Compartment Syndrome of the Lower Leg

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Geoffrey De Vos

Top Contributors - Delmoitie Giovanni, Scott Cornish, Geoffrey De Vos, Admin, Lucinda hampton, Kim Jackson, Glenn-Gerlo, Bettina Vansintjan, Karen Wilson, Wanda van Niekerk, Naomi O'Reilly, WikiSysop and Fasuba Ayobami  

Search Strategy

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

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

Patients with exercise-induced lower leg pain, the differential diagnosis includes: medial tibial stress syndrome (MTSS), fibular and tibial stress fractures, fascial defects, nerve entrapment syndromes, vascular claudication and lumbar disc herniation ².

Diagnostic Procedures

ACS: -Upon inspection, the primary finding is swelling of the affected extremity
-The inability to actively move flexors and extensors of the foot is an important indicator¹.
- Signs such as progression of pain complaints.
-Pain with passive stretching of the affected muscles.
-Often a sensation disturbance in the web space between the first and second toes is found as a
consequence of compression or ischemia of the deep peroneal nerve. This nerve is found in the
anterior compartment; reduced sensibility represents a late sign of the ACS
- absence of arterial pulsations is more often a sign of arterial injury than a very late sign of the
ACS.

CECS: - Pain starts within first 30 minutes of exercise and can radiate to ankle/foot².
- Pain ceases when activity is stopped.
-Daily activities usually not provocative.
-Upon inspection, the primary finding is swelling of the affected extremity
-The inability to actively move flexors and extensors of the foot is an important indicator.
- Signs such as progression of pain complaints.
-Recording of intra-compartmental tissue pressures ² (needle and manometer, wick catheter, slit
catheter): 1) A pre-exercise pressure of ≥ 15 mmHg,
                  2) 1 minute post-exercise pressure of ≥ 30 mmHg,
                   3) 5 minute post-exercise pressure of ≥ 20 mmHg.
-MRI

By recognizing these signs in a timely fashion, it is possible to identify an ACS en CECS early, so that the treatment can be started immediately.

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

Examination

add text here related to physical examination and assessment

Medical Management

Treatment should begin with rest, icing (RICE), activity modification and sometimes nonsteroidal anti-inflammatory drugs.

Physical Therapy Management

The only nonoperative treatment that is certain to alleviate the pain of CECS is the cessation of causative activities. The patient should continue his normal physical activities, to the limit that the pain allows it, so lower intensity of frequency of exercising (activity modification). Unfortunately, this is an unappealing option for the competitive and recreational athlete. Cycling may be substituted for running in patients who wish to maintain their cardiorespiratory fitness, as it is associated with a lower risk of compartment pressure elevation. Massage therapy may provide some benefit to patients with mild symptoms or to those who decline surgical intervention. Overall, however, nonoperative treatment has been generally unsuccessful².
The symptoms will not disappear without treatment. Untreated compartment syndrome can cause ischemia of the muscles and nerves and can eventually lead to irreversible damage like tissue death, muscle necrosis and permanent neurological deficit within the compartment.
The only treatment that’s effective in this disease is surgical treatment, more specifically a fasciotomy. A little incision will be made in the lower leg (one of the compartments) to decrease the intra compartment pressure and eventually the symptoms will disappear and most of the patients recover well² (M Béuima M. et al).

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

Articles:

Oprel PP., Eversdij MG., Vlot J., Tuinebreijer WE. The Acute Compartment Syndrome of the Lower Leg: A Difficult Diagnosis? Department of Surgery-Traumatology and Pediatric Surgery, Erasmus MC, University Medical Center Rotterdam, The Open Orthopaedics Journal, 2010, 4, 115-119 ( BEOORDELING A1, EBP article)

Bong MR., Polatsch DB., Jazrawi LM., Rokit AS. Chronic Exertional Compartment Syndrome, Diagnosis and Management. Hospital for Joint Diseases 2005, Volume 62, Numbers 3 & 4 ( BEOORDELING A2)

Rorabeck CH. The treatment of compartment syndromes of the leg. Division of Orthopaedic Surgery, University Hospital, London, Ontario, Canada, © 1984 British Editorial Society of Bone and Joint Surgery vol. 66-b ( BEOORDELING A2/B)

Literature: Secundary Resources

M Béuima M., Bojanic I.. Overuse injuries of the musculoskeletal system. CRC press,

C Reid D.. Sports injuries assessment and rehabilitation. Churchill Livingstone USA, 1992

Clinical Bottom Line

add text here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.

1) Oprel PP., Eversdij MG., Vlot J., Tuinebreijer WE. The Acute Compartment Syndrome of the Lower Leg: A Difficult Diagnosis? Department of Surgery-Traumatology and Pediatric Surgery, Erasmus MC, University Medical Center Rotterdam, The Open Orthopaedics Journal, 2010, 4, 115-119

2)Bong MR., Polatsch DB., Jazrawi LM., Rokit AS. Chronic Exertional Compartment Syndrome, Diagnosis and Management. Hospital for Joint Diseases 2005, Volume 62, Numbers 3 & 4

3)Rorabeck CH. The treatment of compartment syndromes of the leg. Division of Orthopaedic Surgery, University Hospital, London, Ontario, Canada, © 1984 British Editorial Society of Bone and Joint Surgery vol. 66-b