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  Ercan Cetinus
  Published on: 11 October 2022
• Re: Exercise induced compartment syndrome in a professional footballer
  Mike R Barnes
  Published on: 11 October 2022

• Published on: 11 October 2022

  Reply to authors' comments

  • Ercan Cetinus, Physician
  • Other Contributors:
    • Ercan Cetinus, Murat Uzel, Erkal Bilgic¸, Ahmet Karaoguz, Mustafa Herdem

  Dear Editor

  Our reply to the comments raised by an author is submitted as follows. Author Comment (AC):I would be very interested to know what the authors actually mean by the term “shin splints”

  Reply: Shin splints, which we cited in our article as one of the main causes of recurrent lower leg pain, refers to a condition that produces pain and discomfort in the leg owing to repetitive running or hiki...

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  Dear Editor

  Our reply to the comments raised by an author is submitted as follows. Author Comment (AC):I would be very interested to know what the authors actually mean by the term “shin splints”

  Reply: Shin splints, which we cited in our article as one of the main causes of recurrent lower leg pain, refers to a condition that produces pain and discomfort in the leg owing to repetitive running or hiking. Further, the condition is limited to musculotendinous inflammations and should exclude stress fractures and ischemic disorders. Although the term shin splint syndrome is out of date its common usage in classical textbooks ensures its survival. (Andrish JT: The leg DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed. WB Saunders 2003, OKU Sports Medicine 2 1999 Ed. Arendt EA)

  AC: They state that “Exercise-induced compartment syndrome is the least common” (cause of lower leg pain). Perhaps exercise-induced acute compartment syndromes are very rare, but certainly not chronics. It is debatable as to whether CCS (Chronic Compartment Syndrome) or MTSS (Medial Tibial Stress Syndrome)is the most common cause of exercise-induced lower leg pain, and it is impossible to prove either way. However CCS is at least 100 times more common in athletes than either venous diseases or obliterative arterial diseases. This is supported by both common sense and the literature. For example, in the April 2004 issue of the Journal, Cunningham & Spears maintain that CCS is the most common form of leg pain in athletes

  Reply: We stated EICS as the least common among the causes of lower leg pain in normal population, on the contrary to athletes.Detmer et al. reported that only three cases per year came from a university population of 40000 students. (Detmer D, Sharpe K, Sufit R, et al. Chronic compartment syndrome: diagnosis, management and outcomes. Am J Sports Med 1985;13:162–70.) Since the vast majority of EICS cases are treated with conservative procedures successfully, we as orthopaedic surgeons, rarely encounter such cases.

  AC: EICS is a misleading term because it does not distinguish between Chronic and Acute, which is a very important difference in terms of possible sequelae and urgency of treatment. CCS is better, exercise is implicit in the name as, unlike acutes, which can have many causes, there is no other cause of a CCS.

  Reply: In our case report, we actually mention a case with exercise induced chronic compartment syndrome by stating EICS in our paper. We aggree with the comments of the author.

  AC: Why was the Superficial posterior compartment decompressed, when it was clearly shown by the pressure tests to be completely normal?

  Reply: In our case, the soleus was bulky and wrapped around the deep compartment. Therefore we performed partial fasciotomy to the soleus fascia in order to gain access to the deep compartment.

  AC: The most common causes of acute compartment syndrome must certainly include tibial fractures and crush injuries, but muscle ruptures and blood diseases are extremely rare causes. External compression and burns are far more common. But are these facts really relevant in a paper about CCS.

  Reply: Since the case in our paper was exercise induced chronic compartment syndrome, we mentioned only some causes of acute compartment syndrome as a general statement. External compression and burns may be added to the article.

  AC: Bilateral involvement is much more common than unilateral (as per Detmer (5) 82/94 patients), it is not just an occassional finding as implied here.

  Reply: We did not imply unilateral involvement as an occasional finding in our paper. Moreover we cited the study of Detmer et al. in our discussion section by giving the same ratio as bilateral involvement being much more common.

  AC: Fascial defects have only ever been reported in the Anterior compartment, so are not relevent to Deep Posterior compartments.

