Compartment syndromes are potentially serious problems and can be hard to diagnose. Compartment syndromes come in two varieties. Acute compartment syndrome occurs with a quick hit, a sudden trauma, or a relatively sedentary person undertaking strenuous exercise. Acute compartment syndrome progresses quickly and is a medical emergency requiring immediate surgery. Exercise (also known as chronic or exertional) induced compartment syndrome develops over time as a result of a repetitious activity. This syndrome can plague many athletes but is predominate in runners. It is seen most frequently in cross country runners, track athletes, and soccer players who run extensively, especially on uneven surfaces. As these athletes run, the muscles in the lower leg compartments hypertrophy causing increased pressure in the compartment. Exercise induced compartment syndrome if gone undiagnosed and untreated can lead to an acute compartment syndrome. Symptoms Exercise induced compartment syndrome is identified with exercise related pain. Symptoms start gradually, usually with and increase in training or training on hard surfaces. Pain is only present with exertion, it’s rarely present on first impact, and can develop within 2-3 minutes of activity. Pain dramatically decreases or is absent at rest. The pain is described as aching, burning, or cramping. The athlete may feel tightness, pain, numbness, and tingling in typically one lower extremity. Symptoms usually occur around the same time each time the athlete participates in the activity and remains constant if the activity continues. The pain can be so severe the athlete is unable to continue to exercise or compete and resolves within minutes after cessation of exercise. As symptoms progress, a dull aching pain may persist and foot drop may be noticed with running. Pain may be localized in one or multiple compartments. Exercise induced compartment syndrome gone untreated can develop into acute compartment syndrome, which is a medical emergency. Acute compartment syndrome symptoms include pain out of proportion to the injury, swelling, and tenderness in the area. Other symptoms include severe pain with passive motion of the muscles within the affected compartment; skin pallor, sensory changes and paresthesias of the nerves. These types of symptoms require immediate medical attention and surgery. Causes Classified as an overuse injury, clinical manifestations of this condition include increased intracompartmental pressure leading to ischemic changes within the compartments effected. The cause of elevated intracompartmental pressures is trauma or excessive muscle hypertrophy resulting in excessive fluid or blood accumulation within a closed space. Muscle compartments in the body are wrapped in relatively flexible fascia. Also enclosed are the nerves and blood vessels, which serve these muscles. Exertion-related fiber swelling and increased intracompartmental blood volume or increased osmotic pressure associated with myofiber damage may cause pressures to rise. If the fascia does not stretch to accommodate the pressure the athlete can develop elevated compartment pressures. Once the tissue pressure rises above the arterial perfusion pressure, the flow of oxygen and blood will cease and tissue hypoxia will occur. If pressures remain elevated long enough, a potentially irreversible cycle of swelling and ischemia can occur, leading to acute compartment syndrome, in which tissue metabolic demands are not met leading to restriction of blood flow and muscle necrosis. Irreversible muscle necrosis releases a product called myoglobin. High concentrations of myoblogin in the urine leads to high serum creatine phosphokinase levels ultimately resulting in acute renal failure. Acute compartment syndrome can result in permanent tissue impairment, contractures, rhabdomylosis, limb loss, kidney failure, and even death. Compartment syndrome (either acute or exercise induced forms) occurs more commonly in one of the four smaller lower extremity compartments: anterior, lateral, deep and superficial posterior. The compartments most commonly involved are the anterior and lateral. Diagnosis Differential diagnosis includes stress fractures, shin splints, and tenosynovitis of the anterior tibia or peroneal muscle. Often physical examination is often unrevealing, but occasionally the compartment is tender with palpation and muscle herniation is found with active dosiflexion of the foot in 20-60% of patients with anterior compartment symptoms. Generally imaging studies are helpful to rule out differential diagnosis, i.e.: bone scan, plain film, MRI, but is not helpful in the diagnosis of exercise induced compartment syndrome. Measuring compartment pressures is an effective way to confirm the diagnosis of exercise induced compartment syndrome. This procedure is performed before and after exercise in an outpatient setting. Normal compartment pressures should be less than 10mm Hg. The commonly accepted pressure criteria for the diagnosis of exercised induced compartment syndrome is as follows: – A resting pressure greater than 15mm Hg – An exertional pressure greater than 30 mm Hg – A pressure of 20mm Hg or higher 5 minutes after stopping exercise In order to effectively measure compartment pressures a catheter is inserted within the effected compartment under sterile procedure. Insertion of the catheter causes minimal discomfort for the patient due to skin anesthetization. Once the catheter is stabilized an opening pressure is obtained before exercise this is recorded as the resting pressure. The patient is then placed on a treadmill and exercises until pain develops. The speed and incline are variable according to the patients’ pain tolerance and exercise performance. A visual analog scale is used to asses the patients’ pain. At two minutes the patients’ pain VAS is recorded. The patient continues to exercise until pain is rated 7-8 on VAS then total time is recorded. Pressures are attained and recorded at one minute post exercise (recorded as exertional pressure) and five minutes post exercise. The newest specific and sensitive testing method to diagnosis compartment syndromes is thallous chloride scintigraphy. Use of stress thallium revealed reversible ischemia in the involved compartments of the lower extremity during exercise. This testing is easily ordered and noninvasive, unfortunately it is expensive and insurance authorization may be difficult. Treatment Traditionally, treatment of acute compartment syndrome involves immediate surgical intervention, and fasciotomy is the procedure of choice. Exercise induced compartment syndrome focuses on conservative treatment of: rest, ice, and gentle stretching. A trial of non-steroidal anti-inflammatory drugs may be beneficial in decreasing swelling. If symptoms persist with conservative care, surgery may be indicated and necessary for the athlete to return to sport. If fasciotomy is performed, post-surgical rehabilitation for exercise induced compartment syndrome should follow: – Weight bearing as tolerated and gentle range of motion are begun at 1-2 weeks – Establishing normal muscle lengths throughout the kinetic chain, especially the lengthening of the gastrocnemius, posterior and anterior tibialis. – Full return to activity, such as running, usually takes 8-12 weeks. Prevention Prevention includes patient education of avoiding running on hard surfaces and to wear running shoes with the appropriate amount of cushion and a flared heel. Massage has been shown to be promising. Finally, the control of pronation in the arches with orthotics is important. Conclusion Compartment syndrome can be very dangerous. It can occur quickly and can lead to devastating results including permanent loss of function. Compartment syndrome (acute or chronic) can affect not only lower extremities but also any part of the body that has a compartmental anatomy. This includes the hands, forearms, abdomen, thighs, and gluteal regions. A quick diagnosis and treatment is crucial before permanent damage takes effect. If you have developed similar signs and symptoms please consult your physician immediately. References Edwards P, Myerson, M: Exertional Compartment Syndrome of the Leg: Steps for Expedient Return to Activity. The Physician and Sportsmedicine 1996; (24):1-7 [Free Full Text] Potteiger JA, Randall JC, Schrodeder C, Magee LM, Hulver MW: Elevated Anterior Compartment Pressure. Journal of Athletic Training 2001; (1): 85-88 Frontera WR, Silver JK: Essentials of Physical Medicine and Rehabilitation:2002; 316-321
Provided by
