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.

Surgery

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.

Massage

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

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.

Weight-Loss

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

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Article by John Miller

Common Youth Leg Injuries

Why are Children's Injuries Different to Adults?

youth sports injuries

Adolescent Leg Injuries

Adolescent injuries differ from adult injuries, mainly because the bones are still growing. The growth plates (physis) are cartilaginous (strong connective tissue) areas from which the bones elongate or enlarge. Repetitive stress or sudden large forces can cause injury to these areas.

In the adolescent leg, common injuries include:

Osgood-Schlatter's Disease

Pain at the bump just below the knee cap (tibia tubercle). Overuse injuries commonly occur here. The tibia tubercle is the anchor point of your mighty quadriceps (thigh) muscles. Because of excessive participation in running and jumping sports, the tendon pulls bone off and forms a painful lump that will remain forever. This type of injury responds to reduced activity and physiotherapy.

More info: Osgood Schlatter's Disease

Sinding-Larsen-Johansson Disease

Pain at the lower pole of the knee cap (patella). Overstraining causes Sinding-Larsen-Johansson disease. Because of excessive participation in running and jumping sports, the tendon pulls bone off the knee cap. This type of injury responds to reduced activity and physiotherapy.

More info: Sinding Larsen Johansson Syndrome

Anterior Knee Pain

Anterior knee pain or patellofemoral syndrome frequently gets passed off as growing pains. Cause of this pain includes overuse, muscle imbalance, poor flexibility, poor alignment, or more commonly, a combination of these. Anterior knee pain is one of the most challenging adolescent knee injuries to sort out and treat. Accurate diagnosis and treatment with the assistance of a physiotherapist with a particular interest in this problem usually resolves the condition quickly.

More info: Patellofemoral Pain Syndrome

Knee Ligaments

The cartilage between the leg bones has a better blood supply and is more elastic in adolescents than adults. As adolescents near the end of bone growth, their injuries become more adult-like. Hence more meniscal and ACL (anterior cruciate ligament) injuries are likely. MCL (medial collateral ligament) injuries result from a lateral blow to the knee. Pain felt on the inner side (medially) of the knee. MCL injuries respond well to protective bracing and conservative treatment.

More info: Knee Ligament Injuries

ACL (Anterior Cruciate Ligament) Injuries

This traumatic knee injury is significant. Non-contact injuries of the ACL are becoming more common than contact injuries of the ACL. Adolescent females are at high risk. Combination injuries with MCL or menisci are common. Surgical reconstruction is needed if the adolescent wishes to continue participating in "stop-and-start" sports.

More info: ACL Injury

Meniscal Injuries

Your meniscus is crescent-shaped cartilage between the thigh (femur) and lower leg (tibia). Meniscal injuries usually result from twisting. Swelling, catching, and locking of the knee are common. If physiotherapy treatment does not resolve these damages within six weeks, they may require arthroscopic surgery.

More info: Meniscus Tear, Discoid Meniscus

Sever's Disease

Heel pain is commonplace in young adolescents due to the stresses of their Achilles tendon pulling upon its bony insertion point on the heel (calcaneum). It is a common overuse injury due to excessive training and competition, particularly when loads are increased dramatically in a short period. Diminished flexibility and muscle-tendon strength mismatching may predispose you. Physiotherapy, reduced activity, taping and orthotics are the best ways to manage this debilitating condition for the active young athlete.

More info: Sever's Disease

Ankle Sprain

An ankle sprain is probably the most common injury seen in sports. Ankles sprains involve stretching of the ligaments and usually occur when the foot twists inward. Treatment includes active rest, ice, compression and physiotherapy rehabilitation. With the correct treatment, a low ankle sprain usually improves in two to six weeks. Your ankle physiotherapist should check even simple ankle sprains to eliminate high-ankle sprains. A residually stiff ankle post-sprain can predispose you to several other lower limb issues.

More info: Sprained Ankle

Patellar Instability

Patellar (kneecap) instability can range from partial dislocation (subluxation) to dislocation with a fracture. Partial dislocation treatment is conservative. Dislocation with or without fracture is a much more severe injury and usually will require surgery.

More info: Patella Dislocation

Osteochondritis Dissecans

The separation of a bone from its bed in the knee joint is Osteochondritis Dissecans (OCD). This injury is usually due to one major macro event with repetitive macro trauma that prevents complete healing. This injury is potentially severe. Treatment varies from rest to surgery. An Orthopaedic Surgeon's opinion is vital.

More info: Juvenile Osteochondritis Dissecans (JOCD)

Growth Plate Fractures

A fracture through the growth plate can be a severe injury that can stop the bone from growing correctly. These fractures should be treated by an Orthopaedic Surgeon, as some will require surgery.

Avulsion Fractures

youth pelvis hip avulsion

Image source: https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children

An avulsion fracture occurs when a small segment of bone attached to a tendon or ligament gets pulled away from the main bone. The hip, elbow, and ankle are the most common locations for lower limb avulsion fractures in young sportspeople.

Treatment of an avulsion fracture typically includes active rest, ice and protecting the affected area. This active rest period is followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Your physiotherapist should supervise your post-avulsion exercises. Most avulsion fractures heal very well.  You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. An avulsion fracture to your foot or ankle may require a cast or walking boot.

An excessive gap between the avulsed bone fragment and main bone may not rejoin naturally in rare cases. Surgery may be necessary to reunite them. In children, avulsion fractures that involve the growth plates also might require surgery. All avulsion fractures should be reviewed and managed by your trusted physiotherapist or an Orthopaedic Surgeon.

