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 DOI: 10.1177/0363546514555970

2015 43: 392 originally published online November 18, 2014Am J Sports MedDavid Roscoe, Andrew J. Roberts and David Hulse

New and Improved Diagnostic CriteriaIntramuscular Compartment Pressure Measurement in Chronic Exertional Compartment Syndrome:

  

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Intramuscular Compartment PressureMeasurement in Chronic ExertionalCompartment Syndrome

New and Improved Diagnostic Criteria

David Roscoe,*yz§ MRCGP, MFSEM(UK), MSc(SEM), DipIMC RCSEd, MPA,Andrew J. Roberts,y|| MSc, and David Hulse,y MB ChB, MSc, FFSEM(UK)Investigation performed at the Defence Medical Rehabilitation Centre (Headley Court),Epsom, UK

Background: Patients with chronic exertional compartment syndrome (CECS) have pain during exercise that subsides with rest.Diagnosis is usually confirmed by intramuscular compartment pressure (IMCP) measurement. Controversy exists regarding theaccuracy of existing diagnostic criteria.

Purpose: (1) To compare dynamic IMCP measurement and anthropometric factors between patients with CECS and asymptom-atic controls and (2) to establish the diagnostic utility of dynamic IMCP measurement.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: A total of 40 men aged 21 to 40 years were included in the study: 20 with symptoms of CECS of the anterior compart-ment and 20 asymptomatic controls. Diagnoses other than CECS were excluded with rigorous inclusion criteria and magneticresonance imaging. The IMCP was measured continuously before, during, and after participants exercised on a treadmill, wearingidentical footwear and carrying a 15-kg load.

Results: Pain experienced by study subjects increased incrementally as the study progressed (P\ .001). Pain levels experiencedby the case group during each phase of the exercise were significantly different (P = .021). Subjects had higher IMCP immediatelyupon standing at rest compared with controls (23.8 mm Hg [controls] vs 35.5 mm Hg [subjects]; P = .006). This relationship per-sisted throughout the exercise protocol, with the greatest difference corresponding to the period of maximal tolerable pain(68.7 mm Hg [controls] vs 114 mm Hg [subjects]; P \ .001). Sensitivity and specificity were consistently higher than the existingcriteria with improved diagnostic value (sensitivity = 63%, specificity = 95%; likelihood ratio = 12.5 [95% CI, 3.2-49]).

Conclusion: Anterior compartment IMCP is elevated immediately upon standing at rest in subjects with CECS. In patients withsymptoms consistent with CECS, diagnostic utility of IMCP measurement is improved when measured continuously during exer-cise. A cutoff of 105 mm Hg in phase 2 provides better diagnostic accuracy than do the Pedowitz criteria of 30 mm Hg and20 mm Hg at 1 and 5 minutes after exercise, respectively.

Keywords: exercise-induced leg pain; chronic exertional compartment syndrome; intramuscular compartment pressure; diagno-sis; anthropometric factors.

Exercise-induced leg pain accounts for a significant clinicalburden for those practitioners dealing with militaryrecruits, service personnel, and athletes in running andjumping sports.8,29,37,39 The phenomenon of chronic exer-tional compartment syndrome (CECS) was first describedas a distinct clinical entity in 1956, and the typical historyand symptoms were subsequently matched to a demonstra-ble rise in intramuscular compartment pressure (IMCP) in1962.18

Exercise-induced leg pain typically occurs with a non-specific description of pain in the lower leg, presentinga diagnostic challenge to the practitioner.8,16,29,35,38,40,42

The patient with CECS usually reports pain on exercisethat is relieved by rest, with subsequent examination ofthe patient typically normal.5,18,21 Commonly seen bilater-ally,14,35,42,46 CECS has subsequently been defined asa painful condition in which exercise induces high pressurewithin a closed myofascial space, resulting in a decrease intissue perfusion and ischemia. It is sometimes accompa-nied by temporary neurologic impairments.8,13,29,31,38,39

This definition is not universally accepted, and the under-lying pathophysiology has not been confirmed.3,6,18,32 Thepain of CECS commonly subsides over a period of minutes

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on cessation of activity.14,35,37,42,49 It is common to heara description of fullness, tightness, or increased girthover the anterolateral aspect of the leg.5,14,18,19,21 Little iscurrently known about any predisposing morphologic dis-criminators that might exist between patients with CECSand healthy controls.

