Best Practice Case Studies-Chronic Exertional Compartment Syndrome

Video Transcription

This is Barry Bailosis, one of the musculoskeletal radiology fellows at Stanford University. 16-year-old female soccer player presents with bilateral exertional lower leg pain.  Concerned for chronic exertional compartment syndrome. Chronic exertional compartment syndrome could be evaluated by measuring the pressure of the compartment of the calves.  If there is contraindication, MRI calf without contrast is usually done to evaluate for other possible mimics,  such as medial tibial stress syndrome or stress fracture, any tendinopathy of the calf, deep vein thrombosis, or possible popliteal artery entrapment syndrome.  This is a different patient who had MRI calf without contrast on a runner with anterior tibial pain.  We use the Fredrickson classification when evaluating for medial tibial stress syndrome. Fredrickson classification is graded 0 to 4, and it evaluates for periosteal edema,  marrow edema, any intracortical signal changes, or any presence of linear region of intracortical signal change.  So for this patient, we can see this periosteal edema as characterized by this T2 hyperintensity, also some intracortical signal change, and some bone marrow edema.  The patient does not have any signal abnormality of the calf muscles, arguing against the presence of exertional compartment syndrome in this specific patient.  Exertional compartment syndrome would typically present with muscle hyperintensity on our fat suppress imaging,  with or without muscular swelling, and it would typically involve one or more compartment. It can also occur simultaneously with the presence of medial tibial stress syndrome.  This is on a different patient who presented with medial tibial pain. Here on our patient, we can see this periosteal edema as characterized by this increased signal,  and increased intracortical signal changes. No appreciable bone marrow edema on this patient. On our T1, we do not see any signal abnormality in the marrow.  When evaluating for the stress fracture or medial tibial stress syndrome, we just want to make sure that the signal abnormality along the cortex is not a vessel,  and we determine that by following it and scrolling through the images, and make sure that it's not a vessel running around the area.  We evaluate for any muscle signal abnormalities such as atrophy or fatty infiltration, but we do not see that on this patient.

Video Summary

A 16-year-old female soccer player experienced bilateral exertional lower leg pain, suspected to be chronic exertional compartment syndrome. Diagnosis can involve measuring calf compartment pressure or using MRI without contrast to rule out conditions like medial tibial stress syndrome, stress fractures, or tendinopathy. The Fredrickson classification assesses medial tibial stress syndrome, focusing on periosteal edema, marrow edema, and intracortical changes. The MRI indicates periosteal edema without significant muscle signal abnormalities, ruling out exertional compartment syndrome. For stress fractures or medial tibial stress syndrome, it's critical to differentiate cortex signal abnormalities from vessels by careful image analysis.

Meta Tag

Edition 2nd Edition

Related Case 2nd Edition, CASE 36

Topic Metabolic Disorders

Keywords

2nd Edition, CASE 36

2nd Edition

Metabolic Disorders

chronic exertional compartment syndrome

medial tibial stress syndrome

MRI diagnosis

periosteal edema

stress fractures