Compartment syndrome: what it is, what to look out for and how it is treated
The muscles in our limbs are split into sections or
‘compartments’ bound by strong and relatively unyielding membranes
of fibrous tissue (deep fascia), which also attach to bone, in effect wrapping
up the different muscle groups. Every compartment has a blood and nerve
Compartment syndrome arises when the pressure inside this enclosed space
increases to the point where it interferes with the blood supply to the
structures. A cascade of injury follows, with disruption to the metabolic
processes of the muscle, cell death and leakage of fluid from capillaries,
which further increases the excessive pressure.
Although legs, feet and arms can all be affected by compartment syndrome,
with sports-people you are most likely to come across it in the lower leg. There
are two forms, acute and chronic, and the sports therapy professional needs to
be aware of both. Chronic compartment syndrome is often overlooked as a
possible cause of muscle pain; and acute compartment syndrome can cause serious and
permanent damage if it is not treated rapidly.
Chronic compartment syndrome
Going under the name of chronic exertional compartment syndrome (CECS), this
overuse condition mainly affects active, athletic people. It is characterised
by muscle pain that repeatedly occurs with vigorous exercise and subsides with
rest. The pain gradually worsens as exercise continues, ultimately restricting
performance. There will often also be swelling and abnormal sensations in the
affected limb during and immediately after exercise.
Chronic exertional compartment syndrome (CECS) can affect athletes of any age, including adolescents. Anyone whose
sport involves a lot of running or jumping, or indeed long-distance walking,
may be at risk. It usually occurs in the lower limb, where there are four
tightly packed muscle compartments. Of these it is most commonly the anterior
compartment containing the tibialis anterior muscle, that succumbs. The thigh
and foot are also vulnerable.
However compartment syndrome is not exclusive to the lower leg. You may come across
compartment syndrome in an arm in a weightlifter(1), sport climber(2) or
motorcyclist(3); in these instances the flexor
forearm compartment is usually involved.
Muscle weakness of the affected limb may be a feature of these episodes and
gradually increasing fullness (literally denseness, crowding or swelling) is a
frequent complaint. Pain increases both on passive stretching and active
contraction. The athlete may also complain of paraesthesia (pins and needles).
In general symptoms disappear within an hour of stopping the activity but recur
when exercise resumes.
Thus the clinical features of chronic exertional compartment syndrome (CECS) are only evident immediately after
exercise, and the nature and location of signs and symptoms will depend on the
As with any compartment syndrome, symptoms are the result of the structures
within a closed myofascial compartment being compressed by increased pressure;
but beyond this we don’t really know what causes Chronic exertional compartment syndrome (CECS), or what
predisposes individuals to it. During exercise, muscle bulk increases by up to
a fifth and it may be this expansion, plus repeated muscle contraction, that
increases the intracompartmental pressure to a level which causes transient
ischaemia and deoxygenation(4,5).
An alternative explanation is that muscle tissue, damaged by repetitive hard
surface exercise, releases protein-bound ions which increase cell leakage,
provoke oedema and so decrease blood flow within the compartment.
Table 1: Lower leg compartments
||Major nerve supply
Extensor hallucis longus
Extensor digitorum longus
||Peroneal longus, brevis, tertius
||Tibialis posterior, long flexors, soleus
Physical examination at rest often provides little helpful information: you
are unlikely to see any abnormalities unless examining immediately
postexercise. It is vital to take a careful history, including training
regimes. You will need to establish the specifics of the pattern of pain: how
long after the start of exercise and at what intensity it sets in; how and when
it eases off again.
Passive stretching of the involved muscle after exercise may increase your
client’s pain. Over time you may notice muscle atrophy, and the client
may report tenderness and increased tension in the involved compartment. But be
careful with differential diagnosis: tenderness directly over the tibia is more
likely to be a stress fracture, tibialis posterior tendinitis or
One further rare condition can present with almost identical symptoms as
chronic exertional compartment syndrome (CECS) and must be excluded: popliteal artery entrapment syndrome (PAES). This
most frequently affects young male athletes who describe exertional calf pain
with possible associated leg weakness and paraesthesia. PAES is the partial or
complete occlusion of the popliteal artery in the popliteal fossa (back of the
knee), secondary to aberrant anatomy. Weaker distal pulses and poor capillary
refill of the extremity with exercise or with provocative manoeuvres (repeated
ankle dorsiflexion with knee extension) and normal compartment pressures help
differentiate PAES from chronic exertional compartment syndrome (CECS). Angiogram provides definitive evidence.
Coupled with a careful history, the gold standard for chronic exertional compartment syndrome (CECS) diagnosis is to
measure the pressure within the affected compartment, first at rest, then at
several points while exercising, and finally 5, 10 and 20 minutes after
exercise. It is very important that symptoms are elicited during this process
and measurements taken at intervals until the symptoms subside. This is usually
an outpatient procedure, requiring the insertion of a pressure probe into the
Several non-invasive forms of investigation have been assessed for
reliability of diagnosis, including MRI, tomographic imaging and spectroscopy,
but all have been shown to have inadequacies.
In the first instance a change of training regimes or complete rest may
resolve the symptoms, especially if the diagnosis is made early.
