Compartment Syndrome - Types, Causes, Signs & Symptoms, Treatment and Prevention, By: Brad Walker

Compartment syndrome is a condition that develops when the pressure inside the fascia surrounding the muscles and bone increases without relief and can cause destruction of the capillaries and nerve cells inside. Compartment syndrome can develop in any of the compartments in the body but is most common in the lower leg. This may develop acutely, from an injury or other cause of immediate swelling, or chronically, as a result of overuse or other chronic swelling.

Pain, numbness, a feeling of pressure, and some swelling usually accompany this condition. Acute compartment syndrome is a medical emergency whereas the chronic syndrome, although still painful and a danger to the blood vessels and nerves, can be treated more conservatively. Both conditions must be treated, however, to prevent permanent damage to the injured area and those distal to the injury as well.

Athletes involved in high impact collision and contact sports, such as football and rugby, are more susceptible to acute compartment syndrome, while those involved in repetitive activities, such as running and jumping, may be more vulnerable to chronic compartment syndrome.

What is Compartment Syndrome?
Muscles are covered by tough fibrous tissue called fascia. This tissue wraps around the muscles and accompanying bone and holds it all in place, forming a compartment. The fascia is large enough to accommodate the bone, nerves, blood vessels, and muscle at its current size. There is just enough stretch in the fascia to allow the normal expansion of the muscle from increased blood flow due to exercise. If the muscle swells or blood collects inside the compartment the pressure will rise. If the pressure exceeds that of the capillaries (usually around 30 mmHG) they will begin to die. This in turn will cause death to the nerve and muscle tissue around them due to loss of blood supply.

Compartment Syndrome Types: Anterior and Posterior. Acute and Chronic.
Compartment syndrome is most common in the lower leg, although it can happen along any long bone, especially with a fracture. The quadriceps muscle is another likely candidate for this condition but due to its size and the lesser incidence of injury it is still far less common than lower leg compartment syndrome.

In the lower leg, compartment syndrome usually involves either the anterior compartment, over the front lateral side of the shin, or one of the posterior compartments, behind the tibia. The posterior area consists of the superficial compartment and the deep compartment. The lateral compartment is the fourth compartment in the lower leg. The anterior compartment is the most commonly injured of the four compartments.

Acute compartment syndrome results from trauma to the muscle or bone in the compartment. This trauma leads to bleeding inside the compartment. As the blood builds up in the compartment, with nowhere to go, the pressure increases. Because this happens at a fairly rapid rate (sometimes within minutes, other times over a period of hours) the pressure can build to a high level and cause serious damage to the nerves and blood vessels.

Chronic compartment syndrome is usually the result of overuse. The muscle becomes inflamed and swells over time and with rest returns to near normal. This causes pressures that are high at times and this high pressure over time can cause damage to the blood vessels and nerve tissue. The longer the pressure is elevated the more damage results.

The anatomy involved with Compartment Syndrome
The anterior compartment houses the tibialis anterior, extensor digitorum longus, extensor hallicus longus, and the peroneus tertius muscles and is bordered by the tibia and fibula. The superficial posterior compartment covers the gastrocnemius, soleus, and plantaris muscles and is behind the tibia and fibula. The deep posterior compartment is tucked in between the tibia and fibula and contains the flexor digitorum longus, flexor hallicus longus, popliteus and the tibialis posterior. Also running through this compartment are the posterior tibial artery and vein along with the tibial nerve.

Acute compartment syndrome involves a trauma to the muscle or bone within any of these compartments. The trauma then causes bleeding or swelling and increases the internal pressure. Since the fascia around the muscle cannot expand enough to accommodate the increase in size, the pressure will rise. Since there is no way for the pressure to release it will continue to rise until the tissues are destroyed. Acute compartment syndrome may also occur post-surgery from a blood flow blockage, or even rapid muscle growth from anabolic steroid use.

Chronic compartment syndrome results from overuse or repetitive stresses to the muscle inside the compartment. When a muscle is worked it becomes engorged with blood causing it to swell. When minor trauma from overwork or repetitive stresses causes the muscle to continue to swell it may become too large for the surrounding fascia thereby increasing the pressure in the compartment. This pressure will begin to diminish after the exercise is stopped, although it may stay up for some time after.

