaine. Patients were instructed to
plantar and dorsiflex repetitively and vigorously. All pa-
tients developed exercise-induced symptoms within 30
seconds. Patients were instructed to continue exercising
until symptoms became unbearable. The Stryker digital
needle and manometer system was inserted immediately
after the cessation of exercise. Pressure measurements
were taken immediately after the cessation of exercise
and at 1, 2, and 3 minutes post exercise.
Deep posterior compartment pressures were measured
using ultrasound catheter placement in a similar fashion
to the one described by Wiley et al.16
An immediate post exercise compartment pressure of
ⱖ 30 mm Hg and an elevated pressure (>15 mmHg) at 3
minutes was considered consistent with a diagnosis of
CECS.
Surgical Procedures
Anterior and lateral compartment fasciotomies were
performed through a two-incision technique as described
by Rorabeck et al.12 Both compartments were released
based on elevated anterior compartment post exercise
pressures for a number of reasons. First, studies done in
the past have released both compartments simulta-
neously based on elevated anterior compartment pres-
sures.8,12,13 Second, although clinical differentiation of
the compartments involved can be difficult, none of the
patients in this study had findings solely confined to the
lateral compartment. Finally, in the authors’ experience,
patients operated on elsewhere had failure of single com-
partment fasciotomy, requiring repeat surgery.
Decompression of deep posterior compartments was
done using a one-incision technique similar to previously
Clin J Sport Med, Vol. 10, No. 3, 2000
178 J. L. HOWARD ET AL.

documented methods.14 The tibialis posterior was de- TABLE 2. The percent pain relief experienced by patients
compressed in all patients with deep posterior compart- and corresponding immediate post exercise
ment involvement. compartment pressures
Immediate post exercise
RESULTS Percent pain relief compartment pressure (mmHg)

Demographics 100 40
Sixty-two patients were identified as potential partici- –31 31
pants in this study. Fifty patients had anterior/lateral 96 45
compartment involvement, 8 patients had deep posterior 37 40
98 37
compartment involvement, and 4 patients had anterior/ 76 51
lateral/deep posterior compartment involvement. There 100 72
were 39 respondents and 23 nonrespondents (63% re- 72 58
sponded). The responders and nonresponders were simi- 28 70
86 70
lar in mean age, sex distribution, mean immediate post 87 100
exercise compartment pressure, leg(s), and compart- 92 60
ment(s) involved (Table 1). The average time of follow- 45 60
up for respondents was 3.4 years (SD ⳱ 2 years). Of the 0 75
23 nonrespondent questionnaires, 15 were returned be- 97 45
28 69
cause the patients had moved while 8 were not returned 82 31
by the patients. 96 75
100 70
Pain Relief, Satisfaction Level, and Activity Level 85 50
The mean preoperation level of pain was 84 (95% CI 100 46
[confidence interval] ⳱ 79 to 89) on a 100 mm VAS. 84 52
The mean postoperation level of pain relief was 26 (95% 78 35
0 47
CI ⳱ 15 to 37). The mean percent pain relief of respon- 99 36
dents was 68% (95% CI ⳱ 54% to 82%). Table 2 shows 19 50
the percent pain relief and corresponding immediate post 100 55
exercise compartment pressures. The correlation coeffi- 100 30
57 45
cient for percent pain relief and immediate post exercise 98 44
compartment pressure was −0.07 (n ⳱ 31). Thirty of 38 51 120
patients (79%) were satisfied with the outcome of the
operation. A clinically significant overall improvement
in symptoms following fasciotomy was reported by 26 of of the patients reported lower activity due to pregnancy
32 (81%) anterior/lateral compartment patients and 3 of and childbirth as well as a change in career. The remain-
6 (50%) patients with deep posterior compartment in- ing seven individuals reported lower activity due to ex-
volvement (Figure 1). Patient level of activity after fas- ercise-related pain. Two of these individuals, one with
ciotomy was classified as equal to or higher than before deep posterior compartment involvement and one with
the operation with a lesser degree of pain by 28 of 36 only anterior/lateral compartment involvement reported
(78%) patients while 8 of 36 (22%) patients reported an increase in the exercise-related pain after the opera-
lower activity levels than before the operation (Figure 2). tion. Two other individuals, one with deep posterior
Of the eight patients reporting lower activity levels, one compartment involvement and one with only anterior/
lateral compartment involvement, reported no pain relief
TABLE 1. The characteristics of respondent and from the operation. The remaining three individuals re-
nonrespondent groups ported some decrease in the degree of pain in their legs
postoperatively.
Questionnaire status Returned Not returned
Reoperations and Complications
Total 39 23
Mean age (years) 31.8 (SD ⳱ 12.0) 33.1 (SD ⳱ 9.5)
Four of the 62 patients (6%) identified in the study
Male:female ratio 14:25 10:13 population had revision surgery for exercise-induced
Mean immediate post 56.0 (SD ⳱ 20.6) 61.1 (SD ⳱ 23.2) pain in the same compartments. These patients would be
exercise compartment considered to have a recurrence of symptoms and there-
pressure (mmHg) fore a failure of the index operation.
Leg(s) involved Right ⳱ 8 Right ⳱ 2
Left ⳱ 8 Left ⳱ 4 Patient 1: A 38-year-old man with bilateral anterior/
Bilateral ⳱ 23 Bilateral ⳱ 17 lateral CECS. This patient had 6 months of relief from
Compartments involved A/L ⳱ 33 A/L ⳱ 17 the initial bilateral fasciotomy before his symptoms re-
DP ⳱ 4 DP ⳱ 4 turned. Repeat compartment pressure measurements
A/L/DP ⳱ 2 A/L/DP ⳱ 2
were elevated. He had a revision fasciectomy 9 months
SD, standard deviation; A/L, anterior, lateral; DP, deep posterior; after the first procedure. At present he reports that his
A/L/DP, anterior, lateral, deep posterior. pain is significantly improved but still present, although

