A 60-Year-Old Man with a 34-Year History of Chronic Exertional Compartment Syndrome and 3 Previous Surgical Fasciotomies, Successfully Treated with Injection of Botulinum Toxin

Patient: Male, 60-year-old Final Diagnosis: Chronic exertional compartment syndrome Symptoms: Pain (bilateral posterior leg/calf) • subjective weakness Clinical Procedure: Intramuscular injection of Onabotulinumtoxin A Specialty: Rehabilitation OBJECTIVE: Unusual clinical course BACKGROUND: Patients with post-fasciotomy CECS recurrence can experience significant mobility issues at baseline that limit independent living. For these patients, a repeat fasciotomy is not ideal because they are older and post-surgical scar tissue will make the fasciotomy technically challenging. Therefore, post-fasciotomy patients with CECS recurrence require new, non-surgical treatment options. Recent studies show botulinum toxin injections can be effective for the initial management of chronic exertional compartment syndrome (CECS) prior to surgery, especially in young patients primarily experiencing pain on exertion with minimal lower-extremity symptoms at rest. However, the ability to treat CECS recurrence status after fasciotomy with botulinum toxin injections of the legs has not been studied. CASE REPORT: We present the first case where botulinum toxin was applied to this patient population. Our patient was a 60-year-old man with a 34-year history of CECS who, 8 years after his third bilateral fasciotomy, progressively developed rest pain in his calves bilaterally, paresthesias, and difficulties when walking or descending stairs, with multiple near-falls due to his toes catching on stair steps. OnabotulinumtoxinA (BTX-A) injections into the posterior and lateral compartments resolved baseline symptoms: within 2 weeks, he was able to walk, negotiate stairs symptom-free, and enjoy an overseas vacation without complications. CONCLUSIONS: Symptoms related to recurrent CECS status after multiple fasciotomies can successfully be treated with BTX-A injections. Our patient’s baseline mobility issues resolved within 2 weeks after the injection and remained that way for over 31 months. However, his exertional symptoms and rest pain recurred at 9 months, suggesting that BTX-A injections are not completely curative.