1030 - Chronic exertional compartment syndrome in a 48-year-old veteran treated with incobotulinumtoxinA

Botulinum Toxin for Treating Chronic Exertional Compartment Syndrome (CECS) 

Case Description: A 48-year-old female smoker presented with a 25-year history of exertional bilateral knee and shin pain. She developed paresthesia, leg heaviness, and weakness in plantarflexion and dorsiflexion after short walks, which resolved within minutes of rest. Treadmill testing showed significantly elevated, multicompartmental pressures bilaterally, confirming CECS. She received ultrasound-guided injections of incobotulinumtoxinA into the tibialis anterior, extensor digitorum longus, peroneus longus, tibialis posterior, and soleus. At four months, she reported an 80% reduction in pain, improved endurance, and no weakness or adverse events. She chose to continue injections while pursuing smoking cessation to improve her candidacy for fasciotomy.

Discussions: This case is notable for multicompartmental CECS, which complicates diagnosis and treatment planning. Fasciotomy is typically definitive, but surgical decision-making becomes more challenging with multi-compartment involvement, increasing the risk of incomplete symptom resolution or unnecessary surgical complications. In this context, botulinum toxin offers both therapeutic and diagnostic benefits. By selectively chemodenervating multiple compartments, it reduces intracompartmental pressure and provides significant symptom relief, while also identifying which compartments most contribute to the patient’s functional limitations. This information can guide surgical targeting, potentially leading to better outcomes for fasciotomy candidates with widespread involvement. Additionally, botulinum toxin may serve as a bridge therapy, maintaining function and quality of life for patients who are poor surgical candidates or working toward surgical readiness, as in this case of ongoing tobacco use. Therefore, chemodenervation not only alleviates symptoms but also helps refine individualized treatment strategies in complex, multicompartmental CECS.

Conclusions: There are no established guidelines for using botulinum toxin in CECS. This case supports earlier reports, showing that botulinum toxin is a viable treatment option that alleviates pain and disability. More prospective studies are needed to compare chemodenervation with fasciotomy, determine appropriate dosing, and clarify its long-term role in management.