Various studies estimate the prevalence of CECS inpatients with exercise-induced leg pain as ranging from10% to 60% depending on the diagnostic criteria adopted,although it has been suggested to be even higher in mili-tary populations.27,39,46,51 In a retrospective study of 150athletes with exercise-induced leg pain, CECS was themost common condition, representing 34% of cases; stressfracture of the tibia accounted for 25% and medial tibialstress syndrome, 13%.8 In a popular paper describinga diagnostic protocol for CECS, Pedowitz et al36 demon-strated CECS by associating invasively measured IMCPrises with a typical clinical picture in 45 of 131 (34%)patients with exercise-induced leg pain. This was thenused to generate their widely used criteria for the diagno-sis of CECS, using IMCP rises measured at discrete timepoints before (supine) and after an exercise challenge4,49:before exercise, .15 mm Hg; 1 minute after exercise,.30 mm Hg; 5 minutes after exercise, .20 mm Hg.36 Intypical clinical practice worldwide, the exercise challengeis not standardized.22,49

Based on unpublished data at this institution, medialtibial stress syndrome, stress fracture, and referred neuro-genic pain from proximal sites form the bulk of exercise-induced leg pain cases in the UK military population,with CECS contributing less. Popliteal artery entrapmentmay occasionally masquerade as CECS.33,37,44 Recently,there has been discussion of the role of lower limb biome-chanics in the origin of this condition. Evidence to supportthis is sparse; however, there has been some reported suc-cess in the development of nonoperative treatments forwhat has traditionally been a surgical problem.12,17,28,40

To date, no consensus has been reached regardinga standardized symptom-provoking exercise protocol orthe timing and levels of IMCP considered diagnostic.49

Recent systematic reviews of the published literaturehave questioned the validity of the existing criteria in con-firming the diagnosis of CECS through IMCP and high-lighted the lack of control and normative IMCP data.2,43

MATERIALS AND METHODS

Twenty consecutive men with symptoms consistent withCECS of the anterior compartment of the leg and 20asymptomatic controls were recruited. The diagnosis ofCECS was established from typical symptoms, with clini-cal examination and magnetic resonance imaging

excluding all other injuries. Cases were recruited fromthe Lower Limb Pain clinic at the Defence Medical Reha-bilitation Centre, Headley Court. Controls were recruitedfrom the UK armed forces. All participants gave informedconsent. Ethical approval was granted by the Ministry ofDefence Research Ethics Committee.

The inclusion criteria were as follows: men aged 18 to 40years (representing the typical age range of UK military ser-vice personnel), body mass index \35, and no lower limblength discrepancy .2 cm. Subjects required the following:symptoms of exercise-induced leg pain consistent with a diag-nosis of anterior compartment CECS, a negative magneticresonance image of the affected limb(s) and lumbar spine,no diagnosis other than CECS more likely, absence of multi-ple lower limb injuries, and no previous lower limb surgery.Healthy controls were included when they had no lowerlimb pain in previous 12 months, no current pain at anysite (including during exercise activities), and no relianceon orthotics and were able to run for up to 20 minutes.

Dynamic Compartment Pressure Testing

Hair was removed and skin cleansed with alcohol at theinsertion site 3 cm distal and 3 cm lateral to the tibialtuberosity before infiltration of the overlying skin with10 mL of 1% lidocaine local anesthetic. A precalibratedelectronic Millar Mikro-Cath catheter wire was insertedinto the tibialis anterior muscle.

Participants were placed in a supine position with theknee extended and the ankle in neutral dorsiflexion. Thecatheter was then inserted at 30� to 45� to the skin in aninferior direction via a modified Seldinger technique.45

The tip was advanced to lie in the center of the musclebelly approximately 3 cm beyond the point of penetrationof the fascia where a large body of uniform pressure hasbeen shown to exist.25 Tip location was then checkedthrough manual palpation of the overlying muscle. Repro-ducibility of pressure changes was checked with singleactive and passive dorsiflexion and plantar flexion of theankle before securing of the catheter to the leg with noncir-cumferential adhesive tape for dynamic studies (Figure 1).Testing did not commence until any negative pressureartefact, which can be associated with transducer-tippedcatheters,47 had disappeared on muscle contraction.

