Musculoskeletal injuries are the most common cause of pain and dysfunction in recreational and professional athletes.^1,2 However, vasculopathies and neurovascular entrapments are another potential cause of pain in athletes. Individuals engaged in sports activities who report lower leg discomfort may have various conditions, including conditions that may lead to chronic exertional compartment syndromes (CECS) or under-recognized neurovascular entrapment syndromes, such as common peroneal nerve entrapment (CPNE). It is not uncommon that a range of specialists, including physical and sports medicine, orthopedic surgeons, neurologist, vascular surgeons, rehabilitation physicians, or vascular medicine specialist, will jointly consult on athletes with exertional leg pain. The aim of this expert analysis is to differentiate and increase awareness between CECS and CPNE in the domain of cardiology, sports cardiology, and vascular medicine. This short review describes two conditions (CECS and CPNE) found in athletes and highlights the need for better strategies and recognition to improve the care of athletes with lower extremity pain.

Exercise-induced lower extremity pain caused by CECS is associated with the accumulation of fluid in the intracompartmental space surround by noncompliant fascia, thereby elevating muscle pressure and reducing venous and lymphatic outflow.³ This causes venous and capillary pressure to increase to a point where if rapidly accumulates, such as in acute compartment syndrome, arterial inflow may be compromised and lead to leg ischemia and muscle death at rest.³ Exertional leg pain caused by CECS leads to local-regional tightness and pain during activities such as walking, running, or even at rest shortly after exercise.^4-6 Three muscle compartments may be involved in CECS. These three muscle compartments in the leg include the anterior, lateral, and posterior (superficial and deep) compartment.^4-7 The muscles in the anterior compartment are responsible for dorsiflexion, eversion and inversion of the foot and ankle and is supplied by the deep fibular (peroneal) nerve and the anterior tibial artery. The superficial fibular (peroneal) nerve and the fibular artery supply the muscles in the lateral compartment. The posterior compartment is responsible for plantarflexion of the foot and ankle and is made up of muscles in the superficial and deep compartment and are supplied by the posterior tibial artery and tibial nerve.

The gold standard diagnostic tool for CECS is provided by a dynamic intracompartmental pressure (ICP) measurement before and after provocative treadmill testing.⁸ A manometer is one device that detects the dynamic ICP by measuring the resistance that is present when saline solution is injected into the compartment. Normal ICP are <15 mmHg and abnormal is >30 mmHg after 1 minute or 20 mmHg after 5 minutes.⁸ The anterior compartment is reportedly the most common CECS location followed by the deep posterior compartment.^7,9 Lateral CECS have either been distinguished as a separate peroneal compartment syndrome,⁹ or instead, always occurring in combination with the anterior compartment, thereby classified as "anterolateral" CECS.^10-12 Unfortunately, it has not been standard procedure to routinely preform ICP testing of both the anterior and lateral compartments simultaneously among athletes with anterolateral complaints.¹³ Therefore, the prevalence of lateral CECS alone is lacking, but reports indicate a 7% incidence rate among patients tested with anterolateral CECS.¹³ In addition, only 58% of patients with complaints of anterolateral CECS had elevated pressures in both compartments.¹³

Anterior and posterior CECS are separate entities with characteristic history and physical examination features that distinctly distinguish them.¹³ Pain exhibited in the calf combined with tenderness of the distal deep flexor muscle with palpation is associated with deep posterior CECS.¹⁴ Isolated lateral CECS is difficult to discriminate from anterior CECS features and therefore simultaneous dynamic intracompartmental measurement of both anterior and lateral compartments is warranted. Increased muscle pressures in the anterior or lateral compartment may cause athletes to have drop foot (in severe cases) caused by compression of the peroneal nerve or experience skin sensations like numbness or tingling in the dermatome of dorsum of foot (superficial peroneal nerve) or between first and second toes (deep peroneal nerve).¹⁵ It is important to recognize that anterior and posterior CECS may occur exclusively, although combinations of both do occur. Definitive treatment of CECS is a complete fasciotomy to the affected compartment after a trial of conservative management.^12,15 Nonsurgical methods may initially include respite from exercise, physical therapy, athletic shoe inserts, or even botulinum toxin injections into the muscles of the leg.

