Treating Compartment Syndrome Without Surgery: One Skier’s Season

Author’s note: From the PT: a Look at Chronic Exertional Compartment Syndrome is a good introduction to the current article and includes a more detailed description of the anatomy, pathophysiology, and associated research. Since it was published on FasterSkier in 2022, that article has served as a resource for the Nordic skiing community, and I have fielded multiple requests for guidance from skiers around the world with CECS. In that article, I suggested that conservative treatment has potential; however, I was still more optimistic about surgical intervention based on the available research. The published research hasn’t changed, but my experience has, and now I’d like to make the case for non-surgical treatment of CECS. As with any medical information found on the internet, this article should be taken as the opinion of the author and not a replacement for direct consultation with a medical provider.

The primary symptoms of Chronic Exertional Compartment Syndrome (CECS) include pain, weakness, and/or numbness that only occurs with exertion. These characteristics are fairly distinct, although there can be enough overlap with other soft tissue disorders, namely tendinopathies, that CECS remains a diagnosis of exclusion when everything else has been ruled out. In Nordic skiers, symptoms affect the anterior, lateral, and/or posterior compartments of the lower legs and are most common with (often exclusive to) skating. Typically, or at least initially, these skiers will be symptomatic with high-intensity skating, but will be asymptomatic with classic skiing and running even at the same intensity.

The physiology is relatively straightforward: our muscles are wrapped in a thin layer of connective tissue called fascia. As muscles repeatedly contract, especially at high intensities, they become enlarged; however, fascia is not elastic and does not stretch. If the muscle size exceeds the volume of the fascial compartment, blood flow is constricted, oxygen delivery is decreased, and the muscle gets strangled. This hypoxia in the muscle triggers a pain response, which is usually a good defense mechanism to make us stop doing something that the body perceives as harmful.

The why is far more complex: some theorize that the fascia is just wrapped too tightly. Others suspect that the muscles are too big for the fascia. In either case, the common solution is a surgical fasciotomy where an incision is made in the fascia to increase the size of the compartment and decrease its stranglehold on the muscle.

The why with skiing is even more complex. With CECS occurring with skate vs. classic, the initial theories centered around the ski retrieval phase. This makes sense with the work being done by the tibialis anterior muscle, which dorsiflexes the ankle while the ski is brought back to its glide phase position. Except that CECS can affect other lower leg muscles/fascial compartments which would not be active during the retrieval phase. Arguably the biggest difference between skate and classic techniques, at least as far as the muscles of the lower leg are concerned, is the stability demand of balancing on the gliding ski: the muscles must work much harder with skating.

A case study

The patient in our story is an 18-year-old male skier. He is a very competitive skier regionally and would have qualified for Junior Nationals had his skate races not been disrupted by leg pain. We had our initial physical therapy visit in mid-January, mid-race season. He reported pain, progressing to numbness, in both shins, which only occurred during high-intensity skate skiing. Symptoms were first noticed the previous winter during a skate race in icy conditions, but he didn’t have any additional episodes for the remainder of that season or during the summer. In October, however, symptoms returned during a skate interval session, persisted with any high-intensity skating, and got progressively worse through the race season. He was unable to finish his last skate race due to severe pain.

In physical therapy exams and diagnostics, we are keen on reproducing patients’ symptoms. If we can do this in specific ways, we can begin to rule in or rule out anatomical structures which may be involved. For better or worse, I was unable to reproduce the patient’s symptoms in the clinic. This would likely rule out a muscle strain or tendinopathy, both of which tend to be painful with resisted tests (assuming we can make the tests both hard enough and specific enough). Differential diagnosis still included lumbar radiculopathy (nerve irritation at the spine leading to symptoms in the leg) or a bone stress injury (a.k.a. stress fracture), but neither of these fit the picture of symptoms being exclusive to high-intensity skating and absent at rest or especially with other modes of exercise. The symptoms really fit the pattern of CECS. To confirm, the gold-standard diagnostic would be compartment pressure testing; however, this testing is quite painful, fairly inconvenient (unless you have a rollerski treadmill in the clinic), and primarily aimed at determining if the patient is a candidate for surgery. Since this patient was looking to salvage his race season and avoid, or at least delay, surgery, we opted to skip the pressure testing but assumed that he was dealing with CECS.

The remainder of the physical exam focused on ski technique, or at least the static components we could observe in the clinic: hip strength (fair), balance (compensated with lateral trunk lean), ankle dorsiflexion range of motion (appropriate), and foot stability (notable flexibility and forefoot varus). These findings were significant enough to suspect that the patient’s lower leg muscles were working very hard to maintain balance on his glide ski. The hip weakness and compensated single-leg balance made me suspect that if he was lacking stability from the top down, then he was having to work much harder from the bottom up, thus overloading the muscles at the ankle and leading to CECS.