Chronic Exertional Compartment Syndrome in the Forearm of a Collegiate Softball Pitcher
Cole et al. Sports Medicine - Open
Chronic Exertional Compartment Syndrome in the Forearm of a Collegiate Softball Pitcher
Austin Cole 0
John L. Hiatt 2
Christopher Arnold 1
Terry Sites 1
Ramon Ylanon 1
Study Design: Case Review
0 University of Arkansas for Medical Sciences , 4301 W Markham St, Little Rock, AR 72205 , USA
1 Advanced Orthopaedic Specialists , 3900 N. Parkview Dr, Fayetteville, AR 72703 , USA
2 University of Arkansas , Fayetteville , USA
Background: Chronic exertional compartment syndrome (CECS) is a recognized condition in the lower limb, with many reports in the literature. However, very few instances include CECS of the upper limb. This article presents the case of a collegiate softball pitcher presenting with CECS in her right forearm. To our knowledge, this is the first case report of a softball player with CECS, with only one similar incident in a major league baseball player. Purpose: The rarity of this condition normally places it low on the differential diagnosis. However, we hope that the presentation of this case and the review of the literature will aid in making swift and accurate diagnoses of CECS in future patients. We discuss the importance of three specific modalities in the diagnosis of this patient, what diagnostic criteria proved less conclusive, and the paradoxical course the syndrome presented with. Results: Over a six-month period, the patient presented with peculiar presentations and exam results. A broad list of differential diagnoses had to be narrowed down through the presence or absence of relevant findings. These included cessation of exercise for 1 month, physical therapy, anti-inflammatory medicines, an electromyography/electromyogram (EMG), nerve conduction study (NCS), non-exercise magnetic resonance imaging (MRI) of the forearm, cervical MRI, and cervical computed tomography (CT) angiogram. After the above interventions were attempted and the relative findings of three important modalities were summarized, a fasciotomy and release of the dorsal, volar, and mobile wad compartments was performed. The patient's symptoms were relieved, and she eventually returned to full play in softball at the university. Conclusions: The three diagnostic criteria we believed to be most helpful in this case, and for future cases of CECS in the forearm, include the clinical presentation, pre- and post-exercise MRI, and pre- and post-exercise compartment pressure measurements. Clinical Relevance: Chronic exertional compartment syndrome of the forearm is extremely rare, especially in the female athlete. This case report and review of the literature may be helpful to the clinician facing similar cases. It describes which clinical tests are most helpful for diagnosis and which findings may be distracting.
-An unusual case of chronic exertional compartment
syndrome in the forearm of a female collegiate softball
-Recommendations developed for the work-up of
chronic exertional compartment syndrome in the upper
-A literature review of intracompartmental pressure
measurement recommendations for diagnosing chronic
exertional compartment syndrome in the forearm
Chronic exertional compartment syndrome (CECS) is
classically defined as a condition presenting with
recurrent, ephemeral increases in pressures of confined muscle
compartments during exercise. Acute compartment
syndrome of an extremity may develop from either traumatic
intracompartmental swelling or external compression.
However, CECS usually only presents with exercise of the
affected compartment, and typically resolves with rest.
Increased pressure within compartments leads to transient
pain, paresthesia, numbness, and hindrance of muscle
activity . CECS is often overlooked as the cause of muscle
pain and paresthesia in the extremities, due to its rarity
and diverse manifestation. CECS may present with many
different symptoms, appear identical to other etiologies,
lack physical exam findings, and appear intermittently as
well as transiently [2, 3]. Diagnosis can be delayed as long
as 22 months in some instances .
The pathophysiology of CECS is not completely
understood, but it is certainly different from the more
familiar acute compartment syndrome. Rather than
through abrupt injury, the pressure within the
compartment involved rises upon exercise of the extremity and
related muscles. The pathophysiology could possibly be a
result of a combination between increased muscle size
from higher blood flow, increased tension of the
surrounding fascia, higher production of metabolic products,
and an increase in extracellular water content [4, 5]. It is
thought that expansion of the exercised muscle
compartment can be up to 20% in volume .
Typically, CECS is seen in the young adult athlete
who maintains a strict schedule of intense exercise.
Most cases of CECS in literature are of the lower
extremities, with only a few involving the forearm.
Furthermore, almost the entirety of the upper extremity
presentations is a result of either manual labor,
rowing, motocross, weight lifting, or kayaking [5–11].
This article presents the case of a collegiate softball
pitcher presenting with CECS in her right forearm.
To our knowledge, this is the first case of a softball
player with CECS in literature, with only one
comparable case in a major league baseball player .
