Investigating lower leg chronic exertional compartment syndrome: A ...

Investigating lower leg chronic exertional compartment syndrome: A prospective comparative 

trial 

P. Brukner* 1,2 , L. Trease3 , K. Bennell1 , M. Kelly3 , C. Bradshaw2 & S. Bell2 1 2 Centre for Sports Medicine Research and Education, University of Melbourne, Olympic Park Sports Medicine Centre, 

Melbourne, 3Alfred Hospital, Prahran 

Introduction 

Chronic exertional compartment syndrome (CECS) can occur in any fascial enclosed space in the body used repetitively for long periods. 

CECS of the lower leg is of major importance due to its prevalence among athletes and its debilitating nature. The aetiology of CECS is 

incompletely understood, but it is widely thought that abnormal increases in intra-muscular pressure during exercise impair local perfusion, 

thereby resulting in tissue ischaemia and pain [1,2,4,6,11,12,15,16,18]. It has been hypothesized that a relatively new investigation may be 

able to detect ischaemia in the context of chronic compartment syndrome. The thallium-201 SPECT scan, currently used to detect myocardial 

ischaemia, has been used to investigate a small number of CECS patients [9,17]. Results of these studies suggest that the pain of compartment 

syndrome may be associated with ischaemia. Consequently thallium-201 SPECT has been touted as a possible non-invasive diagnostic test 

for the syndrome. 

Many patients with exercise induced lower leg pain will undergo additional diagnostic investigations to exclude diagnoses other than CECS. 

Isotopic bone scintigraphy is currently used to investigate possible bony causes of lower leg pain in athletes. However, it has been suggested 

that there may in fact be a typical ‘linear’ scintigraphic uptake appearance in those patients with CECS’[10], that is different from the currently 

recognized focal appearance of a stress fracture, and the patchy or diffuse uptake associated with periostitis. 

Thus this study will correlate and compare the results of two potential alternative investigations, thallium-201 SPECT imaging and bone 

scintigraphy with compartment pressure testing. With a better understanding of the aetiology and diagnosis of CECS, it is anticipated that more 

effective treatment and prevention strategies could be developed for the syndrome. Such developments would allow athletes to continue 

active participation in their sport or return to training more quickly and with fewer complications. 

Materials and Methods 

The Alfred Hospital Human Research Ethics Committee approved the study. All participants provided witnessed informed consent. Participants 

were eligible for inclusion into the study if they were between 18 and 55 years of age and described an exercise related lower leg pain, 

associated with a sensation of fullness or tightness in and around the affected compartment and had firm or tight compartment(s) to palpation 

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following exercise. Any participant who had had previous decompressive surgery for CECS was excluded because of the unknown pathological 

consequences of previous surgery within the same compartment. 

There were 24 male and 16 female participants. The mean age of the study group was 29 years. Seven patients had unilateral symptoms and 

the remaining 33 had bilateral symptoms. There were 15 patients with anterior symptomology, and 14 patients with posterior symptomology, 

the remaining 11 patients presented with concurrent anterior and posterior symptoms. Twenty-eight participants (70%) had both the thallium- 

201 SPECT scan and a bone scan. Six participants (15%) consented only to a thallium-201 SPECT scans and six (15%) participated only in 

the bone scan part of the study. Four medical practitioners performed the compartment pressure tests using a standard testing protocol. 

Participants were then divided into two groups on the basis of CPT results; those with a negative CPT were classified as ‘controls’ and those 

with a positive CPT were classified as ‘patients’. 

Thallous chloride scintigraphy (thallium-201 SPECT imaging) was performed in the Nuclear Medicine Department of The Alfred Hospital, 

Melbourne, Australia. Thallium-201 SPECT images were analyzed quantitatively and qualitatively in a blinded and independent manner. 

