Working Diagnosis:
Previously occult bilateral chronic exertional compartment syndrome

Treatment:
2nd surgical fasciotomy

Outcome:
Postoperative guidelines 2,3
POD 1-2 Passive and active range of motion, weigh bearing activities as tolerated, edema control
POD 3-4 Achieve independence with ADLs
Weeks 1-4 Add stair climbing and increase walking distance
Weeks 4-6 Begin nonimpact aerobic exercise
Week 6+ Unrestricted impact lower extremity activities

Author's Comments:
Exertional leg pain in athletes is often difficult to correctly diagnose
Diligent investigation can delineate causes
More than one etiology may be contributing simultaneously
Popliteal artery entrapment syndrome may lead to false negative compartment pressure readings

Editor's Comments:
Shubert in her review article (see references) cites a recurrence rate of 7-17% in post operative cases and comments that "Recurrence may be due to incorrect diagnosis, inadequate release, failure to release a compartment thought to be asymptomatic, nerve compression by an unrecognized fascial hernia, and development of prolific scar tissue. Abnormal scarring of the fascia or overlying skin has been found to occur following surgical release. Approximately 10% of patients require a revision surgery. Of note, although a fasciotomy is often effective in eliminating the pathological increase in compartment pressure, it does not treat the elusive initial cause of the syndrome."

A key teaching point of this case is that previous surgery for chronic exertional compartment syndrome does not exclude recurrence nor guarantee that the pre-surgical diagnosis was correct. It is also helpful to get a detailed history of the surgical procedure and correlate clinical findings with compartment pressure measurements. Diagnosing and treating chronic anterior lower leg pain is a challenge and maintaining a broad differential diagnosis is important.

References:
Burrus TM, Werner BC, Starman JS, Gwathmey WF, Carson EW, Wilder RP, Diduch DR. Chonic leg pain in Athletes. Am J of Sports Med 2014;XX:1-9.
Rajasekaran S, Kvinlaug K, Finnofff J. Exertional Leg Pain in the Athlete. PM R 2012;4:985-1000.

Schubert AG. Exertional compartment syndrome: Review of the literature and proposed rehabilitation guidelines following surgical release. Int J Sports Ther 2011;6:126-141

Turnnipseed WD. Functional popliteal artry entrapment syndrome: A poorly understood and often missed diagnosis that is frequently mistreated. J Vasc Surg 2009;49)5):1189-95.

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