Rare Case of Compartment Syndrome in the Forearm

Only 25 cases of chronic exertional compartment syndrome (CECS) have ever been reported. This is number 26 reporting on CECS affecting the volar side of the forearm. Volar refers to the flexor under side of the forearm.

Compartment syndrome is an acute medical problem. Pressure within the compartments of the forearm builds up and cuts off the blood supply to the muscles. The increased pressure occurs as a result of inflammation after an injury, surgery, or in most cases, repetitive overuse of the muscles.

There are six known compartments in the forearm. Three on the extensor (back) side and three on the volar (flexor or under) side. In the forearm, the volar compartment is affected more often than the extensor compartment.

Fascia (sheaths of connective tissue) separate the compartments. It's these bands of fibrous tissue that constrict the space. Inflammation in the confined space (fascial compartment) takes up any extra space. Muscles cannot contract and expand. Increasing pressure keeps the cycle of pressure - restriction - blood loss - inflammation - pressure going.

Without prompt treatment, nerve damage and muscle death can occur. This condition is seen most often in the lower leg, but can affect the arm as well. In this report, the case of a 27-year-old Olympic flatwater kayaker was presented. His symptoms started out as left forearm pain and weakness that went away with rest and got worse with activity.

Over time, symptoms started developing even when he wasn't kayaking or training. Eventually, he was no longer able to train and compete. He was evaluated at the Rush University Medical Center (Division of Sports Medicine) in Chicago. A history and physical exam led to the diagnosis of exertional compartment syndrome.

Surgery was performed to release the restricting fascial bands. The procedure is called a fasciotomy. The surgeon had the patient perform resisted forearm exercises right before surgery. Exercising right before the fasciotomy made it easier for the surgeons to identify what compartments and soft tissues were affected most.

Tight, restrictive fibrous bands were released until there was no fascial restriction and no tense muscular swelling. The patient experienced immediate relief of symptoms. Once the stitches were taken out, a rehab program was started. The athlete slowly regained flexibility and strength through stretching and strengthening exercises. He was able to return to training by the end of six weeks.

A follow-up check two years after surgery showed the patient was completely recovered and involved in Olympic trials and training. There was no concern that the condition might return. The surgeons noted that the compartment syndrome probably developed late in this athlete's career because of a pre-existing injury. It looked like a previous forearm injury resulted in the formation of the fibrous bands. Over time and with training to strengthen the forearm muscles, these bands eventually restricted forearm muscles leading to the compartment syndrome.

Most patients with compartment syndrome have been engaged in activities requiring significant demand on the muscles of the forearm. In the previous 25 cases of forearm chronic exertional compartment syndrome reported, patients have included manual laborers, rock climbers, tennis players, and weight lifters.

Because of the potential seriousness of the condition, anyone working with athletes (and athletes themselves) must be aware of the symptoms of compartment syndrome. Seeking medical attention sooner than later can result in early intervention, potentially preventing damage and long-term consequences. This patient was able to return to elite-level training and competition. A wonderful success story.

References: Dana P. Piasecki, MD, et al. Exertional Compartment Syndrome of the Forearm in an Elite Flatwater Sprint Kayaker. In The American Journal of Sports Medicine. November 2008. Vol. 36. No. 11. Pp. 2222-2225.