For more information regarding your youth sports injury, please consult your physiotherapist or doctor.

Youth Leg Injuries

Pelvis & Hip

Knee

Heel & Ankle

Common Youth & Teenager Sports Injuries

Common Youth Neck & Back Pain

Common Youth Arm Injuries

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Acute Injury Signs

Acute Injury Management.

Here are some warning signs that you have an injury. While some injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop.

For detailed information on specific injuries, check out the injury by body part section.

Don't Ignore these Injury Warning Signs

Joint Pain

Joint pain, particularly in the knee, ankle, elbow, and wrist joints, should never be ignored. Because these joints are not covered by muscle, pain here is rarely of muscular origin. Joint pain that lasts more than 48 hours requires a professional diagnosis.

Tenderness

If you can elicit pain at a specific point in a bone, muscle, or joint, you may have a significant injury by pressing your finger into it. If the same spot on the other side of the body does not produce the same pain, you should probably see your health professional.  

Swelling

Nearly all sports or musculoskeletal injuries cause swelling. Swelling is usually quite obvious and can be seen, but occasionally you may feel as though something is swollen or "full" even though it looks normal. Swelling usually goes along with pain, redness and heat.

Reduced Range of Motion

If the swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion. Compare one side of the body with the other to identify major differences. If there are any, you probably have an injury that needs attention.

Weakness

Compare sides for weakness by performing the same task. One way to tell is to lift the same weight with the right and left sides and look at the result. Or try to place body weight on one leg and then the other. A difference in your ability to support your weight is another suggestion of an injury that requires attention.

Immediate Injury Treatment: Step-by-Step Guidelines

  • Stop the activity immediately.
  • Wrap the injured part in a compression bandage.
  • Apply ice to the injured part (use a bag of crushed ice or a bag of frozen vegetables).
  • Elevate the injured part to reduce swelling.
  • Consult your health practitioner for a proper diagnosis of any serious injury.
  • Rehabilitate your injury under professional guidance.
  • Seek a second opinion if you are not improving.

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Article by John Miller

Elite Sports Injury Management

You probably already know that a sports injury can affect not only your performance but also your lifestyle. The latest research continues to change sports injury management considerably.  Our challenge is to keep up to date with the latest research and put them to work for you.

How we treated you last year could vary significantly from how we treat you this year. The good news is that you can benefit considerably from our professional knowledge.

What Should You Do When You Suffer a Sports Injury?

Rest?

Rest from painful exercise or a movement is essential in the early injury stage. "No pain. No gain." does not apply in most cases.  The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days.  After that, you need to get it moving, or other problems will develop.

Ice or Heat?

We usually recommend avoiding heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early. In traumatic injuries, such as ligament sprains, muscle tears or bruising, ice should help reduce your pain and swelling.

Once the "heat" has come out of your injury, you can use heat packs. We recommend 20-minute applications a few times a day to increase the blood flow and hasten your healing rate. The heat will also help your muscles relax and ease your pain. If you're not sure what to do, please call us to discuss your situation specifically.

Should You Use a Compressive Bandage?

Yes. A compressive bandage will help to control swelling and bleeding in the first few days.  In most cases, the compressive dressing will also help support the injury as you lay down the new scar tissue. This early healing should help to reduce your pain. Some injuries will benefit from more rigid support, such as a brace or strapping tape. Would you please ask us if you are uncertain about what to do next?

Elevation?

Gravity will encourage swelling to settle at the lowest point.  Elevation of an injury in the first few days is beneficial, especially for ankle or hand injuries.  Think where your damage is and where your heart is. Try to rest your injury above your heart.

What Medication Should You Use?

Your Doctor or Pharmacist may recommend pain killers or an anti-inflammatory drug. It is best to seek professional advice as certain medications can interfere with other health conditions, especially asthmatics.

When Should You Commence Physio?

sports injury

In most cases, "the early bird gets the worm".  Researchers have found that the intervention of physiotherapy treatment within a few days has many benefits.  These include:

  • Relieving your pain quicker via joint mobility techniques, massage and electrotherapy
  • Improving your scar tissue using techniques to guide the direction it forms
  • Getting you back to sport or work quicker through faster healing rates
  • Loosening or strengthening of your injured region with individually prescribed exercises
  • Improving your performance when you return to sport - we'll detect and help you correct any biomechanical faults that may affect your technique or predispose you to injury.

What If You Do Nothing?

Research tells us that injuries left untreated take longer to heal and have lingering pain.  They are also more likely to recur and leave you with either joint stiffness or muscle weakness. It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve.  The sooner you get on top of your symptoms, the better your outcome.

What About Arthritis?

Previously injured joints can prematurely become arthritic through neglect. Generally, there are four main reasons why you develop arthritis:

  • An inappropriately treated previous injury (e.g. old joint or ligament sprains)
  • Poor joint positioning (biomechanical faults)
  • Stiff joints (lack of movement diminishes joint nutrition)
  • Loose joints (excessive sloppiness causes joint damage through poor control)

What About Your Return to Sport?

Your physiotherapist will guide you safely back to the level of sport at which you wish to participate.  If you need guidance, ask us.

What If You Need Surgery or X-rays?

Not only will your physio diagnose your sports injury and give you the "peace of mind" associated, but they'll also refer you elsewhere if that's what's best for you. Think about it. You could be suffering needlessly from a sports injury.  Would you please use our advice to guide you out of pain quicker? And for a lot longer.

If you have any questions regarding your sports injury (or any other condition), don't hesitate to get in touch with your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.

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