Compartment Syndrome of the Lower Leg

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Original Editors - Geoffrey De Vos

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Search Strategy

I searched the PEDro –database, The Physiotherapy Evidence Database and Pubmed (medline)database to gain some information. In this databases I mostly searched for information (articles, EBP) that can be useful for physiotherapists, so subjects like diagnosis and treatment were my aim. I also searched information in books (literature) (see resources). I often used keywords as: compartment syndrome of lower leg・chronic exertional compartment syndrome ・Rehabilitation ・diagnosis ・treatment

Definition/Description

Compartment syndrome, in this case compartment syndrome of lower leg, is the compression of nerves, blood vessels, and muscle(s) inside a closed space (compartment) within the body ( see clinically relevant anatomy for more information about these compartments). This injury may lead to tissue death (necrosis) due to the blood vessels being compressed by the raised pressure within the compartment. So this compression causes an ischemia, a lack of oxygen, that can result in serious and dangerous tissue damages or tissue death when this injury isn’t treated well. Compartment syndrome most often involves the forearm and lower leg, and can be divided into acute, subacute, and chronic compartment syndrome ¹. This syndrome occurs fairly regularly and occurs in most of the times in athletes, such as long distance runners, soccer players and basketball players. It can also occur in children, adolescents or adults, but more often in adults^2&3.

Clinically Relevant Anatomy

The lower leg has four compartments. These four compartments are bordered by the tibia, fibula, interosseous membrane and the surrounding fasciae. The anterior compartment contains the profound peroneal nerve, tibial anterior muscle, extensor hallucis longus and extensor digitorum muscle. In the lateral compartment are the nervus peroneus communis and superficial peroneal nerve, the peroneus longus and brevis muscle. In the deep posterior compartment are the arteria, vena and nervus tibialis, the posterior tibial muscle, musculus flexor hallucis longus and flexor digitorum longus. The superficial posterior compartment consists of the sural nerve, the gastrocnemius muscle and the soleus muscle.¹
All this compartments are surrounded by fascia. This fascia is connected to bone and each of them has a blood and nerve supply. These fascias do not expand and when a compartment swells the pressure inside the compartment will increase which will cause tissue necrosis due by the compressing of blood vessels (decreased or no oxygen supply) and nerves.

Epidemiology /Etiology

Any condition that results in an increase or decrease of pressure in a compartment can lead to the development of an acute (ACS) or chronic exertional compartment syndrome (CECS). In most of the times ACS occurs after trauma (fractures), arterial injury, drug overdose, or burns². One of the main causes of CECS is repetitive and strenuous exercise (sports). During strenuous exercise, there can be up to a 20% increase in muscle volume and weight due to increased blood flow and oedema, so the pressure increases². Oedema of the soft tissue within the compartment further raises the intra-compartment pressure, which compromises venous and lymphatic drainage of the injured area. If the pressure further increases, it will eventually turn in to a vicious circle, that can lead to tissue ischemia. The normal mean interstitial tissue pressure in relaxed muscles is ± 10-12 mmHg. If this pressure elevates to 30 mmHg or more, small vessels in the tissue become compressed, which leads to reduced nutrient blood flow, ischemia and pain^1&2.

Characteristics/Clinical Presentation

Pain and swelling are the leading symptoms in this disease and it appears and aggravates during physical activities such as running and other sports like basketball and soccer. The pain is usually located over
the involved compartments and may radiate to the ankle or foot. Burning, cramping, or aching pain and tightness develop while exercising. In extreme cases (no or bad treatment) it is possible that the lower leg, ankle and foot can be paralysed² (C Reid D. et al).

Differential Diagnosis

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Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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