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Running Injuries: Compartment Syndrome - An Acute Lower Leg Injury

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As a runner, it’s the lower leg that suffers the most. But if you have the undying passion for running, then nothing can stop you! However, these running injuries often come as a hindrance in the path of your run. The ultimate step you can take to prevent running injuries is prevention. But what if even that fails? Well, for all that we are here. Leave it to us, we have a solution for all (you are in safe hands). When we mentioned lower leg injuriesshin splint, plantar fascia, knee pain are some of the common injuries that take a toll on running. One such traumatic injury is the compartment syndrome. Running stimulates blood flow to the lower leg muscles and thereby the muscles expand. But, when the expansion leads to a point that the compartment around the muscles becomes tight and oxygen depletion occurs- that's when a runner experiences acute pain, called compartment syndrome. This condition needs medical attention and if not can elevate and cause extreme pain. Runners often confuse this injury with shin splints, but not anymore. From symptoms to how to treat it to lifestyle changes, you get informative knowledge here. Let’s get started.

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What is Compartment Syndrome?

Compartment syndrome in running is also referred to as Chronic or recurrent Exertional Compartment Syndrome (CECS) and is basically a condition in which the lower leg gets affected. It can lead to swelling, pain and at times disability in the affected muscles. Anyone can develop this condition but it is found to be more common in athletes who take part in activities which involve repetitive impact. 

The lower leg is divided into about four or five compartments with different nerves, muscles, tendons and blood vessels that run through these compartments. Each of the compartment is surrounded by the fascia that aids in improving the contraction’s efficiency and divides the muscles from the surrounding tissues. 

At times, the pressure in one or more of the compartments increases to such an extent that the muscle, nerves or blood vessels get compressed and this leads to discomfort. The end result is building pressure in that area which can be rather painful. It can lead to pain and in extreme cases, loss of function. Compartment syndrome treatment without surgery in most of the cases is possible. However, if that doesn’t seem to help, your doctor would recommend surgery. 

Compartment Syndrome
Pain in the lower leg

Causes of Compartment Syndrome

The cause of compartment syndrome isn’t clear completely. In runners, compartment syndrome in running happens usually due to an increase in activity or in training. This issue is usually the result of repetitive stress in a particular area. Runners of both genders are at equal risk however, it most commonly strikes those who are fit and thin with lower body fat. 

As the muscles are being used on a regular basis, there happens a build-up of waste product and an increase in the blood flow. This leads to the volume of the muscle being increased by say about 8 to 20%. This would cause increased pressure within the compartments of the muscle.  The muscle’s resting size might also increase due to training. However, all of these changes are quite normal with the pressure that had increased reducing 5 minutes after you have stopped exercising. 

In most cases, compartment syndrome tends to develop because of different anatomy. 

  • Because of the extra ‘fifth’ compartment

In a few people, there exists an extra ‘fifth’ compartment somewhere deep down in the lower leg. This also has an extra sheath of fascia which extends up to the leg. The risk of compartment syndrome increases if the sheath extends further up the leg. 

  • Because of the fascia becoming thickened

The other cause of compartment syndrome is the fascia becoming thickened or fibrotic. This might happen because of a surgery or a chronic inflammatory process and can make the fascia less flexible than before. 

In both of the above-mentioned cases, the pressure tends to increase to a very large extent and then takes a much longer time to reduce after the exercise or run. There is a reduced blood flow in the muscles and a reduced amount of oxygen for the tissues because of the extra internal pressure in the compartment.  A few experts also suggest that the way in which you move might also have an effect and can play a role in causing compartment syndrome while running.

reasons for compartment syndrome in leg
What can cause compartment syndrome (source)

Symptoms of Compartment Syndrome

In most cases, the symptoms of compartment syndrome can be confused with those of stress factor and shin splints.

So how do you know if you have compartment syndrome?

Well, as any of the four compartments can develop compartment syndrome, the specific location of the symptoms would vary accordingly. 

