Anterior leg pain is common for those with active lifestyles, and there are a number of conditions that can appear in this region of the body, including compartment syndrome. Compartment syndrome occurs most often in the lower leg, although other regions (such as the thigh, arm, or gluteal region, among others) can also be affected.¹ There are two forms of compartment syndrome: acute and chronic (often called exertional compartment syndrome). Recognizing acute versus chronic compartment syndrome is crucial.

Chronic compartment syndromes may respond well to massage, but acute compartment syndromes are an emergency condition that need immediate care by a physician. Differentiating between a medical emergency and nonemergency is essential when the possibility of acute compartment syndrome exists. Delayed treatment on an acute compartment syndrome can cause tissue necrosis and lead to limb amputation. To understand how compartment syndromes arise, let’s explore this condition.

Anatomical Background

The compartments in the lower leg are the most susceptible to compartment syndrome. The lower leg muscles are organized in groups containing muscles that perform similar functions. Each group is separated from the adjacent group by fascial walls, bones, or a tough interosseous membrane. These soft- and hard-tissue boundaries of each muscle group form the individual compartments.

There are four compartments in the lower leg (Images 1 and 2). The anterior compartment contains the dorsiflexor muscles. The lateral compartment contains the fibularis (peroneal) muscles. The superficial posterior compartment contains the gastrocnemius and soleus (plantar flexors), while the deep posterior compartment contains the three long muscles extending into the foot: tibialis posterior, flexor hallucis longus, and flexor digitorum longus.

In the lower leg, the anterior compartment is the one most susceptible to compartment syndrome. It also contains the tibial artery and vein and the deep fibular nerve (Image 3). There are also lymphatic vessels and other more superficial cutaneous nerves in the compartment.

Even though some of the compartment walls are composed of fascial tissue or other soft tissue like the interosseous membrane, these tissues may be stiff and unyielding. A compartment syndrome occurs when the muscles within the compartment swell as a result of exercise or inflammation from trauma. When the muscles increase in size, the compartment must expand. If the stiff walls of the compartment don’t allow it to expand sufficiently, pressure builds up from the decreasing space and growing size of the expanding muscles. As the compartment pressure increases, the contents are squeezed. A host of symptoms can result from this increased compartmental pressure.

Compartment Syndrome: Acute or Chronic

An acute compartment syndrome usually results from some type of acute trauma like a direct blow to the area, bone fracture, or other sudden injuries that cause inflammation. Other causes include vigorous exercise with immediate symptom onset, blood clots, tight bandaging, or surgical procedures. Symptoms don’t always appear immediately, which makes identifying the condition difficult.

Acute compartment syndromes are less common than chronic ones, but are far more dangerous because they usually involve greater degrees of swelling and greater pressure levels within the compartment. If the sudden increase in pressure is not relieved, tissue necrosis and permanent damage can result. Subsequent tissue necrosis could potentially lead to the necessity for limb amputation, thus why immediate care is necessary.

Acute compartment syndromes also occur from unusual activities in which tissues are compressed for long periods. One clinical case reported a man who passed out on a staircase for 8–10 hours as a result of a drug overdose. The prolonged pressure on his thigh and gluteal region from the staircase caused compartment syndrome that resulted in irreversible neurological damage to his sciatic nerve.² Acute forms can also result from long surgeries where a body part is immobile for long periods on the operating table, so medical staff must prevent constant pressure in one location.

There is also some indication that rapid muscle growth, such as that resulting from anabolic steroids, may lead to compartment syndrome. For example, a boxer taking steroids developed bilateral foot drop after a sudden vigorous run. Foot drop is often a symptom of some type of neurological disease or problem at the nerve root level. However, in this case, bilateral compartment syndrome had put pressure on the deep fibular nerve on each side, causing the foot drop.³

Chronic compartment syndrome, also called exertional compartment syndrome (ECS), is far more common than the acute form. ECS usually occurs as a result of repetitive activity like running or dancing. During the activity, the muscles swell and increase pressure on the compartment’s contents. However, with ECS, the aggravating symptoms generally subside within about 15–60 minutes. Because the swelling subsides within a short period, it is not as serious as the acute form in which swelling can put tissue health at risk.

With ECS, it is common to see pain or other symptoms begin consistently after a certain amount of time, distance, or intensity of exercise. These symptoms generally increase as exercise progresses. Once the exercise or activity is stopped, symptoms tend to dissipate, usually within about an hour.

While the lower leg is certainly the most common location for ECS, it can occur in other regions of the body as well. ECS of the forearm can occur after prolonged activities requiring significant grip strength. The condition is reported in competitive motorcycling where it is known as “arm pump,” but is also reported in gymnastics, hockey, wheelchair athletics, climbing, waterskiing, and kayaking.⁴

Identifying Potential Compartment Syndrome

One of the most important factors in identifying compartment syndrome is an accurate health history. Identify any recent trauma or instance where the affected area was exposed to a direct blow, trauma, or unusual sustained pressure that might indicate an acute compartment syndrome. If the symptoms came on as activity progressed, and then subsided a short time after activities ceased (without any acute trauma), a chronic exertional compartment syndrome would be more likely.

The most accurate way to identify increased compartmental pressure is with an intracompartmental compression monitor. This monitor has a needle probe that is inserted into the compartment and can measure the internal pressure. However, this monitor is not always available or practical and is, of course, out of the massage therapist’s scope of practice. Compartment syndromes are most often evaluated by clinical presentation and exclusion of other possible causes.