Another important condition to recognize causing lower extremity pain in athletes that may mimic CECS are neurovascular entrapments, such as CPNE. This condition is crucial to correctly diagnosis as treatment with neurolysis without fasciotomies are often successful.¹⁶ This diagnosis may be overlooked due to the lack of an appropriate index of suspicion, as presenting symptoms are similar to CECS, especially anterior CECS. Neurovascular entrapment in the lower extremity can cause severe neuropathic pain exacerbated by exertional activities. Unlike in CECS, ICP measurements, imaging, and functional tests are normal. CPNE in athletes, similar to CECS, occur in activities that consists of repetitive inversion and eversion of the leg such as cyclists or runners.¹⁶ Several studies reported specific clues in patient history and physical examination that are pivotal in helping diagnose CPNE.^16,17 Patients have reported a history of leg pain or numbness during certain body positions such as when in a crouched position or sitting with crossed legs.¹⁷ Moreover, individuals had consistently complained of disturbed sleep patterns when lying on the affected side due to unfavorable leg positions that further compress the entrapped nerve.¹⁶ On physical exam, features to diagnose CPNE have included a shiny appearance of the leg skin, altered lateral leg sensations detected with a swab test, out-of-portion pain with skin pinching or tapping the nerve at the fibular head (positive Tinel sign), limb atrophy, drop foot, and a positive "scratch collapse test".^16-18 Sensory and motor deficits with EMG, including nerve conduction studies, are not consistently reliable in CPNE and may be negative.¹⁶ Once the diagnosis of CPNE is made, conservative treatment with physical therapy, stretching and massage is tried, and if not successful, surgery with neurolysis is often beneficial.^16,19

In summary, history and physical examination, imaging, EMG including nerve conduction studies, and muscle compartment pressure measurements are useful to differentiate leg pain between CECS and CPNE.

Summary Key Points:

• Chronic exertional compartment syndrome is repetitive pain that can present in any muscular compartment during physical exertion (most common in the anterior compartment of the lower extremity), which returns to normal with exercise cessation.
• Common peroneal nerve entrapment is leg pain or numbness, during unfavorable leg positions or conditions, which can lead to localized pain over the anterior and lateral aspects of the leg and foot, weakness of the foot in dorsiflexion, and foot eversion (foot drop) due to compression of the entrapped nerve.
• History and physical examination, imaging, EMG including nerve conduction studies, and muscle compartment pressure measurements are useful to differentiate these two conditions. Unlike in chronic exertional compartment syndrome, common peroneal nerve entrapment intracompartmental pressure measurements, imaging, and functional tests are normal.
• Definitive treatment of chronic exertional compartment syndrome is a complete fasciotomy to the affected compartment and surgery with neurolysis for common peroneal nerve entrapment after a trial of conservative management.

References

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14. Winkes MB, van Zantvoort APM, de Bruijn JA, et al. Fasciotomy for deep posterior compartment syndrome in the lower leg: a prospective study. Am J Sports Med 2016;44:1309–16.
15. Gatenby G, Haysom S, Twaddle B, Walsh S. Functional outcomes after the surgical management of isolated anterolateral leg chronic exertional compartment syndrome. Orthop J Sports Med 2017;5:2325967117737020.
16. van Zantvoort APM, Setz MJM, Hoogeveen AR, Scheltinga MRM. Common peroneal nerve entrapment in the differential diagnosis of chronic exertional compartment syndrome of the lateral lower leg: a report of 5 cases. Orthop J Sports Med 2018;6:2325967118787761.
17. Fabre T, Piton C, Andre D, Lasseur E, Durandeau A. Peroneal nerve entrapment. J Bone Joint Surg Am 1998;80:47–53.
18. Gillenwater J, Cheng J, Mackinnon SE. Evaluation of the scratch collapse test in peroneal nerve compression. Plast Reconstr Surg 2011;128:933–39.
19. Burrus MT, Werner BC, Starman JS, et al. Chronic leg pain in athletes. Am J Sports Med 2015;43:1538–47.

Clinical Topics: Cardiovascular Care Team, Sports and Exercise Cardiology, Vascular Medicine

Keywords: Peroneal Neuropathies, Tibial Arteries, Saline Solution, Hypertonic, Peroneal Nerve, Physical Exertion, Hypesthesia, Compartment Syndromes, Lower Extremity, Athletes, Tibial Nerve, Physical Examination, Neuralgia, Fascia, Sports Medicine, Palpation, Ischemia, Physical Therapy Modalities, Neural Conduction, Botulinum Toxins, Reference Standards

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