Working Diagnosis:
Chronic Exertional Compartment Syndrome (CECS) of the dorsal and lateral compartments of the forearm.

Treatment:
Decompressive fasciotomy of dorsal and lateral compartments of the right forearm

Outcome:
The patient was seen by orthopedic hand surgery and decided to proceed with decompressive fasciotomy. In the operating room, following fascial opening, muscle significantly bulged outside the area of release. The patient was discharged home the same day with a short arm splint. She experienced significant symptom relief and gradual return to light activity was initiated two weeks post-operatively. Four weeks after initial follow-up she returned back to practice with gradual increase to full play under the guidance of her trainer.

Author's Comments:
This case report highlights the diagnosis and successful management of Chronic Exertional Compartment Syndrome (CECS) in a high-level female tennis player. Early recognition and appropriate treatment of CECS are both crucial to ensure optimal outcomes and facilitate a safe return to play. Decompressive fasciotomy remains an effective treatment approach for upper extremity CECS. Initially, the patient received treatment for suspected lateral epicondylitis, however lack of improvement led to consideration of alternative diagnoses, including radial tunnel syndrome, muscle strains, radial head collateral ligament injury and autoimmune inflammatory arthropathy given history of Crohn's disease. Notably, the possibility of CECS was included in diagnostic considerations, despite its rarity given the history of recurrence in the setting of repetitive activity and appropriate work-up and referrals were initiated. Other than our case, only one other case of CECS in a tennis player has been reported in the literature.

Editor's Comments:
Chronic exertional compartment syndrome involves recurrent episodes of increased compartmental pressure and ischemia with activity resolving with cessation of activity due to reduction in fascial compartment pressures. Increased blood flow and fluid can lead to up to 20% increase in muscle swelling during exercise leading to increase in pressure (6). CECS is often a diagnosis of exclusion that can be overlooked leading to, on average, a 22-month delay in diagnosis (1). This case presents an even greater diagnostic challenge given that CECS occurs most commonly in the lower extremity and only a single case has been described in a tennis player (7,8). Especially given this background, the team did an excellent job with the exclusion of other conditions, in addition to providing the correct initial management for CECS and other diagnostic considerations. This management involves the initiation of conservative measures such as activity modification, therapy, and anti-inflammatories. It can also include modifications such as footwear changes, use of orthotic inserts and bracing when applicable (2). Although conservative measures are a reasonable starting point, the likelihood of failure in a competitive athlete is high given their continued engagement in the provocative movements. The gold standard for diagnosis is pre- and post-exercise compartment testing, although non-invasive methods such as dynamic MRI have been increasingly utilized for the diagnosis by demonstrating post-exercise edema (2-4). CECS can occur bilaterally in 70-95% of cases, therefore should be higher on the differential in patients who have a history of this rare condition (6).

References:
(1) Chatterjee R. Diagnosis of chronic exertional compartment syndrome in primary care. Br J Gen Pract. 2015;65(637):e560-e562. doi:10.3399/bjgp15X686329
(2) Vogels, S., Ritchie, E.D., van der Burg, B.L.S.B. et al. Clinical Consensus on Diagnosis and Treatment of Patients with Chronic Exertional Compartment Syndrome of the Leg: A Delphi Analysis. Sports Med 52, 3055–3064 (2022).
(3) Van der Kraats AM van, Winkes M, Janzing HMJ, Eijkelenboom RPR, de Koning MTG. Review of Reliable and Valid Noninvasive Tools for the Diagnosis of Chronic Exertional Compartment Syndrome. Orthopaedic Journal of Sports Medicine. 2023;11(1).
(4) David T. Ryan, Marion Hanley, Sarah K. Eustace, Stephen J. Eustace. Chronic exertional compartment syndrome of the quadriceps femoris, Radiology Case Reports, 2024 19 (1): 8-81,
(5) Kunal Sindhu, Brian Cohen, Joseph A. Gil, Travis Blood & Brett D. Owens (2019) Chronic exertional compartment syndrome of the forearm, The Physician and Sportsmedicine, 47:1, 27-30
(6) Chandwani D, Varacallo M. Exertional Compartment Syndrome. (Updated 2023 May 23). In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2023
(7) Piasecki DP, Meyer D, Bach BR Jr. Exertional compartment syndrome of the forearm in an elite flatwater sprint kayaker. Am J Sports Med. 2008;36 (11):2222-2225.
(8) 5. Berlemann U, al-Momani Z, Hertel R. Exercise-induced compartment syndrome in the flexor-pronator muscle group. A case report and pressure measurements in volunteers. Am J Sports Med. 1998 May-Jun;26(3):439-41.

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