Quantitative analysis was performed. Images obtained from an Optima NX Gamma Camera [General Electric Medical Systems, Milwaukee] 

were reconstructed into 11 slices each 12mm in thickness and displayed proximal to distal. Three regions of interest (ROI) were demarcated; 

the antero-lateral compartment, the superficial posterior compartment, and the deep posterior compartment. The mean pixel count per ROI and 

the maximum pixel count per leg were calculated. Quantitative data were only analyzed for those compartments and legs with confirmed 

pressure measurement values. Intra-observer reliability was calculated by repeat analysis of 240 slice data sets while inter-observer reliability 

was performed by comparing the analysis of 270 slice data sets with an experienced nuclear medicine technologist. Intra-class correlation 

coefficients for the different compartments were 0.85-0.98 for intra-observer reliability and 0.82-0.98 for inter-observer reliability indicating 

excellent agreement’[14]. Qualitative analysis was performed by two experienced Nuclear Medicine Physicians with a third physician used 

when there was a discrepancy between the readers. Study participants were classified into one of five levels of perfusion in the stress images, 

and one of five levels of redistribution in the rest images. Each compartment on stress imaging was graded as either very hypoperfused (1), 

moderately hypoperfused (2), mildly hypoperfused (3), equally perfused (4) or hyperperfused (5) in relation to the other compartments within 

the same leg. Redistribution images for each compartment were graded to have either markedly redistributed (1), moderately redistributed (2) 

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or mildly redistributed (3), remained unchanged (4) or to have undergone reverse redistribution (5) relative to the stress images. Scans were 

deemed to be positive for a compartment perfusion deficit if they had a summed stress and redistribution score of less than or equal to five. 

Bone scintigraphy was performed at The Alfred Hospital Nuclear Medicine Department, Melbourne, Australia using a Maxxus Gamma Camera 

System [General Electric Medical Systems, Milwaukee]. Following injection of 800 MBq Technetium-99m MDP, the bone scan performed was 

a standard three-phase procedure with images taken at three time points. Blood flow and initial uptake images were performed within half an 

hour of the injection. Delayed bone uptake images were performed at least three hours after the injection, when the target to background ratio 

was at a maximum. Interpretation of the bone scan was made using a blinded protocol. 

Comparisons of mean pixel ratios for stress and redistribution in the 11 slices between patients and controls were made using a mixed 2x11 

analysis of variance. The compartments were combined for these analyses given the small numbers. For qualitative thallium-201 SPECT 

image scores and bone scintigraphy results, comparisons between groups were made using Chi square. Comparisons of symptom duration in 

those with and without linear uptake on bone scintigraphy was made using the Mann Whitney U test as the data were not normally distributed. 

An alpha level of p


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Participants were classified as having CECS typical linear uptake or non-linear uptake (either normal uptake, focal ovoid or diffuse patchy) on 

bone scintigraphy. Of those with a positive CPT result, 60% showed linear uptake on bone scan compared with 44% of those with a negative 

CPT result. There was no significant difference in bone scan appearance between those patients who had a positive CPT and those with a 

negative CPT result (X2(1)=0.65, p=0.46). The sensitivity and specificity of linear findings on bone scintigraphy for the diagnosis of CECS was 

60% and 56% respectively. 

Those patients who had a positive CPT were then separated on the basis of their involved compartments and compared with the different linear 

classifications (medial [posterior], lateral [anterior] and ‘tram-track’ [combined anterior and posterior]). While the numbers in each cell are too 

small to permit statistical analysis of the data, it is apparent that the site of uptake on the bone scan does not correspond to the affected 

compartment. 

Discussion 

This study measured the muscular perfusion of participants with exercise-induced lower leg pain using thallium-201 SPECT imaging and found 

no difference between those participants with and without CECS as diagnosed by compartment pressure testing. These results suggest that 

the pathophysiology of CECS may not involve ischaemia. This concurs with the results of Amendola et.al [3] who used MRI and Baulduini et. 

al. [5] who used phosphorous-31 nuclear magnetic resonance (31P-NMR) SPECT. In this latter study, ischaemia was only demonstrated in 

those patients where intracompartmental pressure was greater than systolic blood pressure (>160mmHg), a situation which is to be expected. 

No participant in this study recorded CPT values higher than 110mmHg. 

From the results seen in this study, it is apparent that clinically, thallium-201 SPECT imaging would provide little diagnostic assistance for 

suspected CECS cases. Although, it was a very specific investigation for CECS, with no false positive results (100% specific), it had extremely 

low sensitivity and so would not be able to distinguish positive CECS cases from actual negatives. 

