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 Revista de Medicina Desportiva informa march 2018 · 27