Participants then followed a standardized exercise pro-tocol wearing identical military-issue running shoes (Sil-ver Shadow; Hi-Tec) with IMCP recorded throughout thefollowing phases:

A. Resting supine for 2 minutes.B. Standing in a relaxed resting state for 30 seconds.C. Exercising on a treadmill (Woodway Desmo) according

to the following protocol:

*Address correspondence to David Roscoe, MRCGP, MFSEM(UK), MSc(SEM), DipIMC RCSEd, MPA, Academic Department of Military Rehabilitation,Defence Medical Rehabilitation Centre (Headley Court), Epsom, Surrey, KT18 6JW, UK (e-mail: dave.roscoe314@mod.uk).

yAcademic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (Headley Court), Epsom, UK.zCentre for Biomedical Engineering, University of Surrey, Guildford, UK.§Institute of Naval Medicine, Gosport, UK.||Department of Sport and Health Sciences, University of Exeter, Exeter, UK.

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

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1. Carrying a standard military-issue 15-kg weightedbackpack wearing their usual footwear, walkingpace set at 6.5 km/h for 5 minutes on a level treadmill.

2. Carrying 15-kg backpack, the treadmill inclineincreased to 5%, and walking pace set at 6.5 km/hfor 5 minutes.

3. Backpack weight removed, treadmill incline set at5%, and running pace set at 9.5 km/h for 5 minutes.

D. Resting supine for 5 minutes after exercise recovery.

Participants were encouraged to continue for as long astolerated but were allowed to terminate the test at anytime. Pain scores were recorded every minute for eachleg with a numerical rating scale of 0 (no pain) to 10 (worstpain imaginable). On completion of the exercise challenge,participants lay supine in a relaxed position for 5 minutes.During this time, they were asked to focus on relaxingtheir leg muscles. At the end of this time, the catheterswere removed. Participants were monitored throughoutfor bleeding from the catheter site.

The mean IMCP was calculated for each phasedescribed above via a custom Labchart script (ADInstru-ments). The mean pressure over a 5-second period at 1minute and 5 minutes after exercise was recorded. Themaximum pain score experienced during each phase wasused for analysis. If participants stopped early, only com-pleted periods were used.

Anthropometric Assessment

Measurements of height, leg length, calf girth (10 cm distalto the tibial tuberosity), and body mass were performedwith a stadiometer (SECA), tape measure, and medicalgrade scales (SECA), respectively. The same operator,using the same landmarks and techniques, assessed allsubjects. Calf girth measurement was repeated throughthe same landmarks 90 seconds after exercise.

Statistical Analyses

Descriptive statistics were obtained for all variables. All val-ues are described as mean 6 SD unless otherwise stated.

Independent t tests were carried out on parametric varia-bles to compare variables between groups. The assumptionof equal variance was determined with the Levene test,with the result adjusted if significant.

There is some debate regarding the best way to analyzetrials measuring the same variable on both sides of thebody. As such, separate pressure variables for the rightand left legs were analyzed in each of the 4 possible permu-tations. Left and right legs were then also combined foranalysis. There were no differences in the results of thetests for any permutation or for the combined leg data. Val-ues for the left leg only were thus chosen as representativevalues for reporting.

Differences in pain experienced during each phase weretested with a repeated measures analysis of variance, follow-ing tests for normality and sphericity. The Tukey honestlysignificant difference test was used for post hoc comparisons.The Greenhouse-Geisser correction was used to adjust fordeviance from sphericity.

A forward stepwise logistic regression, based on the pre-dictors detailed above, was carried out to determine thebest pressure variable(s) that could predict group member-ship. The statistic (likelihood ratio, Wald statistic, and con-ditional statistic) used in the test for variable removal didnot affect the final model. Again, all permutations weretested and did not affect the variable in the final model.Goodness of fit was assessed with the Hosmer and Leme-show test. A range of pseudo R2 values (the Cox and Snelland the Nagelkerke) were reported to give an idea of thepower of the prediction. Inclusion of a constant in themodel improved the model significantly. This final modelwas reported.

Receiver operating characteristic curves were con-structed for each variable identified by the t tests to deter-mine specificity and sensitivity (left and right combinedonly). The area under the curve was calculated as an indi-cator of overall diagnostic ability and classified accordingto Tape.48 Optimal cutoffs were generated to maximizethe sum of sensitivity and specificity, with a minimum of60% set for each measure. In the case of a tie, the cutoffvalue with the highest specificity was selected.

