Chronic exertional compartment syndrome in the differential diagnosis of peripheral artery disease in older patients with exercise-induced lower limb pain

Abstract

Objective: Peripheral artery disease (PAD) and chronic exertional compartment syndrome (CECS) both cause exercise-induced lower limb pain. CECS is mostly described in young individuals and may therefore not be considered in older patients with intermittent claudication. The aim of our study was to identify differences in characteristics and symptomatology between patients with CECS and PAD that may help in recognizing CECS in patients ≥50 years with exercise-induced lower limb pain.

Methods: In this case-control study, patients with CECS ≥50 years were selected from a prospectively followed cohort and compared with a sample of newly diagnosed patients with PAD ≥50 years. A questionnaire assessed frequency and severity of lower limb pain, tightness, cramps, muscle weakness, and altered skin sensation at rest and during exercise.

Results: At rest, patients with CECS (n = 43, 42% female, 57 years; range, 50-76 years) reported significantly more pain, tightness, muscle weakness and altered skin sensation (all P < .01) than patients with PAD (n = 41, 39% female, 72 years; range, 51-93 years). Having CECS was associated with a significantly higher combined symptom score at rest (P = .02). During exercise, patients with CECS experienced more tightness, muscle weakness and altered sensation (P < .01), but not pain and cramps (P = .36; P = .70). Exercise-induced complaints occurred much later in patients with CECS than in patients with PAD (15 minutes vs 4 minutes; P < .01). Persistence of pain over 4.5 minutes proved most discriminative for the presence of CECS (sensitivity, 95%; specificity, 54%; positive predictive value, 65%). Exercise cessation completely alleviated complaints in all patients with PAD (n = 41) but not in 73% (n = 29) of the patients with CECS. Ongoing discomfort strongly predicted the presence of CECS (sensitivity, 73%; specificity, 100%; positive predictive value, 100%).

Conclusions: Patients with CECS ≥50 years report a symptom pattern that is different from patients with PAD. These differences may aid vascular surgeons in identifying older patients with CECS.

Keywords: Chronic exertional compartment syndrome; Intermittent claudication; Older patients; Peripheral artery disease.