Clin J Sport Med, Vol. 10, No. 3, 2000

 PATIENT OUTCOMES FOLLOWING SURGICAL TREATMENT OF CECS
his legs are weaker than before the operation and very
sensitive to touch.
Patient 2: A 36-year-old woman with bilateral ante-
rior/lateral CECS. Approximately 4 years following the
initial procedure she developed pain and numbness in the
front of the leg and dorsum of the right foot. She began
to develop exercise-induced symptoms after walking two
blocks. Repeat compartment pressure measurements
were elevated. She had a revision partial fasciotomy/
partial fasciectomy and exploration and neurolysis of the
peroneal nerve of her right leg 4 years and 4 months after
the initial procedure. When last seen in clinic she had
returned to normal levels of activity.
Patient 3: A 22-year-old woman with bilateral ante-
rior/lateral/deep posterior CECS. She found that after the
initial procedure her legs were worse than before the
surgery. Repeat compartment pressure measurements
were elevated. She had revision bilateral fasciectomies 2
years and 9 months after the initial procedure. When last
seen in clinic she had returned to normal levels of activity.
Patient 4: A 26-year-old woman with bilateral ante-
rior/lateral CECS. Following an initial bilateral fasciot-
omy she experienced 3 months of pain relief before her
exercise-induced symptoms returned. Repeat compart-
ment pressure measurements were elevated. A revision
bilateral fasciotomy 1 year and 7 months after the initial
procedure did not improve the pain. Gradually the pain
spread from her anterior/lateral compartments to include
her knees and ankles in both legs. The patient was re-
ferred to a specialist in chronic pain who found that a
sympathetic block relieved the patient’s pain. This led to
the sympathectomy to help with the patient’s chronic
pain due to reflex sympathetic dystrophy (RSD). Unfor-
179
FIG. 1. Level of improvement in patients’
legs following fasciotomy.
tunately, this patient still suffers from extreme pain and
can barely walk one city block in distance at a time.
Three of the 62 (5%) patients in the study population
had subsequent operations for exercise-induced pain on
different compartments than the initial surgical proce-
dure. Two of these individuals (3%) had fasciotomies for
CECS. One individual (2%) had a subsequent operation
for medial tibial stress syndrome.
Of the 39 respondents, 3 patients (8%) had subsequent
operations for reasons other than exercise-induced pain.
One of these patients had a sympathectomy (Patient 4).
One patient had exploration and neurolysis of the pero-
neal nerve in her right leg at the time of partial fasciot-
omy/partial fasciectomy (Patient 2). The final patient
was a 28-year-old woman with bilateral anterior/lateral
CECS. Following the procedure, she experienced lower
activity levels and attributed this to pregnancy and child-
birth as well as a change from a competitive dancing
career. She also experienced numbness and dysesthetic
pain in the distribution of the medial dorsal cutaneous
branch of the superficial peroneal nerve. An operative
repair of a posttraumatic neuroma was attempted. The
nerve damage was not repairable and the patient still
experiences problems with pain. However, she states that
she has experienced an overall improvement compared
with before fasciotomy.
Complications were reported by 5 of 40 (13%) pa-
tients in the additional comments section of the question-
naire (Table 3).
DISCUSSION
The results of this study indicate that the majority of
patients surgically treated for CECS in the leg experience
FIG. 2. Patients’ level of maximum activity af-
ter fasciotomy.
Clin J Sport Med, Vol. 10, No. 3, 2000
180
TABLE 3. Complications according to comments from
patient questionnaires
● Ankle pain
● Lack of feeling at incision site
● Minimal numbness down outside of leg
● Front of legs sensitive to pressure, legs weaker than before
the operation
● Pins and needles in legs, very sensitive to touch, swollen legs
a high level of pain relief and are satisfied with the
results of their operation. Twenty-two of 25 (88%) pa-