Alpha for all analyses was set to 0.05. SPSS (v20; SPSSInc) was used for all analyses.

RESULTS

Participants were recruited between July 2012 and June2013. All participants were men. None declined participa-tion. Study subjects ranged in age between 21 and 40 years(mean, 27.5 6 4.9 years); controls were between 19 and 40years (mean, 28.3 6 7.4 years).

Compartment Pressure Testing

All participants completed the exercise protocol to the end orthe point of maximal pain. Only 7 subjects were able to com-plete the full graduated exercise challenge, as most (n = 13)experienced significant provocation of their symptoms. Foursubjects stopped early because of pain during exercise phase

Figure 1. Final wire placement in anterior compartment,secured in place for dynamic intramuscular compartmentpressure testing.

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2; a further 9 stopped during exercise phase 3. Two controlshad to be stopped early during exercise phase 3 for reasonsunrelated to equipment or symptomatology.

All subjects and 3 controls described some degree ofpain during the first phase in at least 1 leg. All subjectsand 2 controls described some pain during the phases 2and 3 in at least 1 leg. The levels of pain experienced bythe patient group during each phase of the exercise weresignificantly different (F = 5.568, df = 1.33, P = .021).Post hoc tests demonstrated that pain in the patient groupsignificantly increased between the first and secondphases, from 3.4 6 2.0 to 5.1 6 2.6 (P \ .001), and signifi-cantly decreased between phase 2 and phase 3 to 2.94 6 2.4(P = .04).

There were no significant differences between groupsfor pre-exercise supine IMCP in either leg. The patientgroup had significantly higher IMCP in standing at restpre-exercise, during all exercise phases, and at both 1and 5 minutes after exercise. These are summarized inTable 1, and representative curves are shown in Figure 2.

Logistic regression demonstrated that mean pressureduring exercise phase 2 was the best predictor of groupmembership. No other variables added any additional pre-dictive value and were not entered into the logistic regres-sion model (Table 2). The goodness-of-fit test indicated that

the logistic regression model does not misrepresent thedata (P = .360).

Diagnostics

Areas under the receiver operating characteristic curveranged from 0.678 (95% CI, 0.555-0.802; ‘‘poor’’ predictivevalidity) for IMCP after supine 5 minutes to 0.845 (95%CI, 0.762-0.928; ‘‘good’’ predictive validity) for IMCP dur-ing exercise phase 2 (Figure 3). Optimal cutoff valuesand indices of diagnostic accuracy for each phase, withcomparison to the results according to the Pedowitz

TABLE 1Comparisons Between Pressure Variablesa

Pre-exercise Exercise Postexercise, Supine

IMCP Supine Standing Phase 1 Phase 2 Phase 3 1 min 5 min

Controls 14.7 6 4.3 23.8 6 10.6 61.2 6 23.4 68.7 6 22.0 50.2 6 18.4 18.8 6 7.9 14.4 6 6.5Subjects 15.2 6 5.2 35.5 6 14.8 97.1 6 26.6 114.1 6 32.2 91.4 6 40.0 33.9 6 26.3 26.1 6 19.9P .747 .006 \.001 \.001 \.001b .023b .020b

aValues are reported as mean 6 SD (mm Hg). IMCP, intramuscular compartment pressure.bAn adjusted value was used.

Figure 2. Representative intramuscular compartment pressure curves: (A) from healthy control subject, (B) from chronic exer-tional compartment syndrome case.

TABLE 2Logistic Regression Analysis Results: Left Lega

PredictorbRegression

Coefficient (SE)Wald

StatisticOddsRatio

IMCP exercise, phase 2 0.057 (0.018) 9.736 1.058Intercept 25.033 (1.622) 9.625 0.007

aPseudo R2 = 0.411-0.549. IMCP, intramuscular compartmentpressure.

bFor each predictor, df = 1, P = .002.

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criteria for these data, are described in Table 3. A cutoff of105 mm Hg in phase 2 provides better diagnosticaccuracy than do the Pedowitz criteria of 30 mm Hg and20 mm Hg at 1 and 5 minutes after exercise, respectively.

Anthropometrics

Study subjects were significantly shorter than controls(1.71 6 0.13 vs 1.81 6 0.06 m; P = .002), although therewere no differences in weight or height:leg length ratio.There were no significant differences in pre-exercise calfgirth between groups or the change in calf girth beforeand after exercise.