A 21-year-old female softball pitcher and outfielder
presented with a chief complaint of right forearm pain and
paresthesia. The patient described a burning, tingling
sensation over the lateral portion of right forearm for
the previous 4 weeks. Initially, symptoms presented only
with extensive throwing and upper extremity exercise.
However, by this visit it had progressed to presenting in
the weight room and even occasionally at rest. She had
tried activity modification through decreasing both
duration and intensity workouts, along with over the
counter anti-inflammatories. However, these did not relieve
her discomfort. Physical exam showed full range of
motion at the elbow and wrist with flexion, extension,
pronation, supination, and radial and ulnar deviation. There
was no sign of pigment changes, warmth, or erythema.
Palpation revealed hypersensitivity over the lateral right
forearm, tenderness over lateral epicondyle, and slight
tenderness over medial epicondyle. Tinel’s sign was
negative over the cubital tunnel, Adson’s sign was
negative, and there was no epitrochanteric lymphadenopathy.
A broad differential diagnoses at this point included
peripheral nerve entrapment, peripheral neuropathy, motor
neuron pathologies, and muscular disorders.
Subsequently, the plan was to begin non-steroidal
antiinflammatory drugs (NSAIDs) and to order a nerve
conduction study (NCS) and electromyography (EMG).
The NCS and EMG tests were normal, and the
NSAIDs were not effective over a period of 4 weeks.
Due to consistent and reproducible symptoms with lack
of resolve, further work-up was pursued. With a
speculation of previous injury, an anatomic abnormality, or
compartment syndrome, an MRI of the right forearm
was ordered. The result was also normal. With no
conclusive evidence of compartment syndrome or soft
tissue-related etiology of the forearm, the differential
diagnosis shifted toward vascular and neurological
etiologies in the cervical region. Thus, a cervical MRI was
ordered. With the exception of a slightly increased T1
image finding in the right vertebral artery, there were no
significant findings leading to a presumptive diagnosis of
an underlying injury in the cervical region. To follow up
on the right vertebral artery signal, a CTA of the neck
was ordered, which was also found normal.
After weeks of studies, the patient still maintained
symptoms. At a second clinical evaluation, the patient
endorsed some tenderness at rest. The patient was
instructed to exercise, during which she performed
burpees, push-ups, and medicine ball tosses until pain and
tightness in the forearm were felt (at 10 min). She then
continued 5 min longer, totaling 15 min of exercise.
Upon evaluation, the surgeon found discoloration of the
right forearm, tenderness to touch over both
epicondyles, and pain in the flexor and extensor compartments.
The patient also presented with stiffness and a feeling of
heavy pressure within the right forearm. Consequently, a
bilateral pre-exercise and post-exercise MRI was ordered
to work up possible exercise-induced compartment
The post-exercise MRI found abnormal muscle edema
within the flexor and extensor compartments of the
right forearm (Figs. 1 and 2). In the flexor compartment,
edema presented within the flexor carpi radialis, flexor
digitorum superficialis, and flexor carpi ulnaris muscles.
Extensor edema was subtler, extending within the
muscle belly of the extensor carpi radialis brevis and
longus. The left forearm served as a control, with both
pre- and post-exercise values found normal. In
conclusion, radiographic findings were consistent with CECS of
the right forearm, with greater involvement of the volar
compartment than dorsal compartment.
The differential diagnosis at this point included CECS
or an unusual presentation of nerve entrapment. The
patient was informed and was selected to proceed with
intramuscular pressure measurement over a further
work-up of nerve entrapment. For definitive diagnosis of
CECS, compartment pressure increase upon exercise
Pressure was checked three times: pre-exercise, 3 min
post-exercise, and 5 min post-exercise. An injection of
1% lidocaine was used to achieve local pain reduction. A
catheter was then introduced into the dorsal and volar
mid-forearm areas of both the right and the left upper
extremities. The transducer was attached. Pre-exercise
pressure values were then obtained bilaterally.
The patient then proceeded with exercise, with the
identical plan as the exercise MRI work-up. She
continued until symptoms arose (once again at 10 min), and
then continued 5min longer for a total time of 15 min.
Clinical examination revealed an exceptionally swollen
and tight right forearm. There was no radiation to the
hand or fingers. The symptomatic right forearm dorsal
compartment measured 5 mmHg pre-exercise, and
18 mmHg at 3 and 5 min post-exercise. The
symptomatic right forearm volar compartment measured
15 mmHg pre-exercise, 10 mmHg 3 min post-exercise,
Fig. 1 Bilateral forearm MRI pre-exercise
and 30 mmHg 5 min post-exercise. See Figs. 3 and 4 for
comparison of pressures.