tients were satisfied with their outcome in the study by
Rorabeck et al.13 The 95% confidence interval for their
value was 75% to 100%. Therefore, the 79% satisfaction
level in our patient population was similar to the value
found by Rorabeck et al.13 In the study by Detmer et al.,4
89% of patients said they would have the procedure done
again if the symptoms recurred or developed in a new
compartment. Our satisfaction level cannot be compared
with their confidence interval because we did not use the
same outcome measure.
The denominator used to calculate the above satisfac-
tion level (38) was not equal to the number of question-
naires returned (39). The reason for this is that although
39 patients returned the questionnaire, patients did not
always answer all questions. Therefore, any unanswered
questions could not be included in the results. For the
same reason, different denominators had to be used in the
results on level of improvement and level of activity. The
calculation of the correlation coefficient of immediate
post exercise compartment pressure and percent pain re-
lief was based on 31 individuals. Five individuals could
not be included because they did not answer the ques-
tionnaire properly, and a percent pain relief could not be
calculated. For the remaining three individuals, we did
not have immediate post exercise compartment pressure
measurements. For two of these patients, pressure mea-
surements could not be measured. These individuals
were operated on based on their clinical presentation and
both were satisfied with the outcome of their procedure.
The final individual had elevated compartment pressures
measured elsewhere that could not be obtained.
The key element in CECS is the increased pressure
within a muscle compartment.1 Pruranen and Ala-
vaikko17 found that there was a distinct correlation be-
tween intracompartmental pressures on exertion and the
severity of symptoms experienced by patients. The
higher and more rapidly the pressure curve rose with
exertion, the sooner and more severe the symptoms ex-
perienced by patients. Based on this finding, it would
seem logical to hypothesize that those patients with the
highest post exercise compartment pressures would ex-
perience the most pain relief after fasciotomy. Based on
our correlation coefficient value of −0.07, our results
show that the amount of pain relief from fasciotomy is
not related to the magnitude of immediate post exercise
compartment pressure. This result agrees with the series
by Detmer et al.4 where there was no statistically sig-
nificant correlation between resting compartment pres-
Clin J Sport Med, Vol. 10, No. 3, 2000
J. L. HOWARD ET AL.
sures and outcomes. Therefore, although numerous past
studies have demonstrated the use of compartment pres-
sures as a diagnostic tool,10,18,19 the magnitude of the
pressure measurement is not useful as a prognostic indi-
cator for patients undergoing fasciotomy. Future studies
need to examine other possibilities such as the duration
of patients’ symptoms as prognostic indicators for these
patients.
Pain relief for patients who undergo fasciotomy
for CECS has been well documented in the litera-
ture.4,8,9,11–15 However, these studies did not quantify the
level of pain relief experienced by patients. This study
quantified the pain relief experienced by patients using
VAS measurements. The 68% mean percent pain relief
shows that on the average, CECS patients treated by
fasciotomy experience a high level of pain relief. This
corresponded to a drop from a mean preoperation VAS
value of 84 to a mean postoperation VAS value of 26.
However, since this is a retrospective study, patients may
not have accurately reported preoperative pain levels.
Therefore, the information obtained is susceptible to re-
call bias. A prospective trial on a series of patients would
be more accurate in quantifying the level of pain relief
experienced by patients.
Symptomatic improvements occurred more frequently
for patients with anterior/lateral compartment involve-
ment compared with individuals with deep posterior
compartment involvement. The less favorable outcomes