When it comes to compartment syndrome vs. shin splints, people tend to get confused because pain experienced in both the cases is nearly the same. However, the area of the pain differs. Most of the times, the pain would mostly be in your lateral or anterior compartments. Pain experienced on the lower leg’s outside front in the anterior compartment is compartment syndrome’s symptom. However, if you have shin splints, you are most likely to experience pain on the lower legs inside front.

The most common symptoms of compartment syndrome are: 

  • Stiffness, tightness in the affected area of the limb 
  • Cramping pain, aching or burning in the affected limb which usually increases when you run
  • Weakness when attempting to plantarflex or dorsiflex your ankle 
  • Numbness, burning coldness, a tingling sensation in the affected limb 
  • Swollen lumps in the muscles might be present when you touch the affected area 
  • Foot drop in extreme cases if the legs are affected (It is quite common and there’s a very less chance of something like this happening due to compartment syndrome) 

The pain that you experience due to compartment syndrome while running might begin after a certain time or the intensity of exertion experienced after you have started exercising. As you keep exercising, the pain in the affected limb would worsen but would usually subside within say ten to twenty minutes after you stopped the activity. Gradually, your recovery time after the exercise or run would increase. 

Performing activities of low-impact or taking a complete break from performing exercises might aid in relieving your symptoms. However, this would only be temporary. If you return to exercises and running after taking a rest for say about a week, the symptoms would generally come back. The best solution would, therefore, be to consult a doctor.

symptoms of compartment syndrome
Swollen legs- Symptoms of Compartment Syndrome

Compartment Syndrome: Diagnosis 

Most of the times, diagnosing compartment syndrome due to running could prove to be tricky. This is because several other injuries like a stress fracture, tendonitis or periostitis can cause pain in the exact same area. A bone scan or an MRI can help in finding out if you have a stress fracture or shin splints.  A muscle strain in the calf muscles can cause the same kind of pain as is caused by compartment syndrome.  

Fortunately, to treat compartment syndrome, there is a definitive medical test available. Check below:

  • The doctor would ask you to run on the treadmill.
  • You would have to keep running until you start feeling the pain.
  • Once you feel the pain. The doctor would stick a special needle into the several compartments of the legs.
  • These would be attached to a pressure monitor or the needle itself would be equipped with a pressure gauge so that the pressure of your intramuscular compartment can be measured directly. 

In case the difference between the resting pressure and the pressure recorded after running or exercising is too high, then it is a sure sign of compartment syndrome due to running. 

Risk Factors Involved with Compartment Syndrome

There are various factors that can elevate the risk of developing exertional compartment syndrome. Listed below are a few of them. 

  • Type of Exercises You Perform: Relative impact activities like walking fast or running elevates the risk of you developing this condition. 
  • Age: As is known, people of any gender and age can develop exertional compartment syndrome. However, the condition can most commonly be seen in athletes who are under the age of 30.
  • Going Overboard With Exercising: Working out rather frequently and way too intensely can increase the risk of exertional compartment syndrome. This is because the muscles get overstrained, more than what they can sustain. 

Compartment Syndrome Treatment

Options for chronic compartment syndrome treatment include surgical and non-operative methods. The success of non-operative methods would only be possible if you stop or reduce the activity that had resulted in this condition. 

PHASE I - Pain Relief. Minimise Swelling & Injury Protection

This first phase focuses on managing the pain. The doctor or physiotherapist that you have consulted would use an assortment of treatment tools in order to reduce any chronic inflammatory disorder and the elevated pain. It might include soft tissue massage, ice, electrotherapy, acupuncture and de-loading taping techniques.

