Compartment Syndrome of the Foot

Original Editors - Jessie Tourwe

Contents

Definition/Description

A compartment syndrome is a condition in which there arises a swelling in the body in areas surrounded by non-expandable structures. A compartment syndrome occurs when the muscles are compressed together along with nerves and blood vessels in a compartment. This compartment syndrome and also the swelling that follows usually occurs as a result of a bone fracture in the foot or as a compression of the foot itself. The swelling that occurs causes ,in most cases, a pinching of the surrounding nerves and blood vessels and thus causes a reduction in the blood circulation of the tissues. In order to avoid the risk at losing function maintenance and damage of the tissues, there should be performed a pressure relief. [1][2]

Clinically Relevant Anatomy

Anatomical studies of muscles and tendons show that the foot is divided into 4 large compartments (interosseous, medial, lateral, central) each including muscles, nerves and arteries. Early researches identified 9 compartments. However, it is very impractical to divide the foot into more than four compartments. That’s why most of the recent studies still refer to the foot as a whole of four compartments.[3]

There are only three compartments such as medial, lateral and superficial that run the entire length of the foot. Later four compartments were described. Patients who develops progressive claw-toe deformities due to calcaneal fractures, are given a compartment (calcaneal compartment).
The barrier between the flexor digitorum brevis and the calcaneal compartment (quadratus plantae) become incompetent at a pressure gradient of less than 10mm Hg. That means the barrier won’t impair tissue perfusion and allow an independent compartment syndrome. [4][5]

-Interosseous compartment:
Dorsal interossei muscles
Plantar interossei muscles
Plantar lateral artery, vein and nerve


- Medial compartment:
Abductor hallucis
Flexor hallucis brevis
Tendon of flexor hallucis brevis
Medial plantar arteries, veins and nerves


- Lateral compartment:
Abductor digiti minimi/quinti
Flexor digiti minimi
Opponens digiti minimi
Branches of the lateral plantar artery vein and nerve


- Central compartment (3 levels):
First level: Adductor hallucis
Second level: Quadratus plantae
Lumbrical muscles
Tendons of flexor digitorum longus
Third level: Flexor digitorum brevis
All levels of the central compartment contain (deep) branches of the plantar lateral artery, vein and nerve


 





 






 


  [6]
 

Epidemiology /Etiology 

Compartment syndrome of the foot is a syndrome with a low incidence and means that there is a higher than normal pressure in at least one of the 9 compartments of the foot. The calcaneal compartment seems to be at higher risk for developing the compartment syndrome, whereas the interosseous compartments are possibly at lower risk. Therefore, extra attention should be directed at the calcaneal compartment.[1][5][7][8]

Chronic (exertional) compartment syndromes take place when athletes make too many efforts during a sport causing an overuse injury. The muscles get tired and irritated resulting in an inflammation and swelling. Sports like soccer, biking, running, tennis, gymnastics can be risk factors.[9]
It is possible that athletes don’t have the appropriate training program so that they overstrain their muscles. Use of inappropriate footwear.[10]
Other causes can be biomechanical faults in a person’s anatomy.[9] Limb length differences, muscle weakness, tightness in specific joints etc

Acute compartment syndromes can be produced by many different events. Crush injuries cover the majority of compartment syndromes of the foot[3], next to this fact one notices snake bites, burns, metatarsal fractures, talus or calcaneus fractures, dislocation of the Chopart and/or Lisfranc joints etc.[3] [11]
Steroids: Using steroids or creatine makes the muscles increase in volume.[12]  (Level of evidence 1a)

Bandages: If a tape, bandage or cast is too tight fitted, it may lead to a compartment syndrome.

Characteristics/Clinical Presentation

As in almost any disease/injury, pain is also one of the key symptoms for the compartment syndrome of the foot. The pain will occur when the patient does active exercises, When he/she continues exercising, the pain-intensity will increase. After a resting period, the pain and tightness resolve. The most patients typically describe this kind of pain as an aching and burning pain.[13]

Pain during certain movements:[13][1][14][15]
- Pain with passive stretching
- Pain during active (dorsi)flexion of the foot
- Enlarged soreness caused by moving the toes
- Pain while palpating or squeezing the affected compartments[16]

Other relevant sings:[13][1][14][15]
- Swelling and tightness
- Pale skin on the spot of tissue damage
- Sensory deficits caused by neurological deficits[17]
- Firmness of the involved compartments[13]
- Muscle weakness with the intrinsic foot muscles[13]

Considering the 5 P’s: Pain, Pallor, Paresthesia, Paralysis, Pulselessness[6]

Differential diagnosis

The compartment syndrome is characterized by an increase of the interstitial pressure with severe pain and pain associated with passive stretching of the muscles as a result. Other consequences consist of a reduced supply of blood and fluid supply to tissues. Invasive measurement wherein a needle is placed in the body is considered to be a safe and quick method to determine compartment syndrome.[1]

Diagnostic Procedures

In order to diagnose a compartment syndrome there should be an awareness of the signs and symptoms specific to this syndrome as described above by the surgeon. There should also be appropriate clinical examination.[1]
If a compartment syndrome is suspected, frequent examination will be needed in the acute phase.
Some studies proofs that serial examinations that has to been taken at least every hour, are essential. This is due to muscle necrosis that occurs within 3 hours.[18]
A quick and safe procedure to diagnose a compartment syndrome is invasive measurement.[19] It is also the only valuable test to diagnose this syndrome. Otherwise known as Intracompartmental pressure monitoring (ICP). 