Following a full patient discussion and consultation,
with the understanding that CECS of the forearm is an
unusual presentation and difficult diagnosis, it was felt
that these findings (along with the presentation and
extensive work-up throughout the previous 6 months)
were significant enough to proceed with right forearm
fascial releases. An initial curvilinear incision was made
across the antecubital fossa and extended downward on
the right volar forearm. A fasciotomy was then
completed, including release of the bicipital aponeurosis.
Finally, careful palpation for any other tight bands was
performed. Attention was then turned to the dorsal
forearm. A longitudinal incision was made over the
middorsal forearm, and a fascial release was performed
proximally and distally. The mobile wad was released as
well. Copious irrigation was then performed. Tourniquet
time totaled 17 min. Simple nylon closure of the
incisions was performed, followed by a sterile compressive
dressing. There were no noted complications before,
during, or after surgery. The right forearm was then
placed in a posterior splint until the dorsal wound
The patient was seen in clinic 7 days
postcompartment release of the forearm. The right hand was
found swollen, but soft. The patient had a strong radial
pulse and good wrist flexion and extension. Flexion
measured 100°, and extension 60°. A postoperative
hematoma had established under the dorsal wound, and
the posterior splint was discontinued and was replaced
with a sling. A nine-day assessment was made to
evaluate the inflammation, at which the presentation and pain
were much improved. At 13 days, the patient could
make a full fist, pronation measured 90°, supination 90°,
extension 80°, and flexion 150°. 15 ccs of blood was
aspirated from the previously mentioned subcutaneous
hematoma. At 6 weeks post-release, all compartments
were soft, non-tender, and the wounds benign. The
patient was cleared to begin rehabilitation. Specific
exercises for the subsequent 2 months and an
intervalthrowing program were pursued. Slow progression into
Fig. 3 Bilateral dorsal compartment pressures
light weight, high repetition wrist and arm exercises was
the first step. The athlete then began light overhand
throwing of the softball. The patient progressed slowly
to underhand throwing over time with no pain. The
anti-inflammatories Relafin and Voltaren Gel were
prescribed as she started to increase activity. At 4 months
post-compartment release, she was cleared for full play
without the use of any anti-inflammatories. See the
timeline of events in Table 1.
This presentation of CECS in the forearm of a female
collegiate softball pitcher is exceptionally unique. CECS
has appeared in the upper extremity in perhaps only a
few dozen instances in literature, usually in certain
populations (soldiers, motocross, kayaking) [1, 4–8, 10–12].
In addition to the rarity, this case illustrates the difficulty
of diagnosing CECS of the forearm. From the initial
presentation and plan to acquire EMGs and a NCS to
the normal neurological, vascular, and muscular
workups, the diagnosis of CECS can be recognized as very
challenging. In this section, we discuss three modalities
we believe aid most in diagnosing CECS in the forearm,
methods that have proven less effective, and the
paradoxical course this particular case took.
The first of the three useful modalities is simply
clinical presentation. Although this is not a true modality by
definition, patient presentation through signs,
symptoms, and physical examination proved just as vital to
the diagnosis as any true modality would. Specifically,
one should look for forearm pain and paresthesia over
either the dorsal or the volar aspect of the forearm
during exercise. Our patient presented with history of pain
upon exercise in both forearm regions, described it as a
“burning, tingling sensation”. Erythema, numbness, and
hindrance of motion due to discomfort also
accompanied the exertional pain. All these are characteristic of
other cases of CECS [1–4, 6–10, 13]. Notably, the
symptoms never radiated to the hand over the six-month
course. Hypersensitivity to palpation over the lateral
forearm, tenderness to palpation over lateral epicondyle,
and slight tenderness over the medial epicondyle can be
further indications of CECS. Another element to
consider in future diagnoses is a possible vague, seemingly
benign physical exam. The patient maintained full range
of motion at the elbow and wrist with flexion, extension,
pronation, supination, and radial and ulnar deviation
Fig. 4 Bilateral volar compartment pressures
Table 1 Case timeline
First presentation to a sports medicine physician.
EMG and NCS. Results normal.
Second presentation to orthopaedic surgeon
with the same symptoms. Plan included 1 month
of rest and a MRI.
MRI of right forearm and elbow. Results normal.
Second opinion from physician who agreed MRI
was normal, and the presentation was not
developed enough to indicate CECS.
Angiogram of cervical region, specifically right
vertebral artery, to rule out vascular etiology.
Patient was home for the summer. Played no summer
ball and rested the forearm.