This study failed to demonstrate a relationship between raised intracompartmental pressure and linear uptake on bone scintigraphy. However, 

as 44% of the controls and 60% of the patients had linear uptake on bone scan it is apparent that bony changes are relatively common in this 

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group. Other studies in athletes with stress fractures have also noted areas of increased uptake on bone scan at asymptomatic sites [8,19]. It 

is possible that the changes observed on bone scintigraphy in this study are incidental findings and result from the exercise that produces or 

aggravates the patient’s symptoms, but are unrelated to, or independent from the actual cause of their pain. Alternatively, some patients may 

have more than one pathological process occurring concurrently, with both CECS and bony pathology contributing to their pain. In those 

patients with a negative CPT, bone pathology consistent with a stress reaction or periostitis could explain their exercise-induced symptoms. 

Thus, the bone scintigraphic appearance is unlikely to be clinically useful as a diagnostic indicator of CECS. 

Conclusion 

The results of this study do not support the hypotheses that ischaemia may be important in the aetiology of lower leg CECS and that tension of 

tight fascia on the periosteal attachment produces characteristic bony changes. Further research should focus on identifying the pathologic 

process and the pain mechanisms involved. Given the poor sensitivity of thallium-201 SPECT imaging and bone scintigraphy to distinguish 

between those with and without increased intracompartment pressure, it is recommended that the diagnosis of CECS continues to be established 

based on clinical findings in conjunction with compartment pressure testing. 

References 

Allen MJ, Barnes MR: Exercise pain in the lower leg. Chronic compartment syndrome and medial tibial syndrome. JBJS 1986. 68: 818-823, 

1986 

Amendola A, Rorabeck CH: Chronic exertional compartment syndrome, in Current Therapy in Sports Medicine, Torg JS, Welsh RP, Shepard 

RJ, Editors. Decker: Toronto, BC. p. 34, 1985 

Amendola A et al: The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med 18: 29-34, 1990 

Bates P: Shin splints: A literature review. Br J Sports Med 19: 132-137, 1985 

Baulduini FC et al: Chronic exertional compartment syndrome: Correlation of compartment pressure and muscle ishaemia utilizing 31P-NMR 

spectroscopy. Clin Sports Med 12: 151-165, 1993 

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Black K, Taylor DE: Current concepts in the treatment of common compartment syndromes in athletes. Sports Med 15: 408-418, 1993 

Breit G et al: Near-Infrared spectroscopy for monitoring of tissue oxygenation of exercising skeletal muscle in a chronic compartment syndrome 

model. JBJS. 79-A: 838-843, 1997 

Ha KL et al: A clinical study of stress fractures in sports activities. Orthopaed 14: 1089-1095, 1991 

Hayes A, Bower G, Pitstock K: Chronic (exertional) compartment syndrome of the legs diagnosed with Thallous Chloride Scintigraphy. J Nucl 

Med 36: 1681-162, 1995 

Kues J: The pathology of shin splints. J Orthop Sports Phys Ther 12: 115-121, 1990 

Martens MA, Moeyersoons JP: Acute and recurrent effort-related compartment syndrome in sports. Sports Med 9: 62-68, 1990 

Martens MA et al: Chronic leg pain in athletes due to a recurrent compartment syndrome. Am J Sports Med 12: 48-151, 1984 

Mohler LR et al: Intramuscular deoxygenation during exercise in patients who have chronic anterior compartment syndrome of the leg. JBJS 

79-A: 844-849, 1997 

Portney LG, Watkins MP, Foundations of Clinical Research, applications to practice. Connecticut: Appleton and Lange pp. 509-515, 1993 

Puranen J, Alavaikko A: Intracompartmental pressure increase on exertion in patients with chronic compartment syndrome in the leg. JBJS 

63A:1304-1309, 1981 

Styf J: The influence of external compression on muscle blood flow during exercise. Am J Sports Med 18: 92-95, 1990 

Takebayashi S et al: Chronic exertional compartment syndrome in lower legs: Localization and follow-up with Thallium-201 SPECT imaging. 

