Compartment syndrome is an overuse injury which usually occurs in the front of the lower leg. This is known as anterior compartment syndrome, although there are other compartments which can be affected,
The symptoms of compartment syndrome in runners usually start with a tightening feeling in the front of the lower leg, to the outside of the shin bone. As exercise continues this area starts to feel full, swollen and weak and the muscles appear to be bulging. The runner may notice that they can’t control the downward motion of the foot on heel strike – known as a foot slap. Once exercise stops, the symptoms usually fade quite quickly.
Whilst compartment syndrome may be suspected by your therapist / Doctor, the only way to accurately diagnose it is with compartment pressure testing before and after exercise, using probes inserted into the leg.
It is important that the condition is properly diagnosed, to rule out other conditions such as shin splints, deep vein thrombosis, nerve and vascular entrapment syndromes, infections, myopathies and tumours.
What is compartment syndrome?
A compartment is a group of muscles / tendons / nerves / blood vessels and other structures which are all grouped together and surrounded by fascia (a form of relatively inelastic connective tissue). In the lower leg, these compartments include the anterior compartment, lateral compartment and deep posterior compartment.
Compartment syndrome occurs when the contents of a compartment becomes too big for the surrounding fascia. This is usually due to swelling / an increase in blood supply / bleeding.
Compartment syndromes can be either chronic, or acute. Acute cases occur due to a sudden impact to the area which causes bleeding and swelling within the compartment. This is a medical emergency as the increased pressure within the compartment can result in blood supply being cut off and lead to tissue death. Chronic cases are sometimes known as chronic exertional compartment syndromes as they develop gradually due to exercise or other forms of ‘exertion’. This is the type of compartment syndrome we are referring to in runners. It is not as serious as acute compartment syndrome and will usually cause no long term damage, other than putting someone off exercising!
Anterior compartment syndrome is the most common form of compartment syndrome. The anterior compartment is found at the front of the lower leg, just to the outside of where the shin bone can be felt. This compartment contains the Tibialis Anterior, Extensor Digitorum Longus and Extensor Hallucis Longus, as well as the anterior tibial artery and deep peronal nerve. The sheath surrounding this compartment is particularly unwielding, which puts this compartment at particular risk.
Treatment of Compartment Syndromes
The initial course of action with a compartment syndrome is physical therapy – to identify and correct problems which may be contributing to increased muscle expansion within the compartment. These might include faulty foot biomechanics or running form, increased muscle tension, inadequate footwear etc. A podiatrist is usually in a good position to evaluate this and suggest solutions regarding exercises and orthotic inserts if necessary. Soft tissue treatments such as massage may have some effect in loosening the muscle and fascia of the compartment, but so far research has shown little benefit.
My personal experience with anterior compartment syndrome (although not officially diagnosed) came whilst training for a half marathon. The typical symptoms presented, but did ease with stretching, massage and running gait alterations – mainly moving to a more mid-foot landing. Whilst this may not work for everyone, it is well worth a try.
For persistent cases which do not repsond to treatment, surgery by way of a fasciotomy is usually recommended. This involves releasing the tight fascia, to allow more space in the compartment for muscle expansion.
Physical therapy post-surgery varies slightly from surgeon to surgeon but many advocate an early mobilisation program with ankle range of motion exercises starting on day 1 post-op and weight bearing as soon as possible, with unaided walking within 3-5 days. Once surgical scars have healed, non-weight bearing exercise such as cycling and swimming can begin, usually at around 3 weeks. A return to running is expected around 8-12 weeks post surgery.