What causes it?
Acute compartment syndrome is caused by trauma to the structures in the compartment. Any of the following may be a cause;

• Fracture to the bone

• Tearing of the muscle

• Crush injury

• Blood flow blockage; due to injury or clots

• Post-surgical swelling or bleeding

• Anabolic steroid use

• Extreme increase in activity level; increases mileage or speed workouts too quickly

Chronic compartment syndrome results from repetitive trauma and overuse. The following are possible causes:

• Running; especially on hard surfaces or a change of surface

• Use of braces, wrapping or taping that is too tight

• Muscle hypertrophy due to exercise without the accompanying fascia expansion

• Repetitive stress that results in intra-compartment pressure not returning to normal during rest

Signs and Symptoms
Pain will usually accompany compartment syndrome. The pain may be out of proportion for the injury, especially if there is no fracture. Exercise will cause the pain to increase and the pain may diminish with rest. Tenderness and swelling may also be noted in the affected compartment. A tingling or burning sensation may be felt along with a tight or full feeling in the muscle. After a blow to the area the pain may begin to dull with an accompanying increase of pressure in the muscle and a growing numbness. The muscles may be weak and inflexible.

Treatment
Acute compartment syndrome is a medical emergency and should be treated by a physician. It may be treated with ice, sports massage, anti-inflammatory medications and immobilization. For more serious cases or for those that do not respond to these treatments the injury may require surgical intervention to heal. The fascia is cut open to allow the fluids to drain and relieve the pressure.

Chronic compartment syndrome usually responds well to rest from activities that cause pain. Ice and elevation along with anti-inflammatory medications will help to control the swelling that causes the pressure. Sports massage may help to stretch the fascia to accommodate any swelling or growth of the muscle. It is important not to wrap the area since additional compression will only aggravate the problem. In extreme cases where the pressure stays elevated and does not respond to non-invasive treatment then surgery may be required to relieve the pressure and prevent further tissue damage.

Prevention
Prevention of compartment syndrome involves avoiding the conditions and activities that might lead to increased pressure in the compartment. Using the techniques below will help prevent compartment syndrome.

• Warming the muscle properly will prepare it for the upcoming activity and allow a slow increase in muscle size. This will also minimize the chances of injury to the muscles. Warm packs and heat retaining coverings may be used to warm the area before an activity and keep it warm during exercise. Warm muscles are more flexible and less likely to be torn.

• Activities that cause pain should be avoided or limited as much as possible. When new activities are added to the program it is important to note any pain and if they can not be adjusted to relieve the pain they should be discontinued.

• Gradually increasing intensity and duration of activities is important. Rapidly increasing either intensity or duration without an adequate conditioning period can lead to trauma to the muscles and/or bones and cause injury that may lead to bleeding inside the compartment. By slowly increasing the workload the muscles, and surrounding fascia, will have time to adapt.

• Stretching the muscles will help relieve pressure within the compartment. Stretching the muscle causes it to lengthen therefore reducing its thickness and decreasing pressure. Flexible muscles are also less susceptible to injury.

Stretching is one of the most under-utilized techniques for improving athletic performance, preventing sports injury and properly rehabilitating sprain and strain injury. Don't make the mistake of thinking that something as simple as stretching won't be effective.

For an easy-to-use, quick reference guide of more than 100 clear photographs of every possible stretch, for every major muscle group in your body, get a copy of The Stretching Handbook. You'll also learn the benefits of flexibility; the rules for safe stretching; and how to stretch properly. Strengthening the muscles also helps protect the compartment and the bones and muscles in the compartment. Stronger muscles are less likely to be injured and they offer much better shock absorption for the bones.

• It is important to allow adequate rest between intense workouts or training sessions. If muscles are exercised intensely too close together the stress may cause swelling and injury. Muscle tears and strains are often associated with inadequate rest between training sessions. The rest time also allows time for the fascia to stretch and become accustomed to the increase in muscle size.

• Avoiding activities that cause direct trauma to any of the muscles or bones in the compartment will also help prevent compartment syndrome. Using appropriate padding and protection will help to prevent the injuries that might lead to this condition.