The primary symptoms of a lower leg compartment syndrome include:

• Aching, burning, or cramping in the lower leg

• Weakness or motor dysfunction (which usually shows up as foot drop)

• May be present in both limbs if it is an ECS, or just one if there is a traumatic incident indicating an acute compartment syndrome

• Swelling or bulging of the area may be visible or palpable

• Discoloration and/or coldness of the lower leg or foot from vascular compromise

• Possible sensation of tightness or fullness in the extremity due to lack of venous return

• Paresthesia, numbness, or other neurological sensations, especially in the distribution of the deep fibular nerve

Conditions with Similar Symptoms

Other lower leg complaints have similar symptoms to compartment syndrome, especially chronic exertional compartment syndrome, which may cause confusion. Conditions that have similar symptoms include:

• Deep-vein thrombosis

• Medial tibial stress syndrome

• Peripheral nerve entrapment

• Shin splints

• Stress fracture

• Tendinosis, tenosynovitis

• Tumor

• Vascular claudication (blocked vascular structures that reduce blood flow)

Several compartment syndrome symptoms, such as neurological signs like paresthesia, foot drop, or numbness, don’t occur with chronic overuse muscular problems. These symptoms help discriminate a compartment syndrome from muscle-tendon overuse problems, such as shin splints. The vascular symptoms of coldness or color changes in the extremity are also not present with shin splints.

Treatment Strategies

Treating acute compartment syndrome involves an emergency procedure called a fasciotomy to decrease compartmental pressure. In this procedure, the surgeon makes an incision lengthwise along the compartment that allows the bulging muscles to expand outside the compartment wall until the pressure subsides. In some cases, this may take several hours, so the incision may be left open while the pressure decreases. Delaying this procedure can cause irreversible tissue damage. There can also be complications of the surgical fasciotomy procedure because nerves, veins, and arteries can be accidentally cut during the procedure.

While it is unlikely that the massage therapist will be faced with an acute compartment syndrome, it is important to recognize the signs and symptoms. An acute compartment syndrome is one instance in which RICE (Rest, Ice, Compression, and Elevation), the common method for treating an acute injury, is actually a bad idea. Rest is certainly beneficial, but ice can cause decreased tissue fluid movement and that does not help reduce compartmental pressure. It is also obvious that additional compression is a bad idea for a condition where excess compression is the problem. Leg elevation could also impair the return of needed circulation. Clearly, recognition of a potential compartment syndrome should initiate a referral to a physician—and alter your treatment.

Chronic compartment syndromes are most often treated with conservative and noninvasive measures. The most important strategy for addressing this condition is reducing any offending activity. Symptoms may dissipate if the client completely ceases the exercise that caused the problem to begin with. However, that solution is often not acceptable for highly active individuals.

Sometimes biomechanical solutions, like foot orthotics, can alter gait in a manner that helps reduce symptoms. Changing running stride has also shown beneficial results with anterior compartment syndrome treatment. Since the primary problem in this condition is excessive eccentric load on the dorsiflexor group, teaching the individual to impact the ground with the forefoot instead of heel strike can decrease symptom occurrence in some cases.

Should We Treat Compartment Syndrome with Massage?

A key question about treating compartment syndrome is what role massage may play. Almost any massage technique increases pressure on the tissues being addressed. As a result, it would seem that massage would not be a good idea for any compartment syndrome condition. This is certainly true with an acute compartment syndrome, where swelling is immediate and any increased pressure on the compartment can aggravate and damage the compartment contents.

Massage treatment for ECS is beneficial as long as it is not performed immediately after any activity that has flared up the symptoms. For example, if a person has just finished running, is complaining of aching pain in their lower legs, and has other compartment syndrome symptoms, this is not the time to do soft-tissue treatments. On the other hand, if the person is consulting you three days after the last run and the pain has subsided, massage would be appropriate at this point.

A wide variety of massage techniques may help address the symptoms of ECS. I have found any of the approaches used with other common overuse disorders of the lower leg, such as shin splints, help treat ECS. It can be advantageous to start with broad contact surface applications, such as those with the palm or backside of the fist. Slowly and gradually increase pressure as you glide along the compartment muscles to determine what pressure levels might increase existing symptoms. This is not the time to press harder and deeper, even if the client says that feels good!

As treatment progresses, more specific and focused treatment (such as that applied with the fingertip, knuckle, thumb, or pressure tool) gliding parallel to the fibers within the compartment may effectively reduce muscle tension. I have also found active movement along with massage to help chronic muscular irritation that occurs with ECS. If at any point there is an increase in vascular or neurological symptoms, back off the pressure and go to a wider contact surface so that you don’t increase any inflammatory reaction.

Compartment syndromes are not highly common, which is why soft-tissue therapists may not be aware of them. However, inappropriate attention to a compartment syndrome can cause serious medical complications. This is another example of how a broad and comprehensive knowledge base about various potential conditions helps you provide the safest and most effective treatment for your clients.

Notes

1. Alessio Giai Via et al., “Acute Compartment Syndrome,” Muscle, Ligaments and Tendons Journal 5, no. 1 (March 2015): 18–22, https://doi.org/10.11138/mltj/2015.5.1.018.

2. Moo Ing How et al., “Delayed Presentation of Compartment Syndrome of the Thigh Secondary to Quadriceps Trauma and Vascular Injury in a Soccer Athlete,” International Journal of Surgery Case Reports 11 (January 2015): 56–8, https://doi.org/10.1016/j.ijscr.2015.04.003.

3. Andreas Christos Panagiotopoulos et al., “Gluteal Compartment Syndrome Following Drug-Induced Immobilization: A Case Report,” BMC Research Notes 8, no. 35 (February 2015): 35, https://doi.org/10.1186/s13104-015-1003-5.

4. John W. K. Harrison, “Chronic Exertional Compartment Syndrome of the Forearm in Elite Rowers: A Technique for Mini-Open Fasciotomy and a Report of Six Cases,” Hand (New York) 8, no. 4 (December 2013): 450–53, https://doi.org/10.1007/s11552-013-9543-4.