MRI of bilateral forearms pre- and post-exercise.
Results found to be diagnostic of CECS.
Fourth presentation. Some findings unexpected.
7 day follow-up. Symptoms greatly relieved, yet
9 day follow-up. Swelling found subsiding.
13 day follow-up. Stitches removed and subcutaneous
6 week follow-up. Forearm movement back to normal
and wounds benign.
when at rest. Furthermore, pigment changes, warmth,
and erythema was only seen upon exercise. It is
therefore very important to reproduce symptoms by specific
exercise. However, unusual for CECS, our patient did
have some history and one clinical exam where
tenderness presented at rest. A lack of Tinel’s sign and Adson’s
sign, as in this instance, might also aid in diagnosing
CECS. Finally, the lack of anti-inflammatory relief could
suggest a possible CECS case.
A second modality that proved to be extremely helpful
in diagnosing CECS was the pre- and post-exercise
MRIs. This style of imaging allows assessment of signal
intensity changes over time to quantify fluid
accumulation within soft tissues. Furthermore, MRIs are safe and
prevent exposure to radiation. However, we believe it is
important to ensure the history and clinical evaluations
steer toward CECS (specifically reproducing symptoms
with exercise) before ordering such costly studies. In
addition to this case, pre- and post-exercise MRIs have
been proven to aid in the CECS work-up elsewhere in
The third and final modality we recommend is pre- and
post-exercise intracompartmental pressure measurements.
Because MRIs and clinical presentation are non-invasive
techniques, we believe that the addition of compartment
pressure evaluation is obligatory before a definitive
diagnosis is made and a fasciotomy pursued. Although there has
been evidence of variance in normal compartment values,
any significant rise in pressure post-exercise is highly
indicative of CECS [2, 3, 6, 12, 15, 17, 19]. In fact, many other
studies have concluded that the best method for
diagnosing CECS is evaluation of intracompartmental pressures
(ICPs) before and after exercise [2, 5, 12, 15, 17, 20].
However, in agreement with Rorabeck et al., we
believe ICPs are only a supplemental component to the
history and physical examination. In conclusion, we
recommend a work-up of forearm CECS using all
First and foremost, it is important to understand
what the literature proposes as normal for ICP values.
The standard resting pressure in normal
compartments is between 0–15 mmHg in the lower leg.
Borderline pressures are from 16–24 mmHg, while values
above 25 mmHg are consistent with the diagnosis of
CECS. Even though these values are based on the
much more common presentation of CECS in the
lower limb, they are used in most studies of CECS in
the upper extremity [2, 3, 15–17, 19]. Due to the
rarity of upper extremity cases, Ardolino et al. attempted
to experimentally determine normal, asymptomatic,
forearm pressures before and after exercise . With
a 95% CI, normal, asymptomatic forearm extensor
pressures in 41 volunteers were found to be between
0–25.3 mmHg, and normal forearm flexor pressures
between 0–21.4 mmHg . Interestingly, there was
no significant difference between pre- and
postexercise values. Ardolino et al. also found resting and
exercise numerical values significantly higher than
what most forearm studies (using ICP values of the
leg) had considered normal. [15–17, 19]. In fact, the
95% CI, 0–25.3 mmHg dorsal ICP resting range
surprisingly includes the theoretical diagnostic value of CECS
(20 mmHg) used in so many other studies. In conclusion,
we believe the accuracy of normal and resting ICPs that
many studies provide for the forearm is questionable, with
a wide variance [12, 17, 19, 20].
With normal values proving inconsistent in
literature, we now look at what studies recommend for
diagnosing CECS with ICP values. A hypothetical
diagnostic criterion for CECS in the forearm has been
proposed by Pedowitz et al.; a resting ICP of
15 mmHg or greater, a 1–3-min post-exercise ICP of
30 mmHg or greater, and a 5-min post-exercise ICP
of 20 mmHg or greater. Of note, this has only been
tested with compartments of the leg [1, 2, 12, 17].
