Compartment Syndrome

Compartment Syndrome

Article by J. Miller, A.Clarke

What is Compartment Syndrome?

Compartment syndrome, also known as recurrent or chronic exertional compartment syndrome (CECS), is a condition that affects the lower leg. Your lower leg is divided into four or five compartments with different muscles, nerves, blood vessels and tendons running through these compartments.

The compartment is surrounded by fascia, which helps to improve the efficiency of contraction and divide the muscle from surrounding tissue. Sometimes the pressure within one or more of these compartments increases to the point that the muscle, blood vessel or nerves are compressed. This can cause pain and loss of function. It is often found in runners as a result of the high repetitive loads that occur with running.

What Causes Compartment Syndrome?

Compartment syndrome can become evident with an increase in activity or training. As we use our muscles, there is a build-up of waste products and an increase in blood flow to the muscle. This causes the muscle volume to increase by between 8-20%, which results in increased pressure within the muscle compartment. There may also be an increase in the resting size of the muscle as a result of training. These changes are normal, with increased pressures reducing within 5 minutes of ceasing exercise.

Compartment syndrome seems to develop as a result of different anatomy.

  • In some people, there is an extra ‘fifth’ compartment deep in the lower leg, with an extra sheath of fascia extending up the leg. The further the sheath extends, the greater the risk of compartment syndrome.
  • The fascia becomes fibrotic or thickened as a result of a chronic inflammatory process or surgery. This leads to the fascia becoming less flexible.

In either case, pressure increases to a greater degree and takes longer to reduce post-exercise. The extra internal pressure in the compartment means reduced blood flow to the muscle and reduced oxygen for the muscle tissue. We think that the pain is due to a lack of oxygen supply. This is called ischaemic pain.

What are the Symptoms of Compartment Syndrome?

Tightness, burning, pressure, cramping and/or pain in the lower leg every time you exercise, most commonly around the calf and shin region. The pain commonly occurs in both legs.

The onset of these symptoms occurs at predictable intervals (for instance, 4 minutes into every run). Depending on which compartments are affected, you may also experience sudden fatigue on the top of your foot or ankle, numbness in the webbing near your big toe, or even drop your foot (this is quite uncommon). Sometimes there may be lumps or bumps in the tissue due to small hernias.

How is Compartment Syndrome Diagnosed?

It can be difficult to diagnose compartment syndrome as the pain in your leg could be caused by several other problems such as tendonitis, stress fracture or a condition called periostitis. Exertional compartment syndrome is usually diagnosed clinically by what causes the pain and its predictable nature. You have no pain at rest, but when you exercise, the pain comes on, which usually happens after a set period of time. If you continue to exercise, the pain gets worse but is usually completely relieved with rest.

Compartment syndrome can also be diagnosed with a needle inserted into the compartment attached to a pressure monitor. If the difference between the resting pressure and the pressure measured immediately after exercise is too high, this is a positive test for exertional compartment syndrome.

Compartment Syndrome Treatment

PHASE I – Pain Relief. Minimise Swelling & Injury Protection

Managing your pain. Pain is the main reason that you seek treatment. In truth, it was actually the final symptom that you developed and should be the first symptom to improve.

Your physiotherapist will use an array of treatment tools to reduce your pain and any chronic inflammatory disorder. These may include ice, electrotherapy, acupuncture, de-loading taping techniques, soft tissue massage, and temporary mobility aid (e.g. orthotics) to off-load the injured structures. They will advise you on any necessary modification of training or complete rest in severe cases.

PHASE II – Restoring Normal ROM & Posture

There is often a biomechanical fault leading to the increased load. Your physiotherapist will look to restore your normal joint range of motion, muscle length, neural tissue mobility, resting muscle tension, and fascial tissue flexibility.

Treatment may include joint mobilisation and alignment techniques, massage, muscle stretches and neurodynamic exercises, plus acupuncture, trigger point therapy or dry needling. Your physiotherapist is an expert in the techniques that will work best for you.

PHASE III – Restore Normal Muscle Control & Strength

Researchers have found different muscle firing patterns in runners with exercise-related leg pain. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises specific to your needs.

PhysioWorks has developed a “Foot Stability Program” to assist their patients in regaining normal muscle control. Please ask your physio for their advice.

PHASE IV – Restoring Full Function

This stage of your rehabilitation is aimed at returning you to your desired activities. Everyone has different demands for their bodies that will determine what specific treatment goals you need to achieve. For some, it is simply to run around the block. Others may wish to run a marathon.

Your physiotherapist will tailor your rehabilitation to help you achieve your own functional goals.

PHASE V – Preventing a Recurrence

Injuries and the pain associated does tend to return. Insufficient rehabilitation is thought to be one reason for this.

In addition to your muscle control, your physiotherapist will assess your biomechanics and start correcting any defects. It may be as simple as providing you with some foot orthotics to address any biomechanical faults in the legs or feet. Your physiotherapist will guide you on this.

What Results Can You Expect?

The advice that your physiotherapist gives you in conjunction with some ‘hands-on’ therapy can work to reduce your symptoms very well. Unfortunately, many people do not respond as well as we would like, usually due to their underlying anatomy. If we do not see the desired improvements, you may be referred to a sports doctor, podiatrist or orthopaedic surgeon.


The surgery involves cutting the fascia that surrounds the muscle to allow for muscle volume increase. In some cases, surgical release is essential and urgent! Surgery is only considered if a conservative programme has failed and you want to keep exercising.

Other Treatment Options

Specific Interventions, e.g. Injection

Cortisone and other injected substances are usually not successful and are not recommended.


Many patients find that soft tissue massage therapy is beneficial to assist your pain relief, muscle relaxation and swelling reduction. Please ask your physiotherapist if you would benefit from massage.


Acupuncture can be helpful for the relief of your pain. If you are interested in trying some acupuncture, many of our therapists are trained in acupuncture. Please ask for their advice.


Carrying excessive body weight can predispose you to injury or pain.