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Chronic exertional compartment syndrome of the lower leg: a novel diagnosis in diabetes mellitus: a clinical and morphological study of diabetic and non-diabetic patients
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic exertional compartment syndrome (CECS) of the lower leg, defined as a condition with exercise-induced pain due to increased intramuscular pressure (IMP), has previously mainly been described in running athletes, and etiologic factors are poorly described. CECS has not been reported to occur together with other diseases and information about consequences on muscles morphology after treatment with fasciotomy is largely unknown. We investigated etiologic and pathophysiologic aspects to CECS in a consecutive series of 63 patients with exercise-related leg pain and in 17 diabetic patients with symptoms of intermittent claudication but no circulatory insufficiency. Clinical examination, radiography, scintigraphy and IMP measurements at rest and after reproduction of symptoms were done. Patients with CECS were recommended treatment with fasciotomy. Biopsies were taken from the tibialis anterior muscle at time of fasciotomy and at follow-up 1 year later. For comparison muscle samples were taken from normal controls. Enzyme- and immunohistochemical and morphometric methods were used for analysis of muscle fiber morphology/pathology, fiber phenotype composition, mitochondrial oxidative capacity and capillary supply.

Thirty-six of the 63 patients fulfilled the criteria for diagnosis of CECS in the anterior tibial compartment. The CECS patients could be divided into different etiologic groups: 18 healthy, 10 with history of trauma against the lower leg, 4 diabetic patients and 4 others. Only 5 of 36 CECS patients were athletes. The results after fasciotomy were good or excellent in 41 of 57 treated legs.  Sixteen of the 17 diabetic patients were diagnosed with CECS, 11 with diabetes type 1 and 5 with type 2. The diabetic patients differed from the other groups with longer symptom-duration, shorter pain-free walking distance, firm and tender lower leg muscles and higher IMP. The postoperative outcome was good or excellent in 15 of 18 treated legs. The muscle biopsies taken at fasciotomy showed frequent histopathological changes including small and large sized fibers, fiber atrophy, internal myonuclei, split fibers, fibrosis, disorganization of mitochondria in contrast to healthy CECS subjects having low muscle capillarization as the main finding. Muscular abnormalities were generally more complex, severe and widespread in diabetic patients. After 1 year, the majority of CECS patients could return to unrestricted physical activity and the histopathological muscle changes were clearly reduced. The muscle fiber size was larger and the muscles contained signs of regeneration and repair. Remaining muscle abnormalities were present mainly in diabetic patients.

CECS is a new differential-diagnosis in diabetic patients with symptoms of claudication without signs of vascular disease. A low ability for physical activity, reflected by the signs of both myopathy and neuropathy, indicates that high IMP and circulatory impairment has deleterious effects for the involved muscles. Increased physical activity and normalization of muscle morphology 1 year after treatment shows the benefit of fasciotomy. The more severe clinical and morphological findings in diabetic compared to healthy subjects with CECS indicate differences in the pathogenesis. The unrestricted physical ability after treatment is very important for diabetic patients, since physical activity is an essential part of the therapy of the disease.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2010. , 53 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1334
Keyword [en]
Chronic compartment syndrome, diabetes mellitus
National Category
Surgery
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-33694ISBN: 978-91-7264-957-6 (print)OAI: oai:DiVA.org:umu-33694DiVA: diva2:317270
Public defence
2010-05-28, Sal B, Tandläkarhögskolan 9 tr, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2010-05-10 Created: 2010-05-03 Last updated: 2010-05-10Bibliographically approved
List of papers
1. Chronic compartment syndrome also affects nonathletic subjects: a prospective study of 63 cases with exercise-induced lower leg pain
Open this publication in new window or tab >>Chronic compartment syndrome also affects nonathletic subjects: a prospective study of 63 cases with exercise-induced lower leg pain
2007 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 78, no 1, 136-142 p.Article in journal (Refereed) Published
Abstract [en]

Background Chronic exertional compartment syndrome is most often reported in young and physically active people.

Patients and methods We studied 73 consecutive patients (mean age 39 (16–77) years, 45 women) with a history of exercise-induced pain and suspicion of chronic exertional compartment syndrome (CECS) of the lower leg—clinically, radiographically and with intramuscular pressure measurements.

Results Intramuscular pressure increased with reproduction of symptoms and fulfilled the criteria for diagnosis of CECS in 36 patients (mean age 36 (16–65) years, 22 women), with engagement of 66 anterior, 2 lateral and 7 posterior muscle compartments in 72 legs. The patients with CECS of the lower leg were divided into 4 etiological groups: 18 with overuse, 10 with earlier trauma, 4 insulin-treated diabetics, and 4 others. Two-thirds of the patients had pain during walking. The outcome after fasciotomy was excellent or good in 41/57 of the legs.

