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Compartment Syndrome

Compartment syndrome, which is medically termed as chronic exertional compartment syndrome (CECS), affects the lower leg.

Our lower legs is divided into four or five different compartments that contain different

  • muscles
  • nerves
  • blood vessels
  • tendons

contained and going through these compartments. 

Each compartment is contained or surrounded by fascia, which smoothens and helps to ease muscle contractions / movement as well as dividing the muscles from the other tissues.

In the event of compartment syndrome, what happens is that pressure inside one or more of these compartments increases such that the internal pressure is too high, pressing and compressing the muscles, blood vessels or nerves.

In the beginning, patients tend to "only" experience some mild ache, but when it gets worse, the pain can be very intense. In worse conditions, one may lose control and function of the compressed structures, or worse, cellular death through pressure, crush and compression.

What Causes Compartment Syndrome?

Compartment syndrome usually becomes more obvious with increase use, activity or training. As we use the muscles (contractions repeatedly), there will be cumulative build up of waste materials on top of increased blood flow to the muscles involved.

This can cause the volume in the active muscles to increase up to 20%, which increases compressive pressure within the muscle compartment. Also, the normal size of the muscles can increase at baseline due to hypertrophy growth from training.

All these changes are normal, and the increases pressures can decrease normally within 10 minutes after the activities, trainings or exercise.

Here's where it gets different: compartment syndrome seems to happen due to different anatomy -- most individuals have 4 compartments in the lower leg...and in some individuals, there is an "extra 5th" compartment deep inside the lower leg, covered with an additional fascial sheath that extends up the leg.

The higher up this fascial sheath extends, the more the risk of compartment syndrome because this fascia can become thickened (fibrosis) due to ongoing or long term inflammatory process. Not only is the thickening a problem (takes more space) but it will also become less flexible too.

This increases the pressure in the lower leg to increase a lot more than usual and takes a lot more time to recover and reduce after exercise or training. The extra internal pressure (as well as rigidity of the extra sheath) will also cause reduction in the blood flow and oxygen to the muscles.

What are the Symptoms of Compartment Syndrome?

Patients typically report experiencing

  • dull ache
  • cramping
  • burning pain
  • tightness
  • pressure
  • general pain

in the calf or shin with exercise, training, prolonged standing or walking (especially with load)...and more often in both legs rather than just one side.

Also, the onset of these symptoms are fairly predictable, such as:

  • 5 minutes into jogging
  • 25 minutes walking with a backpack of 10 kg weight
  • 10 minutes of climbing up 20 steps 
  • etc

Also, given there are different compartments in the lower leg, sometimes patients may experience

  • sudden fatigue at the top of the foot or ankle
  • numbness or tingling in the area near the big toe
  • rarely but sometimes, foot drop or hernias in the tissues

How to diagnose Compartment Syndrome?

Sometimes it's not easy to diagnose compartment syndrome because pain in lower leg can be caused by multiple different issues, sometimes two or more diagnosis can happen at the same time.

Examples of possible issues in lower leg include:

Specificly, exertional compartment syndrome is diagnosed by WHAT caused the pain AND it's predictable nature (remember the example I gave earlier, on ache / pain in lower leg 5 minutes into a run?). Patients typically dont feel any aches or pains at rest, but upon training or exercise, the pain comes in at a specific time.

Patients will experience worsening pain or pain throughout the exercise but frustratingly complete relief with rest (which most active or sports people dislike, because they enjoy moving and exercising!).

Another way to diagnose compartment syndrome is to insert a pressure monitor needle into the compartment to check the difference in pressure between

  • resting pressure
  • exerting pressure

If the difference in pressure is too high, then it's a positive diagnosis for exertional compartment syndrome.

Compartment Syndrome Treatments

PHASE I – Pain Relief, reduce Swelling & Protect injury

At the very beginning of the treatment, we will first deal and treat the pain in your shin and calf. We will first need to assess the severity before starting our treatments that may include

  1. Soft tissue management
  2. Cold therapy / Heat therapy
  3. Ultrasound therapy
  4. Shockwave therapy
  5. Dry needling
  6. Deep tissue release / massage treatment
  7. De-loading sports taping or supportive rigid taping
  8. Temporary mobility aids (orthotics, insoles, splints) to offload the injured and painful structures

PHASE II – Restoring Normal range of motion and glide

During the initial session (as well as the follow up sessions of course), we will need to pinpoint exactly what biomechanical fault that's causing the increase load in your lower leg, is it:

  • lack of range of motion?
  • nerve not gliding?
  • increased muscle tension?
  • fascia inflexibility?

And we will treat accordingly, including treatments such as

and others, depending on what you need and how your calf or shin responds too.

PHASE III – Restore Normal Muscle Control & Strength

We will assess your leg muscle activation patterns at rest, with mild activities and with intense activities before prescribing specific muscle retraining. 

You may also undergo gait, walking and running retraining as well, to correct any abnormal gait movement patterns too that cause or aggravate the compartment syndrome.

PHASE IV – Restoring Full Function

At stage 4, it's about getting your back to the activities and exercises you love.

Everyone has different hobbies and goals, and they all have different demands on the body, which corresponds with the treatments. For example, a person who wants to run 43 KM will have a very different training from someone who wants to lift 150 kg vs someone who "just" want to chase after their pets or children.

Or leisure jogging for basic cardiovascular health.

We will personalize your physiotherapy program to help you achieve your fitness goals.

PHASE V – Prevent it from coming back

Yes, like any other injuries or pains, compartment syndrome can come back to annoy and hurt you again. One of the key reasons is not continuing lower limb physiotherapy and increasing activities at the same time.

As we correct your biomechanics, treat your pains and restore lower limb muscle activation, you too much consider the training rate, lifestyle practices and schedule regular rests and deep tissue release.

if you need compartment syndrome Surgery

If a doctor or surgeon calls for a compartment syndrome surgery, usually it's because it's an emergency procedure to save the compartment and soft tissues. 

In some cases, patients may opt for surgery or doctors may recommend it on a non-emergency basis if conservative treatment didnt work and you want to keep training, competing and exercising at a level that'd cause more swelling and pain in your lower legs due to the compartment syndrome.

Surgery for compartment syndrome will involve cutting the fascia that surrounds the muscle to free up the muscle from the containing fascia (kinda like a release surgery).

Other Treatment Options

  1. Steroid / Cortisone Injections -- patients usually report that these are short term measures and doesn't solve the problem, but may provide short-term relief of which they can do physiotherapy, or buy time to consider other solutions.

  2. Regular massage is helpful to redirect swelling, bring pain relief and improve range of movement and strength too.

  3. Weight loss can help to decrease the load on the calves and shin, or at least if you're prone to carrying a lot of load in your backpack or hands, then perhaps it's time to consider using a trolley bag or a different method of carrying those loads.