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What is it?

Compartment syndrome occurs when pressure builds up within a muscle compartment, a space bound by muscles and a thick connective tissue called fascia. Fascia serves as a support structure for muscles, helping to maintain shape and enhance movement efficiency. However, when pressure within the compartment rises too high, it can compromise blood flow and damage muscles and nerves.

Muscle Compartments. Source

Types of Compartment Syndrome:

Acute Compartment Syndrome (ACS)

  • Less common but serious.
  • Typically results from trauma, such as fractures, crush injuries, or accidents that cause bleeding or swelling within a muscle compartment.
  • It is a medical emergency requiring prompt surgical intervention, usually a fasciotomy (surgical cutting of fascia) to relieve pressure and restore blood flow.

Chronic Exertional Compartment Syndrome (CECS)

  • More common and exercise-induced.
  • Characterised by a gradual buildup of pressure in the muscle compartments during exercise.
  • Frequently affects the lower limb, particularly the calf (posterior compartment) or shin (anterior compartment).
  • Whilst not an emergency, CECS can significantly affect quality of life by limiting physical activity.
  • This article will focus on CECS.

Signs and Symptoms of CECS

Chronic exertional compartment syndrome is often recognised by its predictable pattern of symptoms:

  • Pain or tightness in the affected area, typically in the shin or calf, during exercise.
  • Symptoms begin shortly after starting activity and progressively worsen, making it difficult to continue.
  • Pain subsides quickly when the activity stops.
  • Swelling or a feeling of fullness in the affected area during activity.
  • Possible tingling or numbness in the foot, due to pressure on nearby nerves.
  • Pain when the muscle is stretched.

Causes and Contributing Factors

The exact causes of CECS are not fully understood, but several theories have been proposed, including:

Medical Theories:

  1. Tight fascia: Fascia naturally adapts to stress, increasing its fibroblastic activity (collagen production). In CECS, this adaptation may be excessive, causing the fascia to become overly tight and restricting the muscle’s ability to expand during exercise.
  2. Muscle swelling: Exercise increases blood flow to muscles, causing them to expand temporarily. In CECS, the veins may struggle to drain blood efficiently, leading to muscles swelling more than usual, causing an abnormal pressure buildup within the compartment.

Mechanical Theories:

  1. Abnormal foot posture: Flat feet or over-pronation can increase stress on the lower leg, leading to overuse and swelling in the muscles.
  2. Tight calf muscles: This may predispose the shin or posterior compartments to excessive strain.
  3. Imbalanced exercise routine: Overtraining certain muscle groups without adequate recovery or strength training for other areas may contribute to dysfunction.
  4. Weak hip stabilisers: Hip weakness can increase load on the lower leg muscles, contributing to CECS symptoms.

Diagnosis

A combination of clinical assessment and diagnostic tests is often used:

  • Clinical signs: Pain that reliably starts after a specific duration of exercise and resolves quickly with rest is a hallmark symptom.
  • Compartment pressure testing: A small needle is inserted into the affected compartment to measure pressure at rest and after exercise. Elevated pressures confirm the diagnosis.

Prognosis

The outlook for CECS varies depending on the severity and treatment approach:

  • Conservative treatment (e.g., physiotherapy) is often effective in mild to moderate cases, especially when biomechanical issues are addressed.
  • Severe cases or those resistant to conservative care may require surgical intervention. Results can vary and may not always resolve symptoms

Treatment Options

1. Physiotherapy and Rehabilitation

Conservative management focuses on reducing symptoms, correcting underlying issues, and gradually returning to activity:

  • Pain relief and inflammation control: Techniques such as taping, massage, dry needling, and activity modification may help.
  • Biomechanical correction:
    • Address foot posture with orthotics or specific exercises.
    • Gait training to improve load distribution.
    • Strengthen weak areas, such as the hips, to offload stress on the lower leg.
  • Graded return to activity: A structured program helps rebuild tolerance to exercise without triggering symptoms.

2. Surgical Intervention

  • Fasciotomy: This involves cutting the fascia to release pressure. While generally safe, the procedure is not always successful, with some patients continuing to experience symptoms. Typically only considered if conservative management fails.

3. Injections

  • Botulinum toxin (Botox): Injected into the affected muscles to reduce their activity and alleviate symptoms. Relief typically lasts about five months, and repeated injections may be needed.

4. Additional Interventions

  • Activity modification: Switching to low-impact activities such as swimming or cycling can reduce symptoms while maintaining fitness. This may be done in the early stages before gradually returning to normal activities.
  • Alternative therapies: Modalities like shockwave therapy and acupuncture may be explored in consultation with a physiotherapist.

This information is provided for educational purposes only. Always consult your physiotherapist or other health professional for personalised advice.