Chronic exertional compartment syndrome (CECS) is usually not identified early, and each successive episode of
inflammation and irritation will cause the compartment fascia to thicken and
become fibrotic, making it increasingly unlikely to be able to return to its
normal state of yield, even with rest. Although there have been reports of
successful conservative treatment, massage and physiotherapy alone are rarely
satisfactory. Fasciotomy (surgical incision of the fascia) is the treatment of
After surgery 70-85% of patients are able to return to pre-treatment levels
of activity, symptom-free. Patients with Chronic exertional compartment syndrome (CECS) in the deep posterior compartment
respond less well than those whose anterior or lateral compartment is
Complications include :
- inability to return to previous performance levels;
- continued muscle weakness;
- recurrence of symptoms.
These may be amenable to further surgery but this may not alter muscle
strength. Cases of recurrent Chronic exertional compartment syndrome (CECS) are almost certainly attributable to scarring
and closure of the initial compartment release.
Acute compartment syndrome
The basic nature of acute compartment syndrome (ACS) is the same as Chronic exertional compartment syndrome (CECS):
increased tissue pressure within a muscle compartment compromises the blood
supply and the function of structures within that space. However, it differs
from CECS in that it does not require exertion of the muscles to incite pain;
and the pain does not subside until treated. It can occur as a complication of
any trauma to a muscle compartment or indeed an adjacent compartment. Acute compartment syndrome (ACS) is
limb threatening and should be treated as an emergency.
Although acute compartment syndrome (ACS) can affect any limb or muscle compartment, including the
abdomen, it mainly occurs after trauma to the lower leg. Fractures – most
commonly of the tibia – are the cause in three-quarters of cases.
Comminuted (multi-fragment) fractures are more likely to give rise to acute compartment syndrome (ACS),
probably reflecting the greater degree of force required to cause this type of
injury. Indeed any high energy trauma is more liable to cause acute compartment syndrome (ACS), and
penetrating injuries such as gunshot wounds often cause severe muscle
laceration and arterial tears, which in turn lead to increased
Muscles tolerate four hours of ischaemia well, but by six hours repair is
uncertain and after eight hours, damage is irreversible(7).
Acute compartment syndrome has very occasionally been recorded in patients
with no history of trauma(8).
The patient will experience severe pain, out of keeping with the injury
sustained and unrelieved by opiate analgesia.
Early signs and symptoms include this disproportionate level of pain, which
can be aggravated by passive muscle stretching; palpable tightness and
tenderness of the area; and sensory deficit in the distribution of any sensory
nerve traversing the involved compartment. Late symptoms include paraesthesia,
muscle weakness and loss of distal pulses. Diagnosis will be confirmed by
measuring compartment pressure, and will lead to fasciotomy.
If you suspect acute compartment syndrome (ACS) in your patient, try to:
- maintain normal blood pressure (low pressure may hasten tissue
- remove any bandaging around the area if possible, as this will add
- do not elevate the limb above heart level;
- administer oxygen if possible.
If a plaster cast has been applied, this should be split immediately: a
split on one side can instantly relieve compartmental pressure by 30% and the
removal of cast and padding will bring pressure down by 85-90%(9).
Fasciotomy is the definitive and only treatment for acute compartment syndrome (ACS). Morbidity from
delay is significant, so the operation should be performed immediately. The
wound should not be stitched until a post-surgical assessment has been done at
48 hours, and subsequent skin grafts may be needed for successful healing.
Acute and chronic compartment syndromes may have linked pathophysiology but
occur in very different clinical settings. Chronic exertional compartment syndrome (CECS) is a condition most commonly
affecting the lower extremities in competitive athletes, probably caused by
raised pressure within a non-compliant muscle compartment due to repetitive
muscle activity causing symptoms during and immediately after exercise.
Diagnosis is more complicated but less urgent than acute compartment syndrome (ACS).
Acute compartment syndrome (ACS) is usually, but not exclusively, associated with a fracture. It is a
serious limb-threatening condition and delay in treatment may lead to
infection, complications and even limb amputation.
- Jawed S, Jawad AS, Padhiar N, Perry JD. Chronic exertional compartment
syndrome of the forearms secondary to weight training. Rhematology (Oxford).
2001 Mar; 40(3): 344-5.
- Schoeffl V, Klee S, Strecker W. Evaluation of physiological standard
pressures of the forearm flexor muscles during sport specific ergometry in
sport climbing. Br J Sports Med. 2004 Aug; 38(4): 422-5.
- Goubier JN, Saillant G. Chronic compartment syndrome of the forearm in
competitive motor cyclists: a report of two cases. Br J Sports Med. 2003;
- Mohler IR, Styf JR, Pedowitz RA, Hargens AR, Gershuni DH. Intramuscular
deoxygenation during exercise in patients who have chronic anterior compartment
syndrome of the leg. JBJS Am 1997; 79(6): 844-9.
- Schissel DJ, Godwin J. Effort-related chronic compartment syndrome of the
lower extremity. Military Medicine 1999; 164(11): 830-2.
- Howard JL, Mohtadi NG, Wiley JP. Evaluation of outcomes in patients
following surgical treatment of chronic exertional compartment syndrome in the
leg. Clin J Sport Med. 2000 Jul; 10(3): 176-84.
- Whitesides TE, Heckman MM. Acute Compartment Syndrome: Update on Diagnosis
and Treatment. J Am Acad Orthop Surg. 1996 Jul; 4(4): 209-218.
- Vanneste DR, Janzing HM, Broos PL. The acute atraumatic peroneal
compartment syndrome, a rare and therefore sometimes unrecognised entity. Acta
Chir Belg 2003; 103(4): 355-7.
- Garfin SR, Mubarak SJ, Evans KL, Hargen AR, Akeson WH. Quantification of
intracompartmental pressure and volume under plaster casts. JBJS1981; 63 A: