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Biomechanical overload syndrome: defining a new diagnosis
  1. Andrew Franklyn-Miller1–3,
  2. Andrew Roberts2,
  3. David Hulse2,
  4. John Foster2
  1. 1Department of Sports Medicine, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  2. 2Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Epsom, Surrey, UK
  3. 3Centre for Health, Exercise and Sports Medicine, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Dr Andrew Franklyn-Miller, Sports Surgery Clinic, Department of Sports Medicine, Santry Demesne, Dublin, Republic of Ireland;afranklynmiller{at}

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Chronic exertional compartment syndrome (CECS) was first described in 1956,1 but little research has been performed since then to confirm the pathological physiology. An assumption is made that elevated subfascial or intramuscular pressure during exercise causes tissue hypoxia and subsequent ischaemic pain due to decreased blood flow.2 To date, no conclusive evidence exists to demonstrate cellular hypoxic damage or decreased capillary perfusion.3 Further supposition is made regarding muscle hypertrophy, reduced compartment volume due to a decreased fascial compliance,4 and shorter periods of muscle relaxation as the underlying pathophysiology of CECS.

There are many questions over whether the technique of intracompartmental pressure measurement is reliable. Examination of the widely accepted diagnostic criteria published in the seminal paper by Pedowitz et al5 reveals significant flaws, as the CECS and non-CECS groups were preselected by their differences in intramuscular pressure. We have also demonstrated significant overlap of the published diagnostic criteria for CECS with the published normative data.6 Furthermore, intramuscular pressure measurement varies considerably with the depth of the catheter tip, the means of measurement and the mode of exercise. It is also important that the criteria presented are only applicable to the anterior compartment. CECS is also reported as being diagnosed in the deep posterior and peroneal compartments of the leg,7 the foot8 and the forearm,9 despite diagnostic pressure criteria never having been established in these other myofascial compartments. What is undeniable however is that exertional lower-limb symptoms localised to the myofacial compartments are commonly reported in elite and recreational athletes,10 military personnel,11 ,12 and non-athletes alike,13 and that CECS is included in the differential diagnosis.

As a tertiary referral centre for exertional leg pain, we have conducted large numbers (c.100/year) of intracompartmental pressure measurements, often with subsequent referral …

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  • Contributor AFM, AR, JF and DH contributed to both the development concepts of the redefined diagnosis, the clinical care of the patients who were responsible for underpinning this work and in the writing of the textual submission. AFM wrote the initial draft manuscript and JF, AR and DH critiqued and re-edited the piece making substantial individual contributions. AFM is the Guarantor of the piece.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.