J Nucl Med 1997. 38: 972-976, 1997 

Veith R, Matsen F, Newell S: Recurrent anterior compartmental syndromes. Phys Sports Med 8: 80-88, 1980 

Zwas ST, Elkanovitch R, Frank G: Interpretation and classification of bone scintigraphic findings in stress fracture. J Nucl Med 28: 452-457, 

1987 

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Figure 1: Quantitative analysis of the mean (SD) pixel ratio of the antero-lateral compartment stress images by slice 

Mean pixel ratio 

1.0 

0.9 

0.8 

0.7 

0.6 

0.5 

0.4 

0.3 

0.2 

0.1 

0.0 

1 2 3 4 5 6 7 8 9 10 11 

Slice 

Print 

Index 

Positive CPT 

Negative CPT 


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Investigating lower leg chronic exertional compartment syndrome: A 

prospective comparative trial 

P. Brukner* 1,2 , L. Trease 3 , K. Bennell 1 , M. Kelly 3 , C. Bradshaw 2 & S. Bell 2 

1 Centre for Sports Medicine Research and Education, University of Melbourne 

2 Olympic Park Sports Medicine Centre, Melbourne 

3 Alfred Hospital, Prahran 

INTRODUCTION: Chronic exertional compartment syndrome (CECS) can occur in any fascial enclosed space 

in the body used repetitively for long periods. CECS of the lower leg is of major importance due to its prevalence 

among athletes and its debilitating nature. The aetiology of CECS is incompletely understood, but it is widely 

thought that abnormal increases in intra-muscular pressure during exercise impair local perfusion, thereby 

resulting in tissue ischaemia and pain [1,2,4,6,11,12,15,16,18]. It has been hypothesized that a relatively new 

investigation may be able to detect ischaemia in the context of chronic compartment syndrome. The thallium-201 

SPECT scan, currently used to detect myocardial ischaemia, has been used to investigate a small number of 

CECS patients [9,17]. Results of these studies suggest that the pain of compartment syndrome may be 

associated with ischaemia. Consequently thallium-201 SPECT has been touted as a possible non-invasive 

diagnostic test for the syndrome. 

Many patients with exercise induced lower leg pain will undergo additional diagnostic investigations to exclude 

diagnoses other than CECS. Isotopic bone scintigraphy is currently used to investigate possible bony causes of 

lower leg pain in athletes. However, it has been suggested that there may in fact be a typical ‘linear’ scintigraphic 

uptake appearance in those patients with CECS [10], that is different from the currently recognized focal 

appearance of a stress fracture, and the patchy or diffuse uptake associated with periostitis. 

Thus this study will correlate and compare the results of two potential alternative investigations, thallium-201 

SPECT imaging and bone scintigraphy with compartment pressure testing. With a better understanding of the 

aetiology and diagnosis of CECS, it is anticipated that more effective treatment and prevention strategies could be 

developed for the syndrome. Such developments would allow athletes to continue active participation in their 

sport or return to training more quickly and with fewer complications. 

MATERIALS AND METHODS: The Alfred Hospital Human Research Ethics Committee approved the study. 

All participants provided witnessed informed consent. Participants were eligible for inclusion into the study if they 

were between 18 and 55 years of age and described an exercise related lower leg pain, associated with a 

sensation of fullness or tightness in and around the affected compartment and had firm or tight compartment(s) to 

palpation following exercise. Any participant who had had previous decompressive surgery for CECS was 

excluded because of the unknown pathological consequences of previous surgery within the same compartment. 

There were 24 male and 16 female participants. The mean age of the study group was 29 years. Seven 

patients had unilateral sympto ms and the remaining 33 had bilateral symptoms. There were 15 patients with 

anterior symptomology, and 14 patients with posterior symptomology, the remaining 11 patients presented with 

concurrent anterior and posterior symptoms. Twenty -eight participants (70%) had both the thallium-201 SPECT 

scan and a bone scan. Six participants (15%) consented only to a thallium-201 SPECT scans and six (15%) 

participated only in the bone scan part of the study. Four medical practitioners performed the compartment 

pressure tests using a standard testing protocol. Participants were then divided into two groups on the basis of 

CPT results; those with a negative CPT were classified as ‘controls’ and those with a positive CPT were classified 

as ‘patients’. 

