Management of chronic exertional compartment syndrome and fascial hernias in the anterior lower leg with the forefoot rise test and limited fasciotomy.

BACKGROUND: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart. METHODS: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years. RESULTS: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation). CONCLUSION: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Relationship between lower extremity alignment and hallux valgus in women.

BACKGROUND: Most previous studies on hallux valgus focused on the possible relationship between this deformity and muscles and/or ligaments in the foot and lower leg. Very little is known about the relationship between hallux valgus and alignment of the proximal joints. The aims of the present study were to determine the extent to which lower extremity alignment characteristics of the hip, knee, ankle, and foot were related to the manifestation of hallux valgus and to identify variables predicting its development in women. METHODS: A group of 25 women with hallux valgus and 24 control women, age 51 to 80 years, were interviewed and screened for the current study. Measurements recorded were hallux valgus angle; intermetatarsal angle; a set of body physique measures (eg, height); range of motion at the hip, knee, ankle, and foot joints; general hypermobility; lower extremity alignment (eg, tibiofemoral angle); and 9 anatomical anomalies (eg, knee valgus/varum). RESULTS: Women with hallux valgus manifested notably higher range of motion at their joints, different lower extremity alignment, higher prevalence of general joint hypermobility, and higher prevalence of anatomical anomalies compared with controls. Estimated marginal means for most joint range of motion and lower extremity alignment measurements were notably higher for the hallux valgus group. CONCLUSION: Lower extremity alignment and joint range of motion were correlated with hallux valgus. Future studies could possibly identify anatomic risk factors for the development of hallux valgus, nonsurgical methods of prevention and adjunctive surgical methods of treatment. LEVEL OF EVIDENCE: Level III, comparative case series.