Revista de Medicina Desportiva (English) March 2018 | Page 29

return. 6,16 The resulting ischemia,
characteristically transient and
reversible, translates clinically into
pain, sometimes intolerable, work
intolerance and loss of function of
involved muscular groups. 2,9 Volar
compartments are the most affected
in CECS, as a result of the greatest
work of these muscular groups in
the aforementioned activities. 20
Clinical Presentation
Clinical history is undoubtedly
the main diagnostic factor. Physi-
cal examination, can help to cor-
roborate data and exclude other
diseases. The usual practice of a
physical activity characterized by
huge and longstanding effort of
upper limb is an essential point to
diagnosis. 1 CECS patients usually
report complaints of intense and
progressive pain, of uncertain char-
acteristics, from tightening to cramp,
in a certain muscular compart-
ment. 1,3,16 Pain starts usually several
minutes after the effort, and can go
along with limb edema and lack of
strenght. 8,18 The clinical picture can
be completed with numbness, dys-
esthesia and limb disability in worst
cases. 1 Symptoms are often bilateral
and there is no traumatic history. 6,16
As previously mentioned, volar com-
partments are the most affected. 1
At physical examination, muscles
are swollen, tight and maybe painful
(Figure 1). 17 Peripheral pulses distur-
bance is not expected. 1 Symptoms
Figure 1 – Tense edema of the anterior
muscles of the athlete’s forearm, right
after a motorcycling race
are expected to disappear gradually,
as soon as activity stops, although
pain may persist until 1 hour after. 21
Physical examination is charac-
teristically innocent at rest, with
no p athological findings, namely at
neurological or vascular examina-
tion. 5,17 However, in the face of a
characteristic clinical history, stress
test that mimic the effort, as heavy
and longstanding hand contraction,
can trigger the clinical picture. 20
At early stages, symptoms are
usually light and unspecific, so
patients often change their activi-
ties, decreasing intensity and dura-
tion of the efforts in order to avoid
symptoms. 16 In high level athletes
it can compromise competitive
performance, achieving limb immo-
bilization during competition in
motorcycle sports. The clinical pic-
ture, similar to volkmann’s ischemic
contracture, has to be clearly in
medical team mind.
Diagnostic workup
The diagnosis of CECS is a clinical
one; nevertheless, intra-compart-
mental pressure evaluation has
been the gold standard test for
diagnostic confirmation. 14,17 There is
still consensus currently about the
criteria of lower limb CECS defined
by Pedowitz in 1990 (Table 1). 22
However, little is known yet about
the limiar of pathological values of
intra-compartmental pressure in
forearm. 3,12 Actually, the studies has
used the same values of the lower
limb to upper limb evaluation, with
seemingly reliable results.
In 2017, Sergi Barrera-Ochoa intro-
duced a new diagnostic criterion
for CECS (Trest) concerning to the
time between maximal intra-com-
partmental pressure immediately
after stress and the return to basal
pressure. 14
Nuclear magnetic resonance
has shown to be a powerful exam,
presenting the advantage of non-
invasiveness. It shows a significant
1
2
3
increase in T2 signal intensity of the
involved compartment, right after
exertion. 17,23 Spectroscopy has also
been studied in this field, assessing
the level of tissue ischemia from
Venue hemoglobin saturation. 1,24
Differential diagnosis
CECS is an exclusion diagnosis, there
having a variety of diseases that
must be differentiated from it. The
typical patient is a young adult, with
very few cases reported in adoles-
cence. 21 It is essential to differenti-
ate CECS from acute compartment
syndrome, an emergent traumatic
pathology, with possible devastat-
ing results. 6 CECS clinical presenta-
tion can mimic some neurological
pathologies, so it should be differ-
entiated from peripheral neuropa-
thies as well as root compression
syndromes. 1,6,9 Vascular lesions,
stress fractures, focal dystonia and
myotendinous chronic inflamma-
tory processes are also differential
diagnosis from CECS. 16,19,21,25
Treatment
Symptoms relief with rest is one
of most important characteristics
of CECS, so stop activity is consid-
ered the only effective conserva-
tive measure. 5,20 Anti-inflammatory
drugs, orthosis and physical therapy
has shown weak results in this dis-
ease. 6,13 Since high-competition ath-
letes are the most affected, decreas-
ing intensity or stopping activity
is not an option in vast majority
of patients. Therefore, decompres-
sive fasciotomy keeps on the gold
standard treatment. 16 There is no
consensus yet regarding the release
of superficial compartment alone
be enough for symptoms relieve.
So, many authors remain advocat-
ing deep compartment fasciotomy
in addition to superficial fasciot-
omy. 13,16 Controversy still remains in
regard to the value of fasciectomy as
Diagnostic criteria of lower limb CECS – Pedowitz (1990) 22
Pre-exertional pressure equal or superior to 15mmHg;
Pressure 1 minute post exercise equal or superior to 30mmHg;
Pressure 5 minutos post exercise equal or superior to 20mmHg
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