Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association
Compartment syndrome is caused by a severe bruise on the lower leg caused by kicking, tackling, etc.
Lower leg compartment syndrome is a disorder in which bruises, fractures, and dislocations caused by sports or traffic accidents increase the pressure in the tissues of the lower leg due to bleeding, resulting in circulatory disturbances of the intramuscular arterioles and death of the musculotendinous nervous tissue. Once the tissue becomes necrotic, disability becomes permanent, so early identification is important. The disease is most common throughout the body, especially in the lower legs (Photos 1 and 2). The lower leg has four small compartments, such as the fascia, that tend to develop increased pressure.
Photo 1 shows the patella facing the front and the lower leg rotating right 90 degrees. Compartment syndrome with marked leg swelling
Photo 2 is an X-ray image of the same case as Photo 1. The tibia and fibula are shown in lateral view with a spiral fracture at the diaphysis, but the ankle is rotated 90 degrees and facing anteriorly.
The figure shows four compartments with the leg cut into whorls.
Cause and mechanism of onset
The lower leg compartment is divided into four compartments (1) anterior, (2) lateral, (3) superficial posterior, and (4) deep posterior depending on the strong fascia. 1) Anteriorly, the tibialis anterior, extensor hallucis longus, and extensor digitorum longus are present; 2) laterally, the long and short muscles of the fibula; 3) superficial posteriorly, the gastrocnemius, soleus, and plantaris; and 4) deeply posteriorly, the posterior tibial muscle, the flexor hallucis longus, and flexor digitorum longus.
Pain, swelling, tenderness, induration, motor pain, sensory paralysis due to intracompartmental nerve palsy, passive movement disorders, and pain during passive movement are observed in each region.
1. Anterior compartment disorders are the most common, with pain, swelling, and tenderness in the anterolateral lower leg, sensory disturbances in the deep fibula area (between the first and second toes), muscle weakness on dorsiflexion of the ankle (tibialis anterior, extensor digitorum), and pain during passive exertion in the plantar flexion of the ankle and toe.
2. Tenderness is lateral in the lateral compartment, with sensory disturbances in the superficial fibula nerve region (lateral lower leg), weakness in the eversion movement of ankle joint (short and long fibula muscles), and pain during passive movement in the inversion movement of ankle joint.
3. In the superficial posterior compartment, tenderness is posterior (calf) and may include sensory disturbances in the sural nerve area, weakness of the plantar flexors (gastrocnemius, soleus), and pain during passive ankle dorsiflexion.
4. In the deep posterior compartment, tenderness is posterior (medial lower leg), and sensory deficits in the area of the tibial nerves (medial plantar), loss of muscle strength of posterior tibial muscle of the ankle or the extensor digitorum pedis, and pain during passive dorsiflexion of the toes are present.
Simple needle manometer procedure is taken that uses a sphygmomanometer or central venous pressure measurement, in which the needles are inserted into different compartments and measured. The disease is considered to be present with a pressure of more than 30 mmHg. X-rays can be used to check for underlying fractures or dislocations. Magnetic resonance imaging (MRI) can show whether a hematoma is present.
Acute cases are more common with skiing, rugby, basketball (when fractures or bruises occur), and chronic cases are more common with long-distance land sports or soccer.
Treatment and rehabilitation
If there is sudden pain, swelling, or deformity, transport the person to a hospital immediately. First aid RICE procedures, such as local immobilization, elevation, and icing, are used. Symptoms of these compartment syndromes can be managed with an understanding of the cause, such as a fracture (reduction of a fracture). Surgery is indicated if internal pressure is greater than 50 mmHg, and consider compartmental fasciotomy (reducing internal pressure) if pressure is greater than 30 mmHg for several hours. The skin and fascia are left open. In chronic cases, exercise should be carefully controlled before and after exercise, including stretching of the tibialis anterior, gastrocnemius, and fibula muscles, avoiding eccentric muscle strength exercises, and focusing on concentric muscle contraction strength training. After the operation, the person is instructed to return to running in about one month.
Associate Professor, the Department of Regional Medicine, Teikyo Heisei University
A certified athletic trainer from the Japan Sport Association, a practitioner of acupuncture and a massage practitioner
Compartment syndrome develops gradually from injuries such as bruises or muscle strains. Delayed treatment can cause irreversible changes in the nerves and muscles. Therefore, to prevent compartment syndrome, it is important to take appropriate first-aid measures for the underlying injury.
On-site evaluation and first aid
First aid for bruises and muscle contusions
See the first aid for bruises or muscle strain of the lower leg where compartment syndrome is common. First aid involves RICE treatment to reduce swelling (Photo 1). Compression is done gently. The affected foot is also kept barefoot to check for sensory disturbances (Photo 2). In addition, the dorsalis pedis artery is checked for any pulsations (Photo 3). A trainer should suspect a blood vessel injury if there is no pulse. Immediately transport to the doctor. Caution should be exercised when swelling and pain become severe despite RICE procedures. A trainer should suspect compartment syndrome and identifies symptoms such as impaired motor activity in the toes and ankles, intense pain with passive movement, and hypoesthesia (Table). People with mild disease may be able to tolerate the pain, but the continuation of play may trigger compartment syndrome, so they should not tolerate the pain. Because symptoms may develop after the person returns home, the player should be instructed to talk about subjective symptoms of compartment syndrome and go to the doctor if they are abnormal.
Photo 1 RICE treatment for prevention of compartment syndromes
Photo 2 Checking for sensory disturbance by touching the dorsum of the foot
Palpable dorsalis pedis artery
・ Pain increasingly intense pain
・ Pain when moving the ankle and toes Pain during active exercise
・ Pain during active movement Loss of active motor function, paralysis of motor nerves
・ Hypoesthesia of the lower leg Sensory neuropathy
・ Swelling → tense?
・ Color of lower leg → shiny, pink
・ Pressure → strong tenderness of the compartment
・ Passive exercises of the ankle and toes → unbearable pain
・ Palpate the dorsalis pedis artery → not necessarily diminished or lost
Okubo et al.: Compensation syndrome, Sports Traumatology IV Lower Extremity, Ishiyaku Publishers, Inc., 2001.
If conservatively treated, weight-bearing is allowed when subjective symptoms are reduced, and the ankle joint range of motion (ROM) and muscle strength are restored, and the person is encouraged to participate in graduated exercises. People who are treated surgically are kept at rest for a week after surgery. Thereafter, ROM and muscle strength are strengthened according to recovery status. Jogging begins at 4 weeks, followed by increased intensity of exercise to the dash, and the person returns to competition in about 3 to 4 months.