Compartment Syndrome of the Foot

Original Editors - Jessie Tourwe

Top Contributors - Jessie Tourwe, Tomer Yona, Scott Cornish, Rachael Lowe and Samrah khan  

Definition/Description

Compartment syndrome is a condition where bleeding or oedema develops in an area of the body which is surrounded by non-expandable structures of bone and fascia, increasing the local pressure and causing circulatory disturbance in that space. This can lead to ischaemia and necrosis if left improperly diagnosed. The cause is usually following trauma (acute) [1] or it can be due to intense or overly frequent exercise (chronic exertional compartment syndrome) or overly tight casts. Fasciotomy is usually performed although non surgical treatment is also an option. [2][3]

Clinically Relevant Anatomy

The foot is divided into 4 large compartments (interosseous, medial, lateral, central) each including muscles, nerves and arteries, although it is debated whether there are actually 9 compartments, however, it is more practical to think of the foot in 4 compartments.[4]

There are three compartments such as medial, lateral and superficial that run the entire length of the foot. although a 4th, the calcaneal compartment has been described in patients who develop progressive claw-toe deformities due to calcaneal fractures,

The boundary between flexor digitorum brevis and the calcaneal compartment (quadratus plantae) becomes incompetent at a pressure gradient of less than 10mm Hg, so tissue perfusion becomes insignificant, effectively creating an independent compartment syndrome. [5][6]

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

[7]

Epidemiology /Etiology 

Compartments of the foot-14E9C44BFB5786DE26D.jpg

Incidence of compartment syndrome of the foot is low. The calcaneal compartment seems to be at higher risk for developing compartment syndrome, whereas the interosseous compartments are usually at a lower risk. [2][6][8][9]

Chronic (exertional) compartment syndrome can develop through over exertion during sporting activity . The muscles become fatigued and irritated resulting in an inflammatory response and swelling. Sports like football, motorcross, running, tennis and gymnastics can be risk factors.[10] Training programmes may be inappropriate or incorrect footwear could be a cause.[11] Other causes can be biomechanical abnormailities, limb length differences, muscle weakness or muscular tightness.[10]

Crush injuries are the most common cause of compartment syndromes of the foot [4], as well as snake bites, burns, too tighlty fittted bandages or casts, metatarsal fractures, talus or calcaneus fractures, dislocation of the Chopart and/or Lisfranc joint dislocations, [4] [12] steroid or creatine use which can cause muscles to increase in volume.[13] 

Characteristics/Clinical Presentation

Pain is one of the key symptoms for compartment syndrome, being severe and spontaneous or occurring during active exercises, often increasing in intensity as the activity continues, only resolving on rest. Typically, the pain is described as an aching and/or sensation burning .[14]

Movement usually eliciting pain [14][2][15][16]

  • Pain with passive stretching
  • Pain during active dorsiflexion of the foot
  • Increased soreness caused by moving the toes
  • Pain on palpation or compressing the affected compartments [17]

Other relevant signs: [14][2][15][16]

  • Swelling and tightness
  • Pale skin in the area of tissue damage
  • Sensory deficits caused by neurological injury [18]
  • Firmness of the involved compartments [14]
  • Muscle weakness of the intrinsic foot muscles [14]

The 5 P’s may be considered when diagnosing compartment syndrome: Pain, Pallor, Paresthesia, Paralysis, Pulselessness [7]

Differential diagnosis

Compartment syndrome is characterised 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.[2]

Diagnostic Procedures

Awareness of the signs and symptoms specific to this syndrome are key to an accurate diagnosis, alongside an appropriate clinical examination.[2] Where compartment syndrome is suspected, frequent examination is required in the acute phase, sometimes hourly, as muscle necrosis can occur within 3 hours.[19]

A quick and safe procedure to diagnose compartment syndrome is invasive measurement.[20] where a needle is placed into the area, 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 visual analog scale have been used to measure quality of life after fasciotomy.[21]

Physical examination

Awareness of the complication, an appropriate clinical examination, comparison of the affected foot to the unaffected foot with attention to the syndrome's specific symptoms are most important. Pain levels are assessed through palpation and active and passive range of motion tests on the patient.

Physically relevant findings that may occur for compartment syndrome: [5][2]

  • Weak dorsiflexion (anterior compartment)
  • Weak eversion (lateral compartment)
  • Weak plantar flexion (posterior compartment)

Medical Management

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. [2]

Emergency decompressive fasciotomy is conducted with an acute compartment syndrome. 