seen in patients with posterior compartment involvement
has been previously documented in the literature.12–14
The reason for the results in this group is not entirely
known. It may be simply due to inadequate decompres-
sion of the posterior compartment. 3,12 This would
seem to be the likely answer in patients who have el-
evated post exercise compartment pressures after fasci-
otomy. Poor results could also be due to inadequate de-
compression of tibialis posterior. It also has been sug-
gested that CECS in the deep posterior compartment is
multifactorial and fasciotomy does not fully alleviate the
cause of the pain.3 Finally, it is possible that the pain
experienced could have been due to an etiology other
than CECS such as a neuropathy or chronic tendonopa-
thy. Fasciotomy would do nothing to address these other
problems and would therefore explain the lack of pain
relief in these patients.
Exercise-induced pain has a major effect on activity
levels of patients. Previous studies have shown that the
majority of patients surgically treated for CECS are able
to increase activity levels following fasciotomy.4,8,13 In
our study, 28 of 36 (78%) patients reported activity lev-
els equal to or higher than before the operation. Of these
28 patients, 19 (53%) reported higher activity levels than
before the operation. Rorabeck et al.13 found that 16 of
25 (64%) patients reported increased activity post fasci-
otomy. The 95% confidence interval for their value is
34% to 72%. Therefore, our results are similar to those of
Rorabeck et al.13 since our value is contained in their
confidence interval. All patients reporting equal or
higher activity levels had a lesser degree of pain in their
legs when exercising. The reason why nine patients did
 PATIENT OUTCOMES FOLLOWING SURGICAL TREATMENT OF CECS
not increase their activity levels despite some relief of
pain is not known. Nevertheless, all 28 of these individu-
als were satisfied with the outcome of their operation.
Therefore, outcomes can be considered successful for all
of the 28 patients despite the fact that some did not
increase their activity level.
Of particular concern are the seven individuals report-
ing lower activity after the operation due to exercise-
related pain. The results from this group of individuals
demonstrate the importance of pain in determining ac-
tivity levels of CECS patients. Five of these patients
were not satisfied with the results of the operation. Two
patients reported increased pain, two patients reported no
relief of pain, and one patient reported the smallest de-
crease in pain. In addition, the proportion of individuals
requiring subsequent operations in this group was higher
than in the population as a whole. Three patients required
revision fasciotomies on the affected compartments (Pa-
tient 1, Patient 2, and Patient 4). One of these patients
also required a sympathectomy following revision sur-
gery (Patient 4).
The poor results experienced by these seven individu-
als demonstrate that although fasciotomy is often an ef-
fective treatment for CECS in the leg, outcomes are not
favorable for all patients. Not all patients experience high
levels of pain relief, and some require subsequent opera-
tions. Therefore, patients who are considering fascioto-
my for treatment of CECS need to be informed of po-
tential problems that could occur after the procedure. In
our study, we examined subsequent operations for exer-
cise-induced pain as well as subsequent operations for
other reasons. In order to determine the most accurate
estimate of the reoperation rate, we chose to consider all
62 patients in the population rather than only the 39
respondents. This was done by combining the results
from the 39 returned questionnaires with information in
the University of Calgary Sport Medicine Centre charts
for the 23 nonrespondents. It is possible that we may
underestimate the reoperation rate using this method
since some patients may have had subsequent procedures
done by other surgeons. However, it is the most accurate
estimate possible. The need for revision surgery has been
