601 - From Scalpel to Syringe: A Minimally Invasive Option for Chronic Exertional Compartment Syndrome

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

RH

Rayghan S. Haskell, MD

Resident Physician
MedStar Georgetown University / National Rehabilitaiton Hospital
Washington, District of Columbia, United States

Co-Author(s)

CS

Corey T. Spector, DO

Attending Physician
Montefiore Einstein
New York, New York, United States
BM

Bryan T. Murtaugh, MD

Physician, Director of Sports Medicine
MedStar National Rehabiliation Network
Washington, District of Columbia, United States

Submitter(s)

RH

Rayghan S. Haskell, MD

MedStar Georgetown University / National Rehabilitaiton Hospital
Washington, District of Columbia, United States

Case Diagnosis: Chronic Exertional Compartment Syndrome

Case Description: A healthy 31-year-old male recreational runner presented with gradual onset bilateral calf pain during exercise progressive over multiple years. Pain developed within 3 miles of running, accompanied by foot numbness that improved with rest. Physical exam was unremarkable with preserved strength, sensation, and range of motion. MRIs of the lumbar spine and lower extremities were unremarkable except for grade 1 stress reaction of the right distal tibia and L5-S1 disc bulge without nerve root compression, neither explaining his symptoms. Compartment pressure testing confirmed chronic exertional compartment syndrome (CECS). The patient failed conservative management with physical therapy and sought to avoid surgery. Given data supporting botulinum toxin A (BoNT-A ) as a nonsurgical alternative, ultrasound-guided BoNT-A injections were performed on the affected compartments. Post-treatment, he was instructed to gradually return to running. At 1 month, he achieved near complete symptom resolution, returning to unrestricted activity without significant weakness or adverse effects.

Discussions: This outcome aligns with emerging evidence, including case series and reports, demonstrating reductions in intramuscular pressure and exertional pain, with moderate to long-term efficacy and a favorable safety profile. Fasciotomy remains the gold standard for CECS; however, recurrence, persistent disability, and complications remain significant drawbacks. BoNT-A shows promise in reducing compartment pressures and alleviating symptoms, though recurrence may occur and some patients experience transient muscle weakness without functional impairment. The proposed mechanism is reduction of compartment muscle pressure via decreased contractility, mitigating ischemia and pain.

Conclusions: BoNT-A represents a viable, minimally invasive option for patients with CECS, particularly those wishing to avoid or unsuitable for surgery. Further randomized controlled trials are necessary to establish long-term efficacy and optimal patient selection.