DISCUSSION

Recent systematic reviews have questioned the validity ofpreviously published IMCP criteria used to diagnoseCECS and have highlighted methodological limitations inhow the criteria were derived.2,43 This study has addressedthose limitations by only performing dynamic IMCP meas-urements on prospectively identified cases and controlsafter reasonable exclusion of other possible diagnoses viaclinical history, examination, and magnetic resonanceimaging. The results provide new diagnostic IMCP recom-mendations with superior diagnostic utility for the investi-gation and diagnosis of CECS.

A novel finding of elevated IMCP in the pre-exercisestanding state was also demonstrated that provides fur-ther insight to the underlying pathologic lesions, and a con-ceptual model of the pathophysiology of CECS, taking intoaccount historical perspectives, is presented.

Diagnosis of CECS

Currently, in most centers,2,4,43 where pressure measure-ment is undertaken at all, IMCP is measured only at restand after exercise, depending on local protocols.47 Thetechnique allows for dynamic assessment to be undertakenso that changes in IMCP can be matched to symptom

propagation during a standardized exercise challenge, usu-ally on a treadmill.7,11,30,34 To overcome the technical diffi-culties relating to the dynamic measurement of IMCP, anelectronic catheter system was used, as it has been shownto be as reliable as traditional fluid-filled measuring sys-tems, with less artifact and test failure.50

The exercise protocol designed at the Defence MedicalRehabilitation Centre and adopted in this study wasdesigned to maximally reproduce symptoms in the patientgroup; consequently, most members of this group wereunable to complete the full protocol. This authenticatesthe utility of this approach by accurately replicating theexercise conditions and intensity at which military sub-jects develop symptoms of CECS. The findings demon-strate that phase 2 provides the best diagnostic criteria.However, it is not clear whether this is due to the reproduc-tion of maximal pain or the use of an incline.

The results demonstrate a greater physical demand,mirrored in IMCP measurements, from loaded militarymarching compared with load-free running. This reflects

1 - Specificity1.00.80.60.40.20.0

Sens

itivi

ty

1.0

0.8

0.6

0.4

0.2

0.0

Figure 3. Receiver operating characteristic (ROC) curve forexercise phase 2.

TABLE 3Optimal Cutoff Points and Their Associated Diagnostic Indicesa

OptimalCutoff, mm Hg Sensitivity, % Specificity, %

PositiveLikelihood Ratio

NegativeLikelihood Ratio

Pre-exercise standing 31 68 (52-80) 83 (68-91) 3.9 (1.9-7.8) 0.39 (0.25-0.63)Exercise

Phase 1 80 70 (55-82) 80 (65-90) 3.5 (1.8-6.7) 0.38 (0.23-0.62)Phase 2 105 63 (47-76) 95 (84-99) 12.5 (3.2-49) 0.39 (0.27-0.59)Phase 3 72 65 (50-78) 83 (68-91) 3.7 (1.8-7.6) 0.42 (0.27-0.66)

Postexercise supine, 1 min 24 63 (50-74) 71 (58-81) 2.2 (1.4-3.4) 0.53 (0.36-0.77)Pedowitz criteria equivalentb 30 50 (35-65) 89 (76-96) 4.8 (1.8-12.7) 0.56 (0.40-0.78)

Postexercise supine, 5 min 19 62 (46-75) 65 (49-78) 1.8 (1.1-2.9) 0.59 (0.38-0.93)Pedowitz criteria equivalentb 20 56 (41-71) 70 (55-82) 1.9 (1.1-3.3) 0.62 (0.41-0.93)

During all exercise 89 63 (47-76) 90 (77-96) 6.3 (2.4-16) 0.42 (0.28-0.63)

aParentheses indicate 95% CI.bAccording to Pedowitz et al.36

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the anecdotal experience of study participants and thewider military population. This can also be inferred fromthe reduction in pain and IMCP levels that occurredbetween phases 2 and 3 of the protocol. This increaseddemand likely contributes significantly to the higher prev-alence of exercise-induced leg pain and CECS reported inmilitary populations.9

Contrary to previous assertions, we have demonstratedrelatively poor validity of the widely adopted Pedowitzcriteria,22,36,49 where IMCP measurement is made at singletime points in the pre- and postexercise phases. Using contin-uous dynamic IMCP measurement, with an indwellingtransducer-tipped catheter, avoids the requirement for multi-ple needle insertions24 and proved to be well tolerated, withdata capture that was reliable, extensive, and not prone tothe same artifact and technical issues associated with fluid-filled devices in a dynamic situation.2,24 This study demon-strates that the greatest diagnostic validity was achievedduring the exercise phases of the protocol (Table 3) ratherthan after exercise, as has been postulated.22 These resultsfurther suggest that no additional diagnostic power is gainedfrom combining multiple time points for diagnosis.