  • Indication: when the intracompartmental pressure measurement has an absolute value of 30-45 mm Hg.
  • Techniques:
    • Dual dorsal incision is the gold standard technique. A dorsal medial and lateral incision is made to release the compartments.
    • A single medial incision is used to release all compartments, but it is technically more challenging.
  • Complications: chronic pain and hypersensitivity are possible complications and can be difficult to manage. Sometimes claw toes develops.[22]

Physical Therapy Management

Nonoperative treatment is on the whole not successful.[23]  Post operatively, patients are advised to use ice and anti-inflammatory medication to reduce swelling and to rest. An exercises programme is given to improve muscle weakness and to stimulate proprioceptive sensors.

Soft tissue massage [10] may be used to provide lymphatic drainage. Passive mobilisation of the ankle joint, the metatarsals and phalanges [10] is useful for increased range of motion and mobility of joints along with lower limb stretches.

Orthotics [10] [11] can be prscribed where there are biomechanical defaults.

Recommended strength exercises for the 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 include mobilising with crutches, gradually progressing to full weight bearing
  • Toe squeeze: Soft objects are squeezed between the toes and held for 5 seconds
  • Toe raises, toe curls:
  • Dorsal and plantar flexion, inversion and eversion using a resistance band [25]

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

Clinical Bottom Line

A compartment syndrome needs an immediate surgical treatment to avoid ischemia, and functional impairment and/or potential nerve damage of the foot.[2]

References

  1. Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment Syndrome of the Lower Leg and Foot. Clinical Orthopaedics and Related Research. 2010;468(4):940-950.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Frink M, Hildebrand F. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010 Apr; 468(4): 940-950.
  3. Abraham T Rasul Jr. Compartment syndrome. eMedicine. 11 March 2009
  4. 4.0 4.1 4.2 Haddad S L, Managing risk: compartment syndromes of the foot. American Academy of Orthopaedics Surgeons, Jan/Feb 2007 http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp
  5. 5.0 5.1 Guyton GP, Shearman CM, Saltzman CL. The compartments of the foot revisited. Rethinking the validity of cadaver infusion experiments. J Bone Joint Surg Br. 2001;83:245–249.
  6. 6.0 6.1 Manoli A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle. 1990;10:267–275.
  7. 7.0 7.1 Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus. Bohn Stafleu Van Loghum, Houten 2005. Pg 463
  8. Myerson, M. S. (1991). Management of compartment syndromes of the foot. Clinical orthopaedics and related research, 271, 239-248.
  9. Shereff, M. J. (1990). Compartment syndromes of the foot. Instructional course lectures, 39, 127.
  10. 10.0 10.1 10.2 10.3 10.4 http://www.physioadvisor.com.au/10513350/compartment-syndrome-chronic-compartment-syndrom.htm
  11. 11.0 11.1 http://orthoinfo.aaos.org/topic.cfm?topic=a00204
  12. Cite error: Invalid <ref> tag; no text was provided for refs named BRON_3
  13. Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010 http://ukpmc.ac.uk/articles/PMC2941579/ (accessed on november/december 2010) Level of evidence: A1
  14. 14.0 14.1 14.2 14.3 14.4 Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010
  15. 15.0 15.1 Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma. 2002;16:572–577.
  16. 16.0 16.1 Abraham T Rasul Jr. Compartment syndrome. eMedicine. 11 March 2009
  17. Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus. Bohn Stafleu Van Loghum, Houten 2010.
  18. Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, Somogyi D. Acute compartment syndrome: How long before muscle necrosis occurs? CJEM. 2004;6:147–154.
  19. Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, Somogyi D. Acute compartment syndrome: How long before muscle necrosis occurs? CJEM. 2004;6:147–154.
  20. Whitesides TE, Jr, Haney TC, Harada H, Holmes HE, Morimoto K. A simple method for tissue pressure determination. Arch Surg. 1975;110:1311–1313.
  21. Han, F., Daruwalla, Z. J., Shen, L., and Kumar, V. P. (2015). A prospective study of surgical outcomes and quality of life in severe foot trauma and associated compartment syndrome after fasciotomy. The Journal of Foot and Ankle Surgery, 54(3), 417-423.
  22. Karadsheh M. Foot Compartment Syndrome. http://www.orthobullets.com (accessed 27 December 2016).
  23. Matthew R. Bong, M.D., Daniel B. Polatsch, M.D., Laith M. Jazrawi, M.D. and Andrew S. Rokito, M.D. Chronic Exertional Compartment Syndrome. Diagnosis and Management. Bulletin, Hospital for joint diseases. Volume 62, N° 3, 4. 2005
  24. Cite error: Invalid <ref> tag; no text was provided for refs named BRON_11
  25. http://www.physioadvisor.com.au/8047989/ankle-flexibility-exercises-ankle-sprains-ankle.htm