previously documented in the literature.4,20,21 A total of
4 of 62 patients (6%) in our study failed the initial sur-
gical procedure and required revision surgery operation
for exercise-induced pain. This result is similar to the
study by Detmer et al.4 in which 5 of 100 (5%) patients
required revision surgery. Three of the patients (Patients
1, 2, and 3) had their condition improved by revision
surgery. Outcomes were more favorable for Patients 2
and 3 than Patient 1. The reasons for the need for sub-
sequent operations in this group are not known. Based on
the fact that their condition was improved by revision
surgery, it is possible that the negative results were due
to inadequate decompression of the compartments.21 The
return of symptoms also may have been due to the com-
partments closing over after the initial procedure.21 The
outcome for Patient 4 was not favorable. Revision sur-
gery and subsequent sympathectomy has not been able to
help her condition. For this patient, it is possible that she
181
has another etiology contributing to her pain that was not
addressed by subsequent operations, or that RSD devel-
oped postoperatively.
Two patients required subsequent operations for
nerve-related problems. Despite the need for these op-
erations, both patients consider their present condition
improved compared with before the surgery. Nerve-
related problems likely occurred in these patients due to
accidental trauma to the nerve area. This is always a
possibility during fasciotomy because the anatomy of the
region can vary from person to person. Similar injuries
can be avoided through care in performing the operative
technique and thorough knowledge of the anatomy of the
region.
Complications were reported in the comments section
of the questionnaire by 5 of 39 individuals (13%). This is
not an accurate estimate of the incidence of complica-
tions since some individuals may not have reported com-
plications in that section. Nevertheless, it gives us an
idea of what long-term complications patients experience
after fasciotomy. Complications including hemorrhage,11
wound infection,4,8,11 nerve entrapment,4,8 swelling, ar-
tery injury, hematoma/seroma, lymphocele, peripheral
cutaneous nerve injury, and deep vein thrombosis4 have
been reported in the literature. Our complication rate was
similar to that found in other studies. Detmer et al.4
reported complications in 11 of 100 (11%) patients while
Wiley et al.11 reported complications in 13% of patients.
The majority of the complications reported in this study
do not appear as severe as those reported by others (with
the exception of the development of RSD in Patient 4).
Nevertheless, the complications reported following fas-
ciotomy can be a significant concern for patients. There-
fore, despite this difference in severity, the possible com-
plications identified in this study need to be outlined to
patients considering fasciotomy for CECS in the leg.
CONCLUSION
The majority of patients surgically treated for CECS
experience a high level of pain relief and are satisfied
with the results of their operation. The level of pain relief
experienced by patients is not related to the magnitude of
the immediate post exercise compartment pressures.
Many are able to participate in activities at levels equal
to or higher than before fasciotomy operation with a
lesser degree of pain. Some individuals have less favor-
able outcomes following surgery and require revision
surgery, subsequent operations for other reasons, or ex-
perience complications. The possibility of these less fa-
vorable outcomes should therefore be outlined to all
patients considering surgical management of CECS. De-
spite these potential problems, fasciotomy is recom-
mended for patients with CECS as there is no other treat-
ment for this condition.
Acknowledgment: The authors would like to acknowledge
the support of the University of Calgary Sport Medicine Centre
during this study. Financial support for the study was supplied
through the University of Calgary Undergraduate Medical Edu-
cation Office.
Clin J Sport Med, Vol. 10, No. 3, 2000
182 J. L. HOWARD ET AL.

