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Rheumatology 2001; 40: 344-345
© 2001 British Society for Rheumatology
Letters to the Editor |
Chronic exertional compartment syndrome of the forearms secondary to weight training
Kingston Hospital, Galsworthy Road, Kingston-upon-Thames, Surrey KT2 7QB and
1 The Royal London Hospital at Mile End, 275 Bancroft Road, London E1 4DG, UK.
SIR, Compartment syndrome (CS) occurs when the interstitial pressure in a closed fascial compartment increases to such a degree that local blood flow is compromised, resulting in tissue ischaemia. CS usually presents acutely, most commonly as a result of fractures, muscle rupture or intracompartmental vascular injury [1], and generally requires immediate surgical treatment [2]. The most common sites involved are the thigh, calf and forearm. Chronic exertional compartment syndromes (CECS) are much less common and usually occur in the lower limb compartments [3]. CECS is extremely rare in the forearm and, as illustrated by the case described here, can present a difficult diagnostic problem.
Here we present the case of young man presenting to a rheumatology clinic with bilateral arm pain, which was subsequently diagnosed as a CECS. A 23-yr-old man was referred with a 2-yr history of pain in the medial side of both forearms which occurred during weight training. The pain was precipitated by resistance exercises which required flexion at the elbow and the wrist (‘biceps arm curls’). The pain slowly resolved on cessation of the exercise but recurred each time this exercise was performed. There were no forearm symptoms when he was not weight-training. There were no other musculoskeletal symptoms and he was otherwise in good health. He was on no medications at the time of presentation and in particular there was no history of the use of illicit performance-enhancing drugs. Physical examination revealed a muscular individual with no wasting or asymmetry of the upper limbs. Neurological examination of the upper limbs was normal. The peripheral arterial pulses were present and normal. No joint abnormalities were found and Tinel's and Phalen's tests for carpal tunnel syndrome were negative.
Initial investigations showed normal plain X-rays of both forearms and a normal radioisotope bone scan of the upper limbs, making stress fractures unlikely. Nerve conduction studies in the right and left ulnar and median nerves were all within normal limits. In the light of the history and these normal results, the intracompartmental pressure (ICP) in both deep flexor compartments was measured using a standard ICP measuring system. The pressure measurements were made at rest and during forearm flexion exercises which reproduced the pain. The resting ICPs were 25–26 mmHg and reached 35 mmHg during exercise (Fig. 1
). These results clearly showed that the exercise-induced ICP in this patient was sufficient to impede muscle perfusion, thereby precipitating his symptoms and confirming the diagnosis of CECS. CECS can be treated conservatively in the first instance but most patients only recover with surgical intervention. Our patient was treated with a bilateral fasciotomy and made an uneventful recovery.
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CECS of the forearm is extremely rare and only a few cases have been described in the literature. They have been described in normal individuals [4–6] and in a professional motorcyclist [7], but this is the first report of a CECS as a result of weight-training. The key to the diagnosis is the history and the absence of physical signs on examination. Included in the differential diagnosis of a young sportsman with forearm pain is the more common ulnar stress fracture which can occur as an overuse injury in athletes [8]. It usually presents with chronic pain, which is often continuous, and there may be an area of localized tenderness on examination. The plain X-ray is normal in the early stages but later shows a periosteal reaction or a fracture line. Radioisotope bone scanning and magnetic resonance imaging are more likely to be helpful in the early stages. Nerve entrapment syndromes can also present with chronic pain with or without a clinically detectable neurological deficit. These can usually be confirmed by nerve conduction studies.
However, this history is typical of a CECS with symptoms worsening as exercise is continued. There is a gradual resolution of pain on cessation of exercise, unlike an acute compartment syndrome, in which the pain is continuous. The diagnosis is confirmed by measuring the ICP before and after exercise. The normal ICP is between 0 and 8 mmHg [9]. Fronek et al. [10] have studied ICP in the lower limbs and suggest that an ICP greater than 10 mmHg at rest or greater than 25 mmHg after 5 min of exercise should be regarded as abnormal. Our patient clearly fits these criteria, although similar studies in the forearm have not been done. The definitive treatment for CECS is fasciotomy, although conservative treatments have been tried with limited success.
The role of weight-training in sport and as part of physical fitness programmes is increasing. Muscular pain as a result of weight training is a common presenting symptom, and it is possible that CECS is much more common than previously thought. It is important to consider CECS in the differential diagnosis in a patient presenting with exercise-related forearm pain, and ICP measurements should be considered in patients presenting with a typical history.
Notes
References
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- Martens MA, Moeyersoons JP. Acute and recurrent effort-related compartment syndrome in sports. Sports Med1990;9:62–8.[ISI][Medline]
- Soderberg TA. Bilateral chronic compartment syndrome in the forearm and the hand. J Bone Joint Surg Br1996,78:780–2.[Medline]
- Pedowitz RA, Toutounghi FM. Chronic exertional compartment syndrome of the forearm flexor muscles. J Hand Surg Am1998; 13:694–6.
- Imbriglia JE, Boland DM. An exercise-induced compartment syndrome of the dorsal forearm—a case report. J Hand Surg Am1984;9A:142–3.[Medline]
- Allen MJ, Barnes MR. Chronic compartment syndrome of the flexor muscles in the forearm: a case report. J Hand Surg Br1989; 14:47–8.[Medline]
- Patel MR, Irizarry J, Stricevic M. Stress fracture of the ulnar diaphysis: review of the literature and report of a case. J Hand Surg Am1986;11:443–5.[Medline]
- Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop1975;113:43–51.
- Fronek J, Mubarak SJ, Hargens AR, Lee YF, Gershuni DH, Garfin SR et al. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop1987;220:217–27.
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