Thallous chloride scintigraphy (thallium-201 SPECT imaging) was performed in the Nuclear Medicine 

Department of The Alfred Hospital, Melbourne, Australia. Thallium-201 SPECT images were analyzed 

quantitatively and qualitatively in a blinded and independent manner. Quantitative analysis was performed. Images 

obtained from an Optima NX Gamma Camera [General Electric Medical Systems, Milwaukee] were reconstructed 

into 11 slices each 12mm in thickness and displayed proximal to distal. Three regions of interest (ROI) were 

demarcated; the antero-lateral compartment, the superficial posterior compartment, and the deep posterior 

compartment. The mean pixel count per ROI and the maximum pixel count per leg were calculated. Quantitative 

data were only analyzed for those compartments and legs with confirmed pressure measurement values. Intraobserver 

reliability was calculated by repeat analysis of 240 slice data sets while inter-observer reliability was 

performed by comparing the analysis of 270 slice data sets with an experienced nuclear medicine technologist. 

Intra-class correlation coefficients for the different compartments were 0.85-0.98 for intra-observer reliability and 

0.82-0.98 for inter-observer reliability indicating excellent agreement [14]. Qualitative analysis was performed by 

two experienced Nuclear Medicine Physicians with a third physician used when there was a discrepancy between 

the readers. Study participants were classified into one of five levels of perfusion in the stress images, and one of 

five levels of redistribution in the rest images. Each compartment on stress imaging was graded as either very 

hypoperfused (1), moderately hypoperfused (2), mildly hypoperfused (3), equally perfused (4) or hyperperfused (5) 

in relation to the other compartments within the same leg. Redistribution images for each compartment were 

graded to have either markedly redistributed (1), moderately redistributed (2) or mildly redistributed (3), remained

unchanged (4) or to have undergone reverse redistribution (5) relative to the stress images. Scans were deemed 

to be positive for a compartment perfusion deficit if they had a summed stress and redistribution score of less than 

or equal to five. 

Bone scintigraphy was performed at The Alfred Hospital Nuclear Medicine Department, Melbourne, Australia 

using a Maxxus Gamma Camera System [General Electric Medical Systems, Milwaukee]. Following injection of 

800 MBq Technetium-99m MDP, the bone scan performed was a standard three-phase procedure with images 

taken at three ti me points. Blood flow and initial uptake images were performed within half an hour of the injection. 

Delayed bone uptake images were performed at least three hours after the injection, when the target to 

background ratio was at a maximum. Interpretation of the bone scan was made using a blinded protocol. 

Comparisons of mean pixel ratios for stress and redistribution in the 11 slices between patients and controls 

were made using a mixed 2x11 analysis of variance. The compartments were combined for these analyses given 

the small numbers. For qualitative thallium-201 SPECT image scores and bone scintigraphy results, comparisons 

between groups were made using Chi square. Comparisons of symptom duration in those with and without linear 

uptake on bone scintigraphy was made using the Mann Whitney U test as the data were not normally distributed. 

An alpha level of p160mmHg), a situation which is to be expected. No participant in this study recorded CPT values higher than 

110mmHg. 

From the results seen in this study, it is apparent that clinically, thallium-201 SPECT imaging would provide 

little diagnostic assistance for suspected CECS cases. Although, it was a very specific investigation for CECS, 

with no false positive results (100% specific), it had extremely low sensitivity and so would not be able to 

distinguish positive CECS cases from actual negatives. 

This study failed to demonstrate a relationship between raised intracompartmental pressure and linear uptake 

on bone scintigraphy. However, as 44% of the controls and 60% of the patients had linear uptake on bone scan it 

is apparent that bony changes are relatively common in this group. Other studies in athletes with stress fractures 

have also noted areas of increased uptake on bone scan at asymptomatic sites [8,19]. It is possible that the 

changes observed on bone scintigraphy in this study are incidental findings and result from the exercise that 

produces or aggravates the patient’s symptoms, but are unrelated to, or independent from the actual cause of their 

pain. Alternatively, some patients may have more than one pathological process occurring concurrently, with both 

CECS and bony pathology contributing to their pain. In those patients with a negative CPT, bone pathology 

consistent with a stress reaction or periostitis could explain their exercise-induced symptoms. Thus, the bone 

scintigraphic appearance is unlikely to be clinically useful as a diagnostic indicator of CECS.