In comparison to the diagnostic criterion, our patient’s
resting symptomatic arm measured 5 mmHg in the
dorsal compartment and 15 mmHg in the volar . Just
the dorsal compartment ICP barely met the diagnostic
value of 15 mmHg that Pedowitz et al. recommends,
and neither ICP was above the upper end of normal
(25.3 mmHg) proposed by Ardolino et al. in the 2010
forearm pressure study [12, 17]. In agreement with
Roscoe et al, we decided to extend exercise 5 min from the
onset of pain in order to build pressure and edema
enough to allow a cushion of time for inserting the
catheters. At 3 min post-exercise, the dorsal ICP rose
13 mmHg to a value of 18 mmHg, while the volar ICP
actually dropped 5 mmHg to a value of 10 mmHg. Once
again, this is contrary to what literature recommends:
30 mmHg at 3 min post-exercise for a CECS diagnosis
[12, 17, 20]. However, at 5 min post-exercise, the dorsal
compartment maintained its 18 mmHg value, while the
volar compartment rose to 30 mmHg. As a very
important conclusion, the dorsal resting ICP and the volar
5min post-exercise ICP were the only values of the six
taken that fit in the diagnostic criterion for CECS
proposed by Pedowitz et al. See Table 2 for ICP value
Because of conflicting studies, variance in results, and
contrasting data with this patient, we believe that
utilizing a particular numerical value for ICP is not helpful.
Instead, the important factor for CECS seems to be the
rise in pressure from resting to 5 min after exercise,
perhaps as a percent, and delayed normalization. All reports
in literature support that as a consistent phenomenon
[1, 2, 12, 17, 20]. Perhaps these two elements should be
investigated more thoroughly in future studies.
Unlike the three above modalities we believe are useful
in diagnosing CECS of the forearm, other choices have
often proven inadequate. As in this case, observation
with cessation of exercise for 1 month, a physical
therapy plan, anti-inflammatory medicines, an EMS, a NCS,
a non-exercise MRI of the forearm, a cervical MRI, and
a cervical CT angiogram have all demonstrated to only
rule out a few differential diagnoses or have proven
inconclusive. Even though the first step taken by the initial
physician in March was to rule out any concomitant
nerve compression through EMG/NCS studies, these
exams may prove misleading or inaccurate at times
[15, 21–24]. Other investigations not done in this
case have proven futile as well; including X-rays,
blood tests, and Doppler ultrasound scans [2, 13].
A final interesting component of this case is the
paradoxical presentations throughout the 6 months. The
September 14 visit, after the exercise MRI, delivered
unexpected findings. First, unlike the earlier examinations,
there was no tenderness to palpation or pain with rest.
The patient stated that now only with exercise she
experienced discomfort, swelling, erythema, and numbness.
However, this constituted only minimal exercise;
manifesting after just 30 s, and even through handwriting.
Second, during this visit, the pain was specifically over
the dorsal compartment, with less in the volar region.
This seems contrary to the MRI findings just 3 days
prior, where abnormal edema was primarily found within
the flexor carpi radialis, flexor digitorum superficialis,
and flexor carpi ulnaris muscles. It is possible that the
cessation of softball and strenuous activity over the
twomonth summer period in July and August alleviated
some of the symptoms. However, it still is important to
understand that CECS may present differently at
Due to the extensive clinical examinations and
diagnostic work-ups, the successful diagnosis of CECS was
finally made in this case. If the three modalities of clinical
presentation, exercise MRIs, and ICP measurements had
already been established as a step by step protocol, the
diagnosis of CECS would have been accomplished much
sooner. In review of this case, we believe these three
modalities are most important and should be considered in
future cases of CECS work-up. Furthermore, we
recommend a case-control study examining percent rise from
pre- to post-exercise compartment pressures and the
time delay in recovery. Finally, the surgical intervention
of CECS in the forearm seems to be necessary, since
therapy, one-month cessation of exercise, and
antiinflammatories did not prove curative. This case
presented over a six-month period without any resolution
Table 2 ICP value comparison
3 min. post-exercise volar
3 min. post-exercise dorsal >25.3 mmHg
5 min. post-exercise volar
5 min. post-exercise dorsal
Note: Ardolino et al. concluded that there was no significant difference in pre- and post-exercise values 
using these techniques (Table 1). Surgical fasciotomy is
encouraged highly in literature for CECS and is proved
to be the definitive solution once CECS was diagnosed
[2, 7, 10, 11, 14, 19, 20, 25–29]. To our knowledge, this
is the first report of a case of chronic exertional
compartment syndrome in the forearm of a collegiate
softball pitcher. The rarity of this condition normally places
it low on the differential diagnosis, however, we hope
that the conclusions of this case will aid in making swift
and accurate diagnoses of upper extremity CECS in
AC is the lead author and contributor of the paper, conclusions, and
research. JLH aided in case note retrieval and timeline of events. CA is the
lead orthopaedic physician in work-up and treatment of athlete. CA also
aided in review of the paper. TS is the assistant orthopaedic physician in
work-up and treatment of athlete. TS also aided in review of the paper. RY is
the sports physician in work-up and treatment of athlete. RY also aided in
review of the paper. All authors read and approved the final manuscript.
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