A mobility aid might also be recommended on a temporary basis to off-load the injured structures. In extreme cases of compartment syndrome due to running, the doctor would recommend you to rest completely for a certain time period. In minor cases, any necessary modifications to your training might be advised by the physiotherapist. 

compartment syndrome treatment
Initial treatment to the pain

PHASE II - Restoring Normal ROM & Posture

A biomechanical fault is more than often the cause behind the increased load. Restoring your normal joint range of motion, neural tissue mobility, muscle length, the flexibility of the fascial tissue and tension caused when the muscle is resting would be your physiotherapist’s main aim. Based upon our condition, the treatment may include techniques for alignment and joint mobilization, 

The treatment might include alignment and joint mobilization techniques, muscle stretches, massages in the affected area for relief, plus acupuncture, neurodynamic exercises, dry needling or trigger point therapy. 

Treatment for compartment syndrome
Neurodynamic exercises for a relief (source)

PHASE III - Restoring Normal Muscle Control & Strength

Your physiotherapist would examine the recruitment pattern of your muscle thoroughly and then prescribe the best exercise according to your condition. Some might have minor exertional compartment syndrome while others might have extreme chronic exertional compartment syndrome due to running. Therefore, careful analysis is necessary. This way with proper diagnosis and care, you would soon be able to regain normal muscle control. 

PHASE IV - Restoring Full Function

Now, you are nearing to complete recovery and would soon be able to return to your desired activities. Each individual has different bodies and their needs, therefore, differ too. Hence, the demands of an individual’s body would be assessed by the physiotherapist and the then the treatment goals would be determined that you would need to achieve so as to recover. For some cases, it might just be a small run around the park while for the other it might be a wish to run the marathon. The physiotherapist would advise you the change that you need to bring to your lifestyle so as to achieve your goals. 

PHASE V - Preventing a Recurrence

By now you might feel that you are perfectly fine but you must understand that pain does have a tendency to return especially if not taken care of. Your physiotherapist would examine your biomechanics and take necessary steps so as to correct any kind of defects. As discussed above, the corrective measures would depend on your condition and your physiotherapist would be able to give you a detailed insight on this. 

Surgery for Compartment Syndrome

Surgery is considered as one of the most effective treatment options available for compartment syndrome due to running. However, it is only considered if a conservative program has failed and you still wish to keep exercising. The surgical procedure is referred to as fasciotomy and involves creating slits in the lower leg’s compartments so as to provide them with more room while exercising. 

Your symptoms might just be confined to one side but the doctor may choose to operate on the compartments of both the legs. This is because compartment syndrome often does occur on both of the sides. If you have it on one side, there’s a high chance that you would be developing it in the other one as well. 

The surgery’s success rate would completely be dependent on the compartment syndrome’s location. surgery for deep posterior compartment syndrome has a success rate of about 50% while Fasciotomy in the anterior compartment has a success rate of about 60 to 80%. In most of the cases, the syndrome tends to return just after a few months of the surgery. 

This happens mostly because the compartments weren’t opened up enough. A follow-up surgery in such cases might be required. You must choose a doctor who is well-trained and has some a few years of experience in this area. 

compartment syndrome surgery
The only solution (source)

Non-Surgical Treatment

The following chronic exertional compartment syndrome non-surgical treatment can be tried at home for some relief from the pain. 

  • Good quality athletic shoes or you can also use athletic shoe inserts (orthotics) 
  • After you are done exercising, apply ice on the affected area
  • Indulging only in the physical activities that don’t cause pain. You could try low-impact activities like cycling. 
  • Other treatment options might include massages, acupuncture, certain interventions like injections and weight-loss. 

Initially, you might be recommended pain medication by your doctor. Orthotics, strengthening or stretching exercises might also be recommended. Your physiotherapist would assess your condition and may teach you several biomechanical techniques like changing the way you land when you are jogging. However, you need to understand that non-operative options generally do not offer long-lasting benefits. 

Summing Up 

This injury isn’t a life-threatening condition. It wouldn’t cause any lasting damage if you get appropriate treatment. But, if do not reduce your frequency of exercising and keep continuing, pain can elevate and numbness and weakness might also be experienced in the affected area. Therefore, the best option would be to get in touch with a doctor at the earliest. 

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