Compartment Syndrome of the Lower Leg

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Original Editors - Geoffrey De Vos

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

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 of the lower leg has been defined as a condition which increased the pressure in a small place. This compromises the circulation and function of the tissues within that space. It is most commonly seen after injuries to the leg and forearm, but also occur in the arm, thigh, foot, buttock, hand and abdomen.^[4] This condition ensures that there will be compression on nervers, blood vessels and muscle(s) inside the compartment of the lower leg.^[2,3,4] 
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. In the literature the speak about three types of compartment syndrome. It can be divided into acute (ACS) , subacute, and chronic compartment syndrome (CECS).^[1]
Acute compartment syndrome (ACS) is caused by bleeding or oedema in a closed, non-elastic muscle compartment which is surrounded by fascia and bone. Among the most common causes of this complication are fractures, blunt trauma and reperfusion injury after acute arterial obstruction. Increasing intracompartmental pressure may lead to nerve damage and reduced tissue perfusion resulting in muscle ischaemia or necrosis mediated by infiltrating neutrophils.^[6]
Chronic compartment syndrome (CCS) is is a common injury in young athletes, causing pain in the involved leg compartment during strenuous exercise.^[10,11] It is clinically manifest by recurrent episodes of muscle cramping, tightness, and occasional paresthesias.^[13] Also their is an increase of pressure in skeletal muscle accompanied by pain, swelling, and impaired muscle function. Unlike other exertional injuries such as stress fracture, periostitis, or tendonitis, this problem does not respond to antiinflammatory medications or physical therapy.^[10,11]
This syndrome occurs fairly regularly and occurs in most of the times in athletes, such as long distance runners, soccer players, basketball players and military men and women.^[7,13] It can also occur in children, adolescents or adults, but more often in adults.^[2,3]

Clinically Relevant Anatomy

In the lower leg, they speak about four compartments. So as you can see on the picture, we have the anterior, lateral, deep posterior and superficial posterior. The bones of the lower leg (tibia and fibula), the interosseous membrane and the anterior intermuscular septum are the borders of the compartments. The anterior compartment include M. tibialis anterior, M. ext. hallucis longus, M. ext. digitorum longus, M. peroneus tertius, A. tibialis anterior and the deep peroneal nerve. The lateral compartment include M. peroneus longus and brevis and also the N. superficial peroneal. The deep posterior compartment include M. tibialis posterior, M. flex. hallucis longus, M. flex. digitorum longus, M. popliteus, A. tibialis posterior and the N. tibialis. The superficial posterior compartment include the M. gastrocnemius, M. soleus, M. plantaris and N. sural. 1All 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 and nerves.^[9,19]

Epidemiology /Etiology

The average annual incidence of ACS for men are 7.3 per 100.000 and by women 0.7 per 100.000. To most of the patients are young men with fractures of the tibial diaphysis, with a injury to the soft tissues or those with a bleeding diathesis. Any condition that results in an increase 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: ^[8,9]
- Fracture of the tibial diaphysis
- Soft-tissue injury
- Intensive muscle use
- Everyday extreme exercise activities
- Arterial injury
- Drug overdose
- Burns

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 increases.^[2] 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 into 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] The anterior compartment is affected more frequently than the lateral, deep and superficial posterior compartments.^[7]

Characteristics/Clinical Presentation

Patients with compartment syndrome of the lower leg suffer from long term impairment such as reduced muscular strength, reduced range of motion and pain.^[6]
The most common symptoms by a compartment syndrome are:^[9]
- Feeling of tightness
- Swelling
- Pain (by active flexion knee and particularly passive stretching of the muscles)
- Paresthesia

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 paralysed.^[2] (C Reid D. et al)

Differential Diagnosis

Patients with exercise-induced lower leg pain, 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]

Pain:
Pain is classically the first sign of the development of ACS, is ischaemic in nature, and is described as being out of proportion to the clinical situation. There are a number of problems with this symptom, not least of which is the subjective nature of the severity of pain with psychosocial factors such as anxiety, heightened concern about illness, beliefs, and expectations influencing pain intensity in patients with disabling musculoskeletal pain. Pain may be an unreliable indication of the presence of ACS because it can be variable in its intensity. It may be absent in ACS associated with nerve injury, or minimal in the deep posterior compartment syndrome, and cannot be elicited in the unconscious patient or where regional anaesthesia is used. Children or patients with learning disabilities may not be able to express the severity of their pain, so restlessness, agitation, and anxiety with increasing analgesic requirements should raise the suspicion of the presence of ACS. Increasing requirements for opiates in all patients should also be considered in assessing the severity of pain.
The sensitivity of pain in the diagnosis of ACS is only 19 % with a specificity of 97 %, which results in a high proportion of false-negative or missed cases but a low proportion of false-positive cases, but if present it is recognised as a relatively early symptom of ACS in the awake alert patient.
Pain with passive stretch is assessed by stretching the affected muscle group. For example, if ACS is suspected in the deep posterior compartment of the leg and the foot is dorsiflexed, increased pain should be evident.

Neurological symptoms and signs:
Paraesthesia and hypoesthesia may occur in the territory of the nerves traversing the affected compartment and are usually the first signs of nerve ischaemia, although sensory abnormality may be the result of concomitant nerve injury. Ulmer reports a sensitivity of 13 % and specificity of 98 % for the clinical finding of paraesthesia in ACS, a false-negative rate that precludes this symptom from being a useful diagnostic tool.
Paralysis of muscles contained in the affected compartments is recognised as being a late sign and has equally low sensitivity as others in predicting the presence of ACS, probably because of the difficulty in interpreting the underlying cause of the weakness, which could be inhibition by pain, direct injury to muscle, or associated nerve injury.

Swelling:
Swelling in the compartment affected can be a sign of ACS, although the degree of swelling is difficult to assess accurately, making this sign very subjective. The compartment may be obscured by casts, dressing, or other muscle groups, for example in the case of the deep posterior compartment. Poor sensitivity, specificity, and negative and positive predictive values have been demonstrated when manual palpation was used to determine whether ICP was raised in cadaveric limbs.

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

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Examination

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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

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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

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Recent Related Research (from Pubmed)

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References

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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