The Use Of Botulinum Toxin For Treatment Of Chronic Exertional Compartment Syndrome

HISTORY: A 19-year-old female NCAA Division I volleyball player presented with a few weeks of intermittent bilateral calf pain and cramping. Episodes would occur with physical activity, last about 20 minutes at a time, and improve with rest. She had been performing rehab in the training room with mild relief. Basic workup was initiated; however, further testing was deferred at this time as she was in the middle of her season and able to tolerate activities. Bilateral calf pain associated with physical activity and lingering achiness continued throughout the remainder of the season, so further evaluation was performed afterwards. PHYSICAL EXAM: On exam in the clinic, her bilateral calves were soft without point tenderness. She had some mild diffuse medial tibial pain bilaterally. Knee and ankle range of motion was full, and strength was 5/5. She was neurovascularly intact with normal sensation and good distal pulses in the bilateral lower extremities. DIFFERENTIAL DIAGNOSIS: Electrolyte derangement Tibial stress reaction/fractureChronic exertional compartment syndrome (CECS)Popliteal artery entrapment syndrome Myofascial pain syndrome TEST AND RESULTS: CBC and CMP within normal limits. Bilateral tibia/fibula X-rays unremarkable. Bilateral lower extremity ultrasound without evidence of popliteal artery entrapment. Left lower extremity MRI unremarkable. Compartment syndrome testing positive in the left lateral compartment and borderline positive in the right anterior compartment. FINAL/WORKING DIAGNOSIS: Chronic exertional compartment syndrome TREATMENT AND OUTCOMES: The athlete had been set up to see physiatry at the end of the season to discuss remaining non-surgical options. She also was referred for surgical consultation to discuss fasciotomy. Through shared decision making, the athlete elected to proceed with Botulinum Toxin injections. In a preliminary case series, Isner-Horobeti et al found Botulinum Toxin injections reduced intramuscular pressure and exertional pain for up to 9 months in patients with anterior and lateral CECS. Over the next 2-3 weeks, the athlete was able to perform more of her off-season training with noticeable improvement. Recently, however, symptoms are slowly returning. She is in the process of discussing repeat Botulinum Toxin injections versus fasciotomy.