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Compartment Syndrome
Each of the muscles in the lower leg are
contained in what is called a muscle compartment. Just like an orange
or grapefruit, where the fruit is divided by fibrous sheaths into
identifiable sections, the muscles of the lower leg are also divided by
fibrous sheaths into identifiable muscle compartments. There are four
muscle compartments in the lower leg: two in the back of the lower leg
(i.e. posterior compartments), one on the front of the lower leg (i.e.
anterior compartment) and one on the outside of the lower leg (i.e.
lateral compartment). Each of the four muscle compartments contain at
least two individual muscles, which are surrounded by the fibrous
sheath which wraps around the muscles of the compartment. Because
of the arrangement of the muscles of the lower leg into four
compartments, an individual can develop two types of compartment
syndrome: acute and chronic. Acute compartment syndrome is caused by
direct trauma to the lower leg, such as that occurs during a motor
vehicle accident where possibly one of the leg bones is broken. Blood
rushing into the muscle compartment has no way to escape, causing a
relatively sudden rise in the pressure in the muscle compartment. The
increased pressure inside the muscle compartment can become so high
that it clamps down on the arteries and nerves going through the leg
into the foot. The result may be a loss of pulse and blood supply to
the foot, loss of nerve function to the foot, and severe pain. Acute
compartment syndrome requires immediate surgical attention or the
individual may develop permanent deformity and disability in the leg
and foot. The more common form of compartment syndrome is seen in athletes who exercise heavily and is called chronic exertional compartment syndrome
(CECS). CECS is caused by the increase in pressure in the muscle
compartment, which results from the muscles actually expanding in
volume because of the increased blood flow to the muscles during
exercise. If the sheath or compartment wall is particularly tight and
thick, then as the athlete's muscles become larger over time from
exercise the muscle compartment will become tighter. The compartment at
the front of the leg is the most common muscle compartment to be
affected by CECS and the pain that results is thought by many athletes
to be shin splints. For runners, pain from CECS will generally
occur within 20-40 minutes into a run and the pain may become so severe
that continuing exercise past that point is impossible. Diagnosis A
thorough history and physical examination must be made of the
individual with suspected chronic exertional compartment syndrome. The
podiatrist will be most interested as to the time during exercise that
the pain starts in the leg, where the pain is located, and whether the
pain dissipates somewhat with rest. The symptoms from CECS generally
starts at the same time or at the same mile mark during running and
also usually gets better soon after as the individual stops exercising.
During the physical examination, the podiatrist
will inspect the leg to determine which muscle compartment is affected
and try to rule out any other pathology in the same area such as stress fractures, muscle strain, tendinitis, or shin splints. Additional tests such as x-rays, bone scans or MRI scans
may be ordered depending on the most likely cause of the pain. Even
though the podiatric physician can diagnose CECS relatively confidently
by taking the proper history and physical of the patient, the only
certain way to diagnosis the condition it is to have the muscle
compartmental pressure measured at rest, during exercise and after
exercise. Most doctor's offices do not have the special instrumentation
to make this diagnosis and often the patient must be sent to a large
hospital or sports clinic to have the test performed. Treatment Chronic
exertional compartment syndrome may be treated conservatively by
modifying the type, duration and frequency of the sports activity that
causes the pain. The condition is often successfully treated by
altering the surfaces the individual runs on and the shoes they run in.
In addition, CECS sometimes responds to altering the function of the
muscles of the lower leg with in-shoe custom supports such as functional foot orthotics.
If all conservative measures do not resolve the pain from CECS
adequately, the podiatrist may refer the patient to an orthopedic
surgeon for possible surgical release of the sheath surrounding the
muscle compartment. In general, most patients who have surgical release
of the muscle compartment sheath are able to resume unrestricted
exercise within a few months of the procedure. Many notable athletes
have had the compartment release surgical procedure performed and have
returned to training without pain or limitations.
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