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Botox for Exertional Compartment Syndrome

Dr. Silberman specializes in the diagnosis and treatment of exertional compartment syndrome.  Compartment testing is the gold standard and only test for the diagnosis of exertional compartment syndrome.  He has been performing compartment tests for more than 20 years and is a referral source for orthopedic surgeons located throughout the United States. He has presented cases at national conferences and has been published in peer-reviewed scientific journals on the topic of exertional leg pain and compartment syndrome.  He has had an interest in exertional compartment syndrome since fellowship when he presented research on the low success of surgical treatment at the Annual AMSSM Sports Medicine Conference.  Click here for his publication on Crural Fascia
Injuries and Thickening on Musculoskeletal Ultrasound in athletes with calf pain, calf ‘strains’, exertional compartment syndrome and botulinum toxin injections
.  He has performed over 500 compartment tests and averages about one per week.

Botox injections are a novel non-surgical intervention that have promising results in published case studies for the treatment of exertional compartment syndrome.  In 2008, Lecocq and Inser-Horobeti were the first to publish the successful use of botox for the treatment of exertional compartment syndrome (Lecocq, J., and Isner Horobeti. "Treatment of exertional compartment syndrome leg with botulinum toxin A: a first open pilot study." J Rehabil Med 40. Suppl 47 (2008): 111-112.)  In 2013, Isner-Horobeti et al. followed that small pilot study with another study on botox for compartment syndrome for those with anterior or anterior lateral exertional compartment syndrome demonstrating a success rate of 94% with a drop in pressures measured at 3 to 9 months post botox treatment. Dr. Silberman to date has had similar results.


















Botox injections also may be an option for those with functional popliteal artery entrapment syndrome.  Childers and Fishman in 2 separate studies in 2002 treated entrapment of a gluteal artery with botox for the treatment of piriformis syndrome.  In 2015, Isner-Horobeti published an article Botulinum Toxin as a treatment for functional popliteal artery entrapment syndrome.  Hislop et al. in 2017 published a case series on 27 patients with functional popliteal artery entrapment syndrome treated with ultrasound guided botox injections.  Dr. Silberman has also treated athletes with functional popliteal artery entrapment syndrome using ultrasound guided botox injections.

Ankle Brachial Index Test used to screen for popliteal artery

entrapment syndrome or iliac artery endofibrosis or kinking.

Botox injections can also be used to treat upper extremity chronic exertional compartment syndrome of the forearm. Dr. Silberman has treated musicians, artists, programmers, rowers, and climbers with chronic exertional compartment syndrome of the forearm.

Dr. Silberman has been performing botox muscle injections in his practice since 2012.  After seeing surgical failures for exertional compartment syndrome and exertional leg pain, having to retest patients who underwent surgery, where extensive scar tissue could be felt during retesting, Dr. Silberman began investigating botox as another option.  New Jersey Sports Medicine and Performance Center is the only known center in the United States to offer Ankle Brachial Index Testing, Compartment Testing, and Botox injections for exertional leg pain under one roof.  Dr. Silberman determines which compartments have the highest pressures based on the compartment test and using those findings, will target the botox injection under US guidance directly into those compartments.  For popliteal artery entrapment the popliteal artery is visualized under ultrasound guidance and the gastrocnemius or other muscle is injected at the site of compression.

Expensive and cancer causing CT Scan imaging are not only harmful but are not indicated for exertional compartment syndrome diagnosis or treatment.  Do date there is not one study validating the use of CT Scan for the
diagnosis and treatment of exertional lower leg compartment syndrome in the scientific literature.  CT Scans give off ionizing radiation and children are more radiosensitive than adults, with a positive association of radiation dose and development of leukemia and brain cancer.

The Process:
After consultation, which may include an Ankle Brachial Index (ABI) Stress Test (...Dr. Silberman has diagnosed Popliteal Artery Entrapment Syndrome in multiple athletes who 'tested positive for compartment syndrome'...), a Compartment Test, review of imaging, ultrasound examination of  your compartment size, and  video gait analysis, the amount of Botox that will be used for your treatment is calculated and a prescription for Botulinum Toxin Type A (Botox) will be given to you to be filled at a pharmacy.  You will then return on a subsequent day with your Botox medication, which must be stored in a refrigerator 2° to 8°C (36º to 46ºF), and on the day of the procedure brought in to the office on ice within one hour.

Dr. Silberman performs Botox injections for compartment syndrome and popliteal artery entrapment under ultrasound guidance. He teaches other physicians how to perform testing and injections.  A local anesthetic will be used and the needle that is used for the Botox injection is a smaller gauge than the compartment testing needle. Botox injections are not injected on the same day as the compartment test.  Botox injections for compartment syndrome and popliteal artery entrapment are currently not covered by insurance.  The cost of  botox injections for exertional compartment syndrome affecting the anterior and deep posterior compartments in bilateral legs is $2000, or $500 per compartment.  

You may experience some soreness after the procedure that may last one to two weeks.  You may experience temporary weakness in the muscle as well.  Within one week, you may already experience a decrease in pain and symptoms.  Within 2 weeks, you may resume light running.   Within one month, you may be back to sports training fully though it may take several weeks to feel the full effect.  Individual results vary.

As an adjunct to botox, for those with compartment swelling, Dr. Silberman has been prescribing low dose diuretics with success, an overlooked and forgotten treatment of exertional compartment syndrome.
The chronic compartment syndrome and response to diuretic treatment.

We enjoy meeting people from other parts of the country and world, and hearing your stories.


Anterior Compartment Botox Ultrasound Guided Injection into Tibialis Anterior Muscle

Anterior Compartment Botox Ultrasound Guided Injection into Extensor Hallucis Longus Muscle directed at the neurovascular bundle

Lateral Compartment Botox
Ultrasound Guided Injection
into Peroneus Longus Muscle

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