APPENDIX: PATIENT QUESTIONNAIRE

Evaluation of Outcomes in Patients Following Surgical Treatment of Chronic Exertional Compartment
Syndrome in the Leg

IDENTIFICATION NUMBER: <<Identification_Number>>

The following questions deal with two major areas. The first set will ask about your activities and how much pain you felt before the
operation. The second set will ask about your activities and how you felt after your operation. Your answers to these two sets of questions give
us an idea of the overall outcome of your operation.
For each question, please make only one response. If the directions tell you to skip ahead to a question, please do not answer the
questions in between.
The first questions deal with your status before the operation.
Q-1: What important activity/sport caused the exercise related pain that required surgery?
PLEASE SPECIFY
Q-2: At what level did you participate?
1 RECREATIONAL/LIFESTYLE
2 LOCAL/REGIONAL COMPETITION
3 NATIONAL COMPETITION
4 INTERNATIONAL
Q-3: What was the level of leg pain you experienced with exercise during this activity/sport?
(Please respond with a vertical slash on the below scale)

| |
No pain Pain as bad as
it can be
Q-4: At what point in your activity/sport did you experience pain?
1 PRIOR TO BEGINNING THE ACTIVITY
2 <15 MINUTES AFTER STARTING
3 15–30 MINUTES AFTER STARTING
4 31–60 MINUTES AFTER STARTING
5 >60 MINUTES AFTER STARTING
Q-5: How did the pain effect your performance?
1 UNABLE TO PARTICIPATE
2 PARTICIPATION AT A DECREASED LEVEL OF ACTIVITY
3 PARTICIPATION AT THE SAME LEVEL BUT WITH PAIN
The last set of questions deal with your status after the operation.
Q-6: What important activity/sport do you presently participate in?
PLEASE SPECIFY
Q-7: If this activity/sport is different from your answer in question 1, please state why.

Q-8: At what level do you currently participate?

1 RECREATIONAL/LIFESTYLE
2 LOCAL/REGIONAL COMPETITION
3 NATIONAL COMPETITION
4 INTERNATIONAL
Q-9: If your present level of participation is different from your answer in question 2, please state why.

If you have not changed your activity/sport or level of activity, please go to question 10.
If you have changed your activity/sport or level of activity due to exercise related pain, please go to question 10.
If you have changed your activity/sport or level of participation for reasons OTHER than exercise related pain, please go to question 14.

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 PATIENT OUTCOMES FOLLOWING SURGICAL TREATMENT OF CECS 183

Q-10: What level of leg pain do you experience during the activity/sport:
(Please respond with a vertical slash on the below scale)

| |
No pain Pain as bad as
it can be
If you have no exercise related leg pain, please go to question 14.
If you do have exercise related leg pain, please go to question 11.
Q-11: How long after surgery did you begin to experience the pain?
1 <6 MONTHS
2 6–12 MONTHS
3 >12 MONTHS
Q-12: At what point in your activity/sport do you experience pain?
1 PRIOR TO BEGINNING THE ACTIVITY
2 <15 MINUTES AFTER STARTING
3 15–30 MINUTES AFTER STARTING
4 31–60 MINUTES AFTER STARTING
5 >60 MINUTES AFTER STARTING
Q-13: How does the pain effect your performance?
1 UNABLE TO PARTICIPATE
2 PARTICIPATION AT A DECREASED LEVEL OF ACTIVITY
3 PARTICIPATION AT THE SAME LEVEL BUT WITH PAIN
Q-14: What is your present level of maximum activity?
1 I CAN TRAIN/PRACTICE/EXERCISE JUST AS MUCH AS BEFORE THE OPERATION
2 I CAN TRAIN/PRACTICE/EXERCISE JUST AS MUCH AS BEFORE THE OPERATION
3 I CAN TRAIN/PRACTICE/EXERCISE LESS THAN BEFORE THE OPERATION

Q-15: How would you evaluate the overall improvement in your leg(s) since the operation?
1 COMPLETELY PAIN FREE
2 SIGNIFICANTLY IMPROVED BUT STILL SOME PAIN
3 SLIGHTLY IMPROVED
4 NO IMPROVEMENT
5 WORSE THAN BEFORE THE SURGERY
Q-16: Overall, were you satisfied with the results of your operation?
1 YES 2 NO
Q-17: Did you have any subsequent operations on your leg(s) for exercise related pain?
1 YES 2 NO
Q18: Did you have any subsequent operations on your leg(s) for other reasons?
1 YES 2 NO
If you answered yes to question 18, please specify what operation was performed on your leg(s)

