Leg pain is a common presentation to the outpatient department. Causes of bilateral calf pain are shown in Figure 2.
First described by Mavor in 1956 [1], CCS is an uncommon cause of bilateral calf pain characterised by exertion-induced increases in pressure within a confined anatomical space, thereby resulting in reduced perfusion to structures within the compartment. The pain of CCS is generally described as an ache or tightness over the affected compartment(s), is often proportional to the level of exertion, and progresses in severity over weeks or months [2]. Many report numbness or paraesthesiae radiating to the lower extremities [3]. The affected compartment is involved bilaterally in 82% of cases, with the smaller anterior and lateral compartments of the calf frequently being implicated [1]. CCS is well described in young athletes such as endurance runners but rarely in bodybuilders, suggesting that the pathophysiology may be more complex than large muscle bulk per se, and has been postulated to require a combination of reduced compartmental compliance, e.g. due to thickened fascia, [3] transient muscle hypertrophy (up to 20% during exercise), and oedema generated from repetitive hard surface contact [4]. Diagnosis can usually be made on clinical grounds, although intracompartmental pressure measurement is the gold standard [3]. Symptoms may be effectively relieved by cessation of the offending activity, but fasciotomy or fasciectomy remain the only definitive treatment [2]. There is no evidence to support the efficacy of physical therapy, orthoses or diuretics in the long term [4].
We performed a literature search on PubMed, EMBASE, and Google using the keywords: compartment syndrome AND legs/lower limbs/calf, and found no previous case reports describing non-traumatic, bilateral calf CCS in the over-65s. CCS in the elderly has been reported once previously by Lutz et al in 1988, [5] who detailed unilateral involvement of the anterolateral calf in a 69 year old retired coal miner who suffered from progressive exertion-induced calf pain for 4 years prior to diagnosis, and promptly became symptom-free after fasciotomy. From the largest series of CCS patients involving 100 young patients, Detmer et al reported that the average duration from presentation to diagnosis was 22 months, with each patient consulting an average of 2.4 physicians before the diagnosis was made, [2] illustrating the underdiagnosis and poor awareness of the condition. Physicians should thus consider CCS as a cause of bilateral calf pain as the condition is readily amenable to treatment, and early recognition is important to minimise morbidity.