  Reply: The author is right on this matter. However we implied not only deep posterior compartment syndrome, but also a general approach to physical examination findings of the exercise induced chronic compartment syndrome.

  AC: Many of the surgical techniques, e.g. fibulectomy are only ever used in acute cases, so mentioning them here is purely padding.

  Reply: We do know that fibulectomy is only applied in acute cases however this was stated only among the different surgical treatment alternatives.

  AC: The reference to a 20% decrease in strength of the compartment following surgery (Mozan & Keagy) is misleading. This is an isolated paper on frog’s legs. There is no in-vivo evidence to suggest any long- term detrimental effects of surgery for CCS, although several investigations have been undertaken.

  Reply: Even though the author is right in his concern, two experimental studies revealed such a decrease in muscle strength and this was cited in Surgery of the Foot and Ankle eds Coughlin MJ, Mann RA. Seventh edition 1999.

  AC: Taken together these points would give the inexperienced reader a rather false and misleading picture of the incidence, diagnosis and treatment of a Chronic Compartment Syndrome.

  Reply: We believe that the author is too rigid in his judgement by this statement. We never want to mislead any of the readers. However, many debateable terms are still used for these cases. As we mentioned previously, the incidence is very different in regular population and the athletes. Our diagnosis is certainly correct and debateable uses of different terms for this case is nonsense. The treatment performed to the patient is also very appropriate even though the route of approach to the deep compartment may be debateable and the complaints of the patient were relieved completely and he continues his professional football career.

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  Conflict of Interest:
  None declared.

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• Published on: 11 October 2022

  Re: Exercise induced compartment syndrome in a professional footballer

  • Mike R Barnes, Clinical Scientist

  Dear Editor

  There are a number of interesting points raised by this case report, as well as some fundamental and misleading errors.

  I would be very interested to know what the authors actually mean by the term “shin splints”

  They state that “Exercise-induced compartment syndrome is the least common” (cause of lower leg pain). Perhaps exercise-induced acute compartment syndromes are very rare, bu...

  Show More

  Dear Editor

  There are a number of interesting points raised by this case report, as well as some fundamental and misleading errors.

  I would be very interested to know what the authors actually mean by the term “shin splints”

  They state that “Exercise-induced compartment syndrome is the least common” (cause of lower leg pain). Perhaps exercise-induced acute compartment syndromes are very rare, but certainly not chronics. It is debatable as to whether CCS (Chronic Compartment Syndrome) or MTSS (Medial Tibial Stress Syndrome)is the most common cause of exercise-induced lower leg pain, and it is impossible to prove either way. However CCS is at least 100 times more common in athletes than either venous diseases or obliterative arterial diseases. This is supported by both common sense and the literature. For example, in the April 2004 issue of the Journal, Cunningham & Spears maintain that CCS is the most common form of leg pain in athletes

  EICS is a misleading term because it does not distinguish between Chronic and Acute, which is a very important difference in terms of possible sequelae and urgency of treatment. CCS is better, exercise is implicit in the name as, unlike acutes, which can have many causes, there is no other cause of a CCS.

  Why was the Superficial posterior compartment decompressed, when it was clearly shown by the pressure tests to be completely normal?

  The most common causes of acute compartment syndrome must certainly include tibial fractures and crush injuries, but muscle ruptures and blood diseases are extremely rare causes. External compression and burns are far more common. But are these facts really relevant in a paper about CCS.

  Bilateral involvement is much more common than unilateral (as per Detmer (5) 82/94 patients), it is not just an occassional finding as implied here.

  Fascial defects have only ever been reported in the Anterior compartment, so are not relevent to Deep Posterior compartments.

  Many of the surgical techniques, e.g. fibulectomy are only ever used in acute cases, so mentioning them here is purely padding.

  The reference to a 20% decrease in strength of the compartment following surgery (Mozan & Keagy) is misleading. This is an isolated paper on frog’s legs. There is no in-vivo evidence to suggest any long- term detrimental effects of surgery for CCS, although several investigations have been undertaken.

  Taken together these points would give the inexperienced reader a rather false and misleading picture of the incidence, diagnosis and treatment of a Chronic Compartment Syndrome.

  Show Less

  Conflict of Interest:
  None declared.

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