Additional Comments:

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184 J. L. HOWARD ET AL.
REFERENCES
1. Murbarak SJ, Hargens AR. Definition and terminology. In: Com-
partment Syndromes and Volkmann’s Contractures. Murbarak SJ,
Hargens AR, eds. Philadelphia: W.B. Saunders Company,
1981:1–4.
2. Barnes M. Diagnosis and management of chronic compartment
syndromes: a review of the literature. Br J Sports Med 1997;31:
21–27.
3. Abramowitz AJ, Schepsis AA. Chronic exertional compartment
syndrome of the lower leg. Orthopaedic Rev 1994;23:219–226.
4. Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compart-
ment syndromes: diagnosis, management and outcomes. Am J
Sports Med 1985;13:162–170.
5. Davey JR, Rorabeck CH, Fowler PJ. The tibialis posterior muscle
compartment: an unrecognized cause of exertional compartment
syndrome. Am J Sports Med 1984;12:391–396.
6. Rorabeck CH. Exertional tibialis posterior compartment syndrome.
Clin Orthop Rel Res 1986;208:61–64.
7. Lutz JL, Goodenough GK, Detmer DE. Chronic compartment syn-
drome. AFP 1989;39:191–196.
8. Fronek J, Murbarak SJ, Hargens AR, Lee, Gershuni DH, Garfin
SR, Akeson WH. Management of chronic exertional anterior com-
partment syndrome of the lower extremity. Clin Orthop Rel Res
1987;220:217–227.
9. Martens MA, Backaert M, Vermaut G, Miller JC. Chronic leg pain
in athletes due to a recurrent compartment syndrome. Am J Sports
Med 1984;12:148–151.
10. Styf JR, Korner LM. Diagnosis of chronic anterior compartment
syndrome in the lower leg. Acta Orthop Scand 1987;58:139–144.
11. Wiley JP, Clement DB, Doyle DL, Taunton JE. A primary care
perspective of chronic compartment syndrome of the leg. Physi-
cian Sportsmed 1987;15:111–120.
Clin J Sport Med, Vol. 10, No. 3, 2000
12. Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of
exertional compartment syndrome in athletes. J Bone Joint Surg
1983;65-A:1245–1251.
13. Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the
management of chronic exertional compartment syndrome. Am J
Sports Med 1988;16:224–227.
14. Schepsis AA, Martini D, Corbet M. Surgical management of ex-
ertional compartment syndrome of the lower leg. Am J Sports Med
1993;21:811–817.
15. Wallenstein R. Results of fasciotomy in patients with medial tibial
syndrome or chronic anterior-compartment syndrome. J Bone Joint
Surg 1983;65-A:1252–1255.
16. Wiley JP, Short WB, Wiseman DA, Miller SD. Ultrasound catheter
placement for deep posterior compartment pressure measurements
in chronic compartment syndrome. Am J Sports Med 1990;18:74–
79.
17. Puranen J, Alavaikko A. Intracompartmental pressure increase on
exertion in patients with chronic compartment syndrome in the leg.
J Bone Joint Surg 1981;63-A:1304–1309.
18. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified
criteria for the objective diagnosis of chronic compartment syn-
drome in the leg. Am J Sports Med 1990;18:35–40.
19. Rorabeck CH, Bourne RB, Fowler J, Finlay JB, Nott L. The role of
tissue pressure measurement in diagnosing chronic anterior com-
partment syndrome. Am J Sports Med 1988;16:143–146.
20. Bell S. Repeat compartment decompression with partial fasciec-
tomy. J Bone Joint Surg 1986;68-B:815–817.
21. Styf JR, Korner LM. Chronic anterior-compartment syndrome of
the leg: Results of treatment by fasciotomy. J Bone Joint Surg
1986;68-A:1338–1347.