Outcome measures

The american orthopaedic foot and ankle society scale and the Visual analog scale have been used to measure quality of life after fasciotomy.[20]

Physical examination

The physical examination starts with the inspection. The physical therapist makes the comparison of the affected foot to the unaffected foot. In this phase of the examination, special attention needs to be paid to the specific symptoms which are described above. After inspection the therapist should examine the pain level by performing palpation and motion tests on the patient.

Physical relevant findings that may occur for compartment syndrome:[4][1]

- Weakness of dorsiflexion (anterior compartment)
- Weakness of eversion (lateral compartment)
- Weakness of plantar flexion (posterior compartment)


Although diagnostic devices are commercially available a complete and careful examination of patients suspected for compartment syndrome is necessary. However, the most important step in diagnosing a compartment syndrome is the surgeon’s awareness of this complication and appropriate clinical examination.[1]

Although this physical examination gives us a lot information, it isn’t enough to diagnose the compartment syndrome. Therefore a complete and careful clinical examination needs to be carried out by a doctor.

Medical Management

After determinating a compartment syndrome it is necessary to immediately carry out a fasciotomy in order to remove the excess pressure. A cast or brace can be used, but they should be left open for patients with severe pain and/or excess pressure in the affected compartment. Affected limbs should not be lifted in order to not affect the already impaired blood flow any more. (level of evidence 3b)[1]

Emergency decompressive fasciotomy is being conducted in acute compartment syndrome. 

  • Indication: decompressive fasciotomy is indicated when the intracompartmental pressure measurement with absolute value of 30-45 mm Hg.
  •  Techniques:

     -Dual dorsal incision is a gold standard technique, in which dorsal medial and lateral incision approach is being applied to release the compartments.

     -Single medial incision is applied through medial approach to release all compartments but it is technically challenging.

  • Complications: following fasciotomy care must be taken, otherwise chronic pain and hypersensitivity are the complications difficult to manage. Sometimes claw toes (fixed flexion deformity of digits) develops.[21]

Physical Therapy Management

Overall nonoperative treatment has been generally unsuccessful.[22]  After undergoing an operation the patient gets the advice to use ice packs and anti-inflammatory medication to reduce the swelling and to get enough rest. A physiotherapist can provide postoperative exercises to improve the muscle weakness and stimulate proprioceptive sensors. (Level of evidence 1b)

Soft tissue massage [9]

  • Effleurages, petrissages
  • Lymphatic drainage

Passive mobilization of the ankle joint, the metatarsals and phalanges [9]

  • Tractions

Use of orthotics [9] [10]
To correct biomechanical defaults
For example: orthopedic soles for pronated feet, flat feet etc.

Stretch exercises to improve flexibility [23]

  • Dorsal and plantar flexion - Let the patient move the feet up and down as far as possible. Repeating 10-20 times.
  • 2.Inversion and eversion - Let the patient move the feet in and out as far as possible. Repeating 10-20 times. 
  • 3. Rotation - Let the patient move the feet in circles as large as possible. Repeating 10-20 times.

Strength exercises for intrinsic foot muscles

  • Toe curl: Place a towel beneath the feet of the patient; he must pull the towel towards him by curling his toes into the towel. [24]
  •  Picking up marbles or other small objects: The patient has to claw his toes to be able to pick up the object from the floor.
  • Walking: Early postoperative exercises involve walking with crutches. Once the patient can painless put weight on his foot and is comfortable in proper shoes, he/she may start to walk.
  • Toe squeeze: Put some soft objects between the toes of the patient. Now he/she has to squeeze the toes and hold for 5 seconds, repeating 10 times.
  • Toe raises, toe curls: to improve dorsal and plantar flexion of the toes, the patient can actively move the toes up and down. This exercise can be performed dynamic or static.
  • Strength exercise for plantar flexion: rotations of the feet (feet must be kept together during the exercise) [24]
  • Strength exercise for dorsal flexion: cycling in the air, feet must unroll properly.[24]
  • Resistance band exercise: the patient can practice dorsal and plantar flexion, inversion and eversion. [23]

A low-key return to activities [22]

  • Walking

How far can the patient rely on his feet?
In case of immobilization, the patient learns to walk with two crutches (no support on foot), with 1 crutch and eventually walk without crutches.

  • When the patient can walk pain free, he/she can start constructive running.
  • Once the patient can run pain free, he/she may participate other sports.

Important! If pain or swelling occurs during or after exercise, elevate the foot and use ice packs to reduce the swelling.

Clinical Bottom Line

A compartment syndrome needs an immediate surgical treatment. Patients with severe postoperative pain, must be completely opened their tissue, to release extracorporal pressure. A diagnosed compartment syndrome needs immediate fasciotomy to release pressure from the affected compartment.[1]

References

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