CONCLUSION: The results of this study do not support the hypotheses that ischaemia may be important in 

the aetiology of lower leg CECS and that tension of tight fascia on the periosteal attachment produces 

characteristic bony changes. Further research should focus on identifying the pathologic process and the pain 

mechanisms involved. Given the poor sensitivity of thallium-201 SPECT imaging and bone scintigraphy to 

distinguish between those with and without increased intracompartment pressure, it is recommended that the 

diagnosis of CECS continues to be established based on clinical findings in conjunction with compartment 

pressure testing. 

REFERENCES: 

1. Allen MJ, Barnes MR: Exercise pain in the lower leg. Chronic compartment syndrome and medial tibial 

syndrome. JBJS 1986. 68: 818-823, 1986 

2. Amendola A, Rorabeck CH: Chronic exertional compartment syndrome, in Current Therapy in Sports 

Medicine, Torg JS, Welsh RP, Shepard RJ, Editors. Decker: Toronto, BC. p. 34, 1985 

3. Amendola A et al: The use of magnetic resonance imaging in exertional compartment syndromes. Am J 

Sports Med 18: 29-34, 1990 

4. Bates P: Shin splints: A literature review. Br J Sports Med 19: 132-137, 1985 

5. Baulduini FC et al: Chronic exertional compartment syndrome: Correlation of compartment pressure and 

muscle ishaemia utilizing 31P-NMR spectroscopy. Clin Sports Med 12: 151-165, 1993 

6. Black K, Taylor DE: Current concepts in the treatment of common compartment syndromes in athletes. 

Sports Med 15: 408-418, 1993 

7. Breit G et al: Near-Infrared spectroscopy for monitoring of tissue oxygenation of exercising skeletal 

muscle in a chronic compartment syndrome model. JBJS. 79-A: 838-843, 1997 

8. Ha KL et al: A clinical study of stress fractures in sports activities. Orthopaed 14: 1089-1095, 1991 

9. Hayes A, Bower G, Pitstock K: Chronic (exertional) compartment syndrome of the legs diagnosed with 

Thallous Chloride Scintigraphy. J Nucl Med 36: 1681-162, 1995 

10. Kues J: The pathology of shin splints. J Orthop Sports Phys Ther 12: 115-121, 1990 

11. Martens MA, Moeyersoons JP: Acute and recurrent effort-related compartment syndrome in sports. 

Sports Med 9: 62-68, 1990 

12. Martens MA et al: Chronic leg pain in athletes due to a recurrent compartment syndrome. Am J Sports 

Med 12: 48-151, 1984 

13. Mohler LR et al: Intramuscular deoxygenation during exercise in patients who have chronic anterior 

compartment syndrome of the leg. JBJS 79-A: 844-849, 1997 

14. Portney LG, Watkins MP, Foundations of Clinical Research, applications to practice. Connecticut: 

Appleton and Lange pp. 509-515, 1993 

15. Puranen J, Alavaikko A: Intracompartmental pressure increase on exertion in patients with chronic 

compartment syndrome in the leg. JBJS 63A:1304-1309, 1981 

16. Styf J: The influence of external compression on muscle blood flow during exercise. Am J Sports Med 18: 

92-95, 1990 

17. Takebayashi S et al: Chronic exertional compartment syndrome in lower legs: Localization and follow-up 

with Thallium-201 SPECT imaging. J Nucl Med 1997. 38: 972-976, 1997 

18. Veith R, Matsen F, Newell S: Recurrent anterior compartmental syndromes. Phys Sports Med 8: 80-88, 

1980 

19. Zwas ST, Elkanovitch R, Frank G: Interpretation and classification of bone scintigraphic findings in stress 

fracture. J Nucl Med 28: 452-457, 1987

Figure 1: Quantitative analysis of the mean (SD) pixel ratio of the antero-lateral compartment stress images by 

slice 

Mean pixel ratio 

1.0 

0.9 

0.8 

0.7 

0.6 

0.5 

0.4 

0.3 

0.2 

0.1 

0.0 

1 2 3 4 5 6 7 8 9 10 11 

Slice 

Positive CPT 

Negative CPT

Investigating lower leg chronic exertional compartment syndrome: A ...

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