Chronic Exertional Compartment Syndrome in the Forearm of a Collegiate Softball Pitcher

Abstract

BackgroundChronic exertional compartment syndrome (CECS) is a recognized condition in the lower limb, with many reports in the literature. However, very few instances include CECS of the upper limb. This article presents the case of a collegiate softball pitcher presenting with CECS in her right forearm. To our knowledge, this is the first case report of a softball player with CECS, with only one similar incident in a major league baseball player.PurposeThe rarity of this condition normally places it low on the differential diagnosis. However, we hope that the presentation of this case and the review of the literature will aid in making swift and accurate diagnoses of CECS in future patients. We discuss the importance of three specific modalities in the diagnosis of this patient, what diagnostic criteria proved less conclusive, and the paradoxical course the syndrome presented with.Study DesignCase ReviewResultsOver a six-month period, the patient presented with peculiar presentations and exam results. A broad list of differential diagnoses had to be narrowed down through the presence or absence of relevant findings. These included cessation of exercise for 1 month, physical therapy, anti-inflammatory medicines, an electromyography/electromyogram (EMG), nerve conduction study (NCS), non-exercise magnetic resonance imaging (MRI) of the forearm, cervical MRI, and cervical computed tomography (CT) angiogram. After the above interventions were attempted and the relative findings of three important modalities were summarized, a fasciotomy and release of the dorsal, volar, and mobile wad compartments was performed. The patient’s symptoms were relieved, and she eventually returned to full play in softball at the university.ConclusionsThe three diagnostic criteria we believed to be most helpful in this case, and for future cases of CECS in the forearm, include the clinical presentation, pre- and post-exercise MRI, and pre- and post-exercise compartment pressure measurements.Clinical RelevanceChronic exertional compartment syndrome of the forearm is extremely rare, especially in the female athlete. This case report and review of the literature may be helpful to the clinician facing similar cases. It describes which clinical tests are most helpful for diagnosis and which findings may be distracting.

MRI findings in chronic exertional compartment syndrome of the forearm: Using signal intensity ratio as a diagnostic tool

“…2,4,7,8,10,11,12,14,15 The pathophysiology of the condition remains incompletely understood but is based on the premise of raised intra-compartmental pressures within a relatively rigid fascial compartment, causing reduced tissue perfusion and subsequent ischaemia. 2,8,15,16,17,18,19,20 During exercise, it is normal for intra-compartmental pressures to rise; however, this increased pressure does not usually cause symptoms or altered tissue oxygenation as in patients with CECS. 2,9,19 Patients with CECS have relatively greater increases in pressure and these pressures also take longer to return to normal after cessation of exercise.…”

“…MRI scanning has been utilised for the past 30 years in the diagnosis of CECS, with numerous studies and case reports published at testing to its usefulness. 4,9,13,16,17,19,26,27,28,29 Despite the relatively strong evidence for the use of a prepost exercise MRI protocol in CECS, no standardised methods regarding exact exercise protocols and imaging acquisition have been published. 6,15,17,26,28,30 Furthermore, in the absence of T2W mapping software, signal intensity (SI) is graded subjectively, presenting the possibility for greater inter-observer variations.…”

“… 2 , 4 , 7 , 8 , 10 , 11 , 12 , 14 , 15 The pathophysiology of the condition remains incompletely understood but is based on the premise of raised intra-compartmental pressures within a relatively rigid fascial compartment, causing reduced tissue perfusion and subsequent ischaemia. 2 , 8 , 15 , 16 , 17 , 18 , 19 , 20 …”

“…MRI scanning has been utilised for the past 30 years in the diagnosis of CECS, with numerous studies and case reports published at testing to its usefulness. 4 , 9 , 13 , 16 , 17 , 19 , 26 , 27 , 28 , 29 …”

Spontaneous compartment syndrome of all limbs: A case report

“…These conditions included diabetes mellitus, the use of anticoagulants, hypothyroidism, leukemic infiltrations, and nephrotic syndrome. [2,5,7] These chronic conditions can cause edema and swelling in a given compartment, leading to compartment syndrome development. [3] There are some theories in multiple case reports correlating compartment syndrome with the use of medications such as non steroidal anti-inflammatory drugs (NSAIDs) (Diclofenac).…”