Working Diagnosis:
Severe deep peroneal neuropathy with tibialis anterior and extensor digitorum brevis fibrosis secondary to a missed Acute Exertional Compartment Syndrome

Treatment:
Early conservative treatment consisted of AFO bracing and rehabilitation with physical therapy but this provided no improvement in his weakness. He then underwent surgical management consisting of posterior tibial tendon transfer, midfoot release, posterior ankle capsulotomy surgery, and fascial release followed by post-operative physical therapy.

Outcome:
There was initial post-operative improvement of foot drop and function where he regained 50% of function. However, due to the patient losing school insurance and moving back to his home country, the patient was lost to follow up.

Author's Comments:
Exertional compartment syndrome should be considered in the differential diagnosis if the patient has extremity (most often lower extremity) pain during or after exertion in the absence of trauma. Acute exertional compartment syndrome (AECS) is the least common form of compartment syndrome and most often missed. Thus, there needs to be a high index of suspicion for AECS especially if symptoms do not resolve with rest and workup continues to be negative. Early surgical intervention in the treatment of AECS increases the likelihood of improved outcomes.

Editor's Comments:
Compartment syndrome is defined as increased pressure within a closed fibro-osseous space causing reduced blood flow and reduced tissue perfusion subsequently leading to ischemic pain and possible permanent damage to the tissues of the compartment. Compartment syndrome could be acute, chronic (exertional) or convert from chronic to acute. Acute compartment syndrome is usually associated with trauma and intracompartmental pressures are elevated and do not subside with rest. Chronic exertional compartment syndrome may convert to acute compartment syndrome in situations where athletes continue to exercise through initial pain. It is important to consider this scenario If pain does not resolve within an appropriate amount of time.

The anterior compartment of the lower leg is affected most often and presents with pain in the anterolateral aspect of the lower leg with exertion. This compartment contains the tibialis anterior, extensor digitorum longus, extensor hallucis longus and peroneus tertius muscles along with the deep peroneal nerve. Patients may present with pain just lateral to the anterior border of the tibia and paresthesia in the first interdigital web space. Physical exam will usually be normal at rest or show generalized tightness of the anterior compartment with possible focal regions of excessive muscle thickening. Tight plantar flexors (gastrocnemius and soleus) may predispose a patient to anterior compartment syndrome. Diagnosis is typically confirmed using pre-exertional and post-exertional compartment testing with needle manometry. Treatment may include heel-drop or orthotics to reduce the load of the muscles of the compartment. Sustained myofascial tension combined with passive and active plantarflexion, transverse friction or dry needling may help alleviate symptoms. Alterations in gait while running (forefoot strike pattern) and intra-muscular botulinum toxin injections may also be considered to help with symptoms. Surgical release may be considered when conservative measures fail.

References:
1. Livingston KS, Meehan WP 3rd, Hresko MT, Matheney TH, Shore BJ. Acute Exertional Compartment Syndrome in Young Athletes: A Descriptive Case Series and Review of the Literature. Pediatr Emerg Care. 2018 Feb;34(2):76-80. doi: 10.1097/PEC.0000000000000647. PMID: 27248777.
2. McKinney B, Gaunder C, Schumer R. Acute Exertional Compartment Syndrome with Rhabdomyolysis: Case Report and Review of Literature. Am J Case Rep. 2018 Feb 8;19:145-149. doi: 10.12659/ajcr.907304. PMID: 29415981; PMCID: PMC5813520.
3. Archbold HA, Wilson L, Barr RJ. Acute exertional compartment syndrome of the leg: consequences of a delay in diagnosis: a report of 2 cases. Clin J Sport Med. 2004 Mar;14(2):98-100. doi: 10.1097/00042752-200403000-00009. PMID: 15014345.
4. Aweid O, Del Buono A, Malliaras P, Iqbal H, Morrissey D, Maffulli N, Padhiar N. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clin J Sport Med. 2012 Jul;22(4):356-70. doi: 10.1097/JSM.0b013e3182580e1d. PMID: 22627653.
5. Fraipont MJ, Adamson GJ. Chronic exertional compartment syndrome. J Am Acad Orthop Surg. 2003 Jul-Aug;11(4):268-76. doi: 10.5435/00124635-200307000-00006. PMID: 12889865.
6. Bruckner P, Khan K. Brukner & Khan's Clinical Sports Medicine. 5th ed. Sydney: McGraw-Hill, 2017.

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