Interpretation CECS of the lower leg probably has a multifactorial etiology and is more common in sedentary individuals than has been recognized previously. Fasciotomy appears to be beneficial in these cases also.

National Category
Surgery
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-23497 (URN)10.1080/17453670610013547 (DOI)
Available from: 2009-06-22 Created: 2009-06-22 Last updated: 2010-05-10Bibliographically approved
2. Intermittent claudication in diabetes mellitus due to chronic exertinal compartment syndrome of the leg: an observation study of 17 patients
Open this publication in new window or tab >>Intermittent claudication in diabetes mellitus due to chronic exertinal compartment syndrome of the leg: an observation study of 17 patients
2008 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 79, no 4, 534-539 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose: Intermittent claudication in diabetes mellitus is commonly associated with arterial disease but may occur without obvious signs of peripheral circulatory impairment. We investigated whether this could be due to chronic exertional compartment syndrome (CECS).

Patients and methods: We report on 17 patients (3 men), mean age 39 (18–72) years, with diabetes mellitus—12 of which were type 1—and leg pain during walking (which was relieved at rest), without clinical signs of peripheral arterial disease. The duration of diabetes was 22 (1–41) years and 12 patients had peripheral neuropathy, retinopathy, or nephropathy. The leg muscles were tender and firm on palpation. Radiography, scintigraphy, and intramuscular pressure measurements were done during exercises to reproduce their symptoms.

Results: 16 of the 17 patients were diagnosed as having CECS. The intramuscular pressures in leg compartments were statistically significantly higher in diabetics than in physically active non‐diabetics with CECS (p < 0.05). 15 of the 16 diabetics with CECS were treated with fasciotomy. At surgery, the fascia was whitish, thickened, and had a rubber‐like consistency. After 1 year, 9 patients rated themselves as excellent or good in 15 of the 18 treated compartments. The walking time until stop due to leg pain increased after surgery from less than 10 min to unlimited time in 8 of 9 patients who were followed up.

Interpretation: Intermittent claudication in diabetics may be caused by CECS of the leg. The intramuscular pressures were considerably elevated in diabetics. One pathomechanism may be fascial thickening. The results after fasciotomy are good, and the increased pain‐free walking time is especially beneficial for diabetics.

Place, publisher, year, edition, pages
Basingstoke: Taylor & Francis, 2008
National Category
Surgery
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-23493 (URN)10.1080/17453670710015544 (DOI)
Available from: 2009-06-22 Created: 2009-06-22 Last updated: 2011-04-20Bibliographically approved
3. Evidence for low muscle capillary supply as a pathogenic factor in chronic compartment syndrome
Open this publication in new window or tab >>Evidence for low muscle capillary supply as a pathogenic factor in chronic compartment syndrome
2010 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 20, no 6, 805-813 p.Article in journal (Refereed) Published
Abstract [en]

There is a paucity of data regarding the pathogenesis of chronic exertional compartment syndrome (CECS), its consequences for the muscles and the effects of treatment with fasciotomy. We analyzed biopsies from the tibialis anterior muscle, from nine patients, obtained during a decompressing fasciotomy and during follow-up 1 year later. Control biopsies were obtained from nine normal subjects. Muscle capillarity, fiber-type composition and fiber area were analyzed with enzyme- and immunohistochemistry and morphometry. At baseline, CECS patients had lower capillary density (273 vs 378 capillaries/mm(2), P=0.008), lower number of capillaries around muscle fibers (4.5 vs 5.7, P=0.004) and lower number of capillaries in relation to the muscle fiber area (1.1 vs 1.5, P=0.01) compared with normal controls. The fiber-type composition and fiber area did not differ, but focal signs of neuromuscular damage were observed in the CECS samples. At 1-year follow-up after fasciotomy, the fiber area and the number of fibers containing developmental myosin heavy chains were increased, but no enhancement of the capillary network was detected. Thus, morphologically, patients with CECS seemed to have reduced microcirculation capacity. Fasciotomy appeared to trigger a regenerative response in the muscle, however, without any increase in the capillary bed.

Place, publisher, year, edition, pages
Copenhagen: Munksgaard, 2010
Keyword
CECS, capillaries, tibialis anterior, muscle, fiber types, fasciotomy, compartment, blood flow
National Category
Surgery
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-32010 (URN)10.1111/j.1600-0838.2009.01013.x (DOI)000283325000005 ()19804582 (PubMedID)
Available from: 2010-03-03 Created: 2010-02-26 Last updated: 2012-05-14Bibliographically approved
4. Muscle changes in diabetics with chronic compartment syndrome
Open this publication in new window or tab >>Muscle changes in diabetics with chronic compartment syndrome
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-33693 (URN)
Available from: 2010-05-03 Created: 2010-05-03 Last updated: 2010-05-10Bibliographically approved

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