These data suggest that the diagnosis of CECS should bemade via dynamic IMCP measurement, with an indwellingelectronic catheter system, after prior exclusion of alterna-tive or overlapping injuries, in line with the inclusion crite-ria of this study. Exercise should be continued beyond 5minutes and, ideally, until maximal tolerable symptomsare provoked. This reveals the greatest diagnostic certaintyand correlates with the highest measured IMCP.

When dynamic IMCP is used in this manner, we recom-mend a diagnostic cutoff value of 105 mm Hg. Based on thisapproach, our data demonstrate a positive likelihood ratio of12.5, which can be considered diagnostically conclu-sive.10,20,40,41 Our diagnostic cutoff was higher than thosepreviously proposed during exercise (50 mm Hg [Puranen,38

Allen and Barnes1] and 85 mm Hg [McDermott et al30]) butfalls close to the previously highest reported IMCP inasymptomatic subjects in the literature,43 providing evi-dence that this cutoff will provide adequately high specific-ity in other populations.

Poor outcomes after surgery for CECS have been reportedand attributed to misdiagnosis.46 Surgical outcome studiesbased on lower postexercise-only criteria may thereforehave included subjects who did not suffer from a pressure-related condition and, as a consequence, reported poorer out-comes. This study suggests that adopting the criteria recom-mended here should better identify those patients who aremore likely to experience positive outcomes after fascialrelease. We recommend that further long-term longitudinalstudies now be carried out to investigate this.

Anthropometrics of CECS

The anthropometric findings described here raise the pos-sibility that these may be related to the pathogenesis ofCECS in military populations. This study demonstratesthat subjects with CECS are significantly shorter in heightthan asymptomatic controls, although there was no differ-ence in the height:leg length ratio. This has not previously

been identified as a possible risk factor for CECS.50 Elon-gated stride length and forced changes to walking and run-ning biomechanics have already been associated with otheroveruse lower limb injuries in active populations.15,22,26

Further work is now required to delineate the possiblecausal role that this may play in CECS.

Limitations

This study is the largest controlled study investigating thiscondition with dynamic IMCP measurements. However, theconfidence intervals of some of the diagnostic indices arestill relatively wide, preventing us from being fully conclu-sive at the population level for every time point. Neverthe-less, this study provides the best evidence to date on thediagnosis of CECS, and the results definitively show thatthe cutoff values for exercise phase 2 are better than allother time points and of greater diagnostic utility than pre-viously published criteria. Additionally, this study was com-pleted in an all-male sample that might limit its translationto women. Finally, although multiple clinical and laboratorycriteria were used to make the diagnosis of CECS, it was notfurther substantiated by following the cases longitudinallyto confirm resolution after compartment release.

CONCLUSION

These data and the described dynamic protocol and IMCPcriteria offer improved sensitivity and specificity overexisting methods in the diagnosis of anterior compartmentCECS. This protocol—IMCP measured beyond 5 minutesof exercise completed to maximal tolerable pain—adds sig-nificant diagnostic value over existing techniques andaddresses the demand for a standardized approach to diag-nosis in CECS.2,23,43 Further studies need to be performedto establish if a full graduated protocol is required toachieve this level of certainty or if simply measuring dur-ing phase 2 of the protocol or to maximal tolerable painmay be sufficient. These measures should not be adoptedin the diagnosis of CECS of other limbs or compartments,owing to the likely variability in IMCP with compartmentsize and other factors.

ACKNOWLEDGMENT

The authors thank Dr Alex Bennett, Head of the AcademicDepartment of Military Rehabilitation, and Dr John Ether-ington, Director of Defence Rehabilitation, for their sup-port and direction in the development and conduct of thisstudy, and Professor Mike Hughes and Dr Aliah Shaheen,Faculty of Biomedical Engineering, University of Surrey,for their academic supervision and guidance in the conductof this study.

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