Intermittent claudication in diabetes mellitus due to chronic exertional compartment syndrome of the leg: An observational study of 17 patients

Abstract

Background and purpose Intermittent claudication in diabetes mellitus is commonly associated with arterial disease but may occur without obvious signs of peripheral circulatory impairment. We investigated whether this could be due to chronic exertional compartment syndrome (CECS).Patients and methods We report on 17 patients (3 men), mean age 39 (18-72) years, with diabetes mellitus-12 of which were type 1-and leg pain during walking (which was relieved at rest), without clinical signs of peripheral arterial disease. The duration of diabetes was 22 (1-41) years and 12 patients had peripheral neuropathy, retinopathy, or nephropathy. The leg muscles were tender and firm on palpation. Radiography, scintigraphy, and intramuscular pressure measurements were done during exercises to reproduce their symptoms.Results 16 of the 17 patients were diagnosed as having CECS. The intramuscular pressures in leg compartments were statistically significantly higher in diabetics than in physically active non-diabetics with CECS (p < 0.05). 15 of the 16 diabetics with CECS were treated with fasciotomy. At surgery, the fascia was whitish, thickened, and had a rubber-like consistency. After 1 year, 9 patients rated themselves as excellent or good in 15 of the 18 treated compartments. The walking time until stop due to leg pain increased after surgery from less than 10 min to unlimited time in 8 of 9 patients who were followed up.Interpretation Intermittent claudication in diabetics may be caused by CECS of the leg. The intramuscular pressures were considerably elevated in diabetics. One pathomechanism may be fascial thickening. The results after fasciotomy are good, and the increased pain-free walking time is especially beneficial for diabetics.

Stiffness and Thickness of Fascia Do Not Explain Chronic Exertional Compartment Syndrome

“…One possible explanation for tissue stiffening is the accelerated formation of the collagen cross-links called advanced glycation end products. Studies have shown CECS is a common cause of lower leg pain in diabetic individuals [11,12]. With this in mind, we included persons with diabetes and CECS (the PDC group) to ensure the detection of a 'stiffer' fascia, which would support the hypothesis of stiff fascia playing a part in the pathophysiology of CECS.…”

“…An anterior intracompartmental pressure (ICP) greater than 15 mm Hg at rest and/or greater than 30 mm Hg 1 to 2 minutes after cessation of exercise and/or greater than 20 mm Hg 5 minutes after exercise is diagnostic [18]. Raised ICP is believed to play an important role in the pathophysiology of CECS, and fasciotomy reportedly yields a good clinical outcome and normalized ICP [11,13,14,25]. Ischemia secondary to a raised ICP is believed to cause the pain symptoms [1,8,17,19].…”

“…It is well accepted that diabetic individuals have generalized stiffening of connective tissue [2][3][4]22]. Recently it was shown that CECS is a common cause of lower leg pain in diabetic individuals [11,12]. It is possible that diabetic individuals are exposed to CECS because of stiffer fascia.…”

Diabetes and its negative impact on outcomes in orthopaedic surgery

“…Seventeen patients with DM and leg pain during walking underwent intramuscular pressure measurements during exercise. Diabetic patients demonstrated significantly higher compartment pressures than a control group of non-diabetic patients with exertional compartment syndrome (P < 0.05) [43] . Despite having higher compartment pressures, patients with DM achieved satisfactory results with release of the involved compartments.…”

“…Claudication like symptoms in diabetic patients may be caused by PAD, radiculopathy or chronic exertional compartment syndrome of the leg, and a careful history and examination is necessary to arrive at the correct diagnosis [43] . Seventeen patients with DM and leg pain during walking underwent intramuscular pressure measurements during exercise.…”