The effectiveness of surgical and non-surgical management strategies in patients with chronic exertional compartment syndrome of the anterior compartment of the leg: a systematic review and meta-analysis
Date
2021
Authors
Kaplan, Sean
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Abstract
Objective: The objective of this review was to evaluate the effectiveness of surgical
management versus non-surgical management on pain, range of motion,
intracompartmental pressure (ICP) values, patient satisfaction, recurrence of
symptoms, return to activity, function, strength, and sensation in patients diagnosed
with Chronic Exertional Compartment Syndrome (CECS) of the anterior compartment
of the leg.
Introduction: CECS is the most prevalent cause of exercise-induced leg pain in
athletes. Current evidence suggests that the best methods for management of the
condition include activity modification or cessation, injection of botulinum toxin into the
affected compartment, or surgical intervention. However, no systematic review has
been done to provide level one evidence of the effectiveness of surgical versus non surgical management of CECS of the anterior compartment of the leg. Findings from
this study will inform clinical practice and identify gaps for further research into this
condition.
Study Design: Systematic review and meta-analysis of case reports, case series,
cohort studies, case-control studies, quasi-experimental studies, and randomised
controlled trials. Level of evidence: 1
Inclusion criteria: Studies were included if they assessed human participants that
were diagnosed with CECS of the anterior compartment of the leg through a
combination of elevated ICP values and patient history. Studies reporting patients with
CECS in addition to diagnoses of another lower limb pathology were included. Studies
that included patient reported outcome measures such as return to activity, pain, and
those that use specific outcome measures related to function were included. Studies
published in all languages were considered for inclusion. Studies were excluded if they
included management of acute compartment syndrome or if they did not mention and
specify the method of ICP measurement and/or other diagnostic parameters. Studies
assessing multiple compartments of the leg were excluded if they do not separately
report results for the anterior compartment.
Methods: MEDLINE via PubMed, SPORTDiscus, Physiotherapy Evidence Database
(PEDro), EBSCOhost MasterFILE Premier, EBSCOhost CINAHL Complete, ProQuest
Health and Medical Complete, SCOPUS and Science Direct were systematically
searched from 1956 to December 2020. Grey literature databases were also
searched. Included full-text studies were critically appraised using JBI SUMARI.
Where statistical pooling was possible, results from the articles were synthesised for
statistical analysis using JBI SUMARI and R. The findings of all included studies were
presented in a narrative review, including results from studies that underwent meta analysis.
Results: A total of 52 studies were included in the review, with a collective sample
size of 1458 participants. The designs of the included studies were case reports
(n=15), case series (n=24), cohort studies (n=8), quasi-experimental studies (n=3),
case-control studies (n=1), and randomised controlled trials (n=1). Regardless of the
type of management intervention, pain scores improved significantly across all studies
(95% CI[1.73-4.11], p<0.01, I2=94%). ICP values improved following intervention in
patients undergoing surgical fasciotomy, gait re-training, and botulinum toxin injection
into the affected compartment (at rest 95% CI [9.74-17.83], p<0.01, I2=98%; at P0 95%
CI [12.08-49.79], p<0.01, I2=99%; at P1 95% CI [13.95-40.63], p<0.01, I2=99%; at P5
95% CI [11.43-30.15], p<0.01, I2=99%). Satisfaction rates for surgical fasciotomy were
greater than both surgical fasciectomy and combination surgery, but comparable to
those reported for non-surgical management (95% CI [2.20-10.70], p<0.51, I2=0%).
Symptom recurrence was reported as 36% for fasciectomy and ranged from 0% to
23% for fasciotomy. Symptom recurrence was not expressly presented for non surgical management. Range of motion for ankle dorsiflexion improved significantly
for patients managed with botulinum toxin and manual therapy. Muscle strength
initially decreased following intervention with botulinum toxin but did not affect function
and returned to normal at follow-up. Sensory deficits were reported following
fasciotomy and were either due to peroneal nerve entrapment, sural nerve damage,
or pre-existing CECS. Rates of return to activity were 25-95% in patients that
underwent fasciotomy and 57-100% for patients receiving gait-retraining (95% CI
[0.40-0.79], p<0.01, I2=95%).
Conclusions: Non-surgical management strategies are a safe and effective
intervention for CECS of the anterior compartment of the leg with low risk and should
be exhausted prior to referral for surgical management, preferably in the form of
surgical fasciotomy. If surgical management is unsuccessful, repeat fasciotomies
including additional compartments may be necessary. A consensus needs to be
reached regarding diagnostic parameters for CECS. Further research into non surgical interventions and novel surgical interventions such as fascial fenestration is
necessary
Description
A research report submitted in fulfilment of the requirements for the degree Master of Science in Physiotherapy to the Faculty of Health Sciences, School of Therapeutic Sciences, University of the Witwatersrand, Johannesburg, 2021