503 - Pressure Relief: Botulinum Toxin in Refractory Chronic Exertional Compartment Syndrome – A Case Report

Chronic exertional compartment syndrome (CECS) is a rare, activity-induced condition marked by a reversible rise in intracompartmental pressure during exertion. It most commonly affects the lower legs of athletes and military personnel, presenting with exertional pain, paresthesia, and weakness that resolves with rest.


Case Description:

A 39-year-old male with CECS presented to physiatry clinic for therapeutic botulinum toxin injections. He reported six years of lower leg pain, pressure, and foot drop with exertion, beginning during FBI fitness training. Intracompartmental pressure (ICP) testing revealed elevated post-exertional pressures in all compartments. He underwent four-compartment fasciotomy with initial symptom relief but later experienced recurrence. Wishing to avoid revision surgery, he sought evaluation of botulinum toxin injections as a conservative treatment option.

Discussions:

Diagnosis of CECS relies on clinical history, physical examination, and ICP measurement. While activity modification and physical therapy may benefit mild cases, fasciotomy remains the gold standard for severe or persistent disease. However, surgery carries risks of nerve injury, hematoma, infection, deep vein thrombosis, and recurrence, with up to 10% of patients requiring revision. Botulinum toxin injection is an emerging, off-label therapy that may reduce intracompartmental pressures and alleviate exertional symptoms. In our patient, ICP was highest in the anterior compartment. Accordingly, 20 units of botulinum toxin were administered to the tibialis anterior, extensor digitorum longus, and extensor hallucis longus, improving pain control and activity tolerance. At three month follow-up, he remained symptomatic in the posterior compartment with exertion and was subsequently treated with 20 units each into the medial gastrocnemius, lateral gastrocnemius, and soleus.


Conclusions:

We describe the case of a physically active male with CECS refractory to fasciotomy who achieved symptomatic improvement with botulinum toxin injections. This case highlights botulinum toxin as a promising, non-surgical treatment option for CECS, particularly in patients with symptoms refractory to surgery.