Understanding Chronic Compartment Syndrome: A Guide for Athletes
- Julian Simpson
- Feb 18
- 5 min read
Updated: Mar 12
Understanding Chronic Compartment Syndrome: A Guide for Athletes
Compartment syndrome is increased pressure within a non-expandable fibro-osseous space, leading to compromised tissue perfusion in that specific area.
Acute vs Chronic Compartment Syndrome
Acute compartment syndrome (ACS) is recognized as a critical medical emergency that arises primarily due to severe injuries or trauma, such as fractures, crush injuries, or significant contusions that can lead to a rapid increase in intracompartmental pressure.
This condition is characterized by intense, often excruciating pain that is disproportionate to the initial injury, as well as other symptoms such as swelling, tightness, and reduced sensation in the affected area. In contrast, chronic compartment syndrome (CCS) does not present as an immediate threat to life or limb; rather, it manifests gradually after prolonged or intense physical activity, particularly in athletes. This condition is often triggered by repetitive movements, leading to pain and discomfort that typically resolves with rest. Treatment for CCS usually involves a period of rest and recovery, along with modifications to training regimens, rather than the urgent surgical intervention often required for ACS.
What causes compartment syndrome?
Compartment syndrome occurs when the pressure within a muscle compartment exceeds the diastolic blood pressure, leading to compromised blood flow.
This situation can arise from various factors, including intense exercise that results in significant increases in muscle volume due to heightened metabolic demands, increased tissue perfusion, and muscle fibre growth.
During strenuous activity, the muscles swell, and if the surrounding fascia—a tough, fibrous tissue—does not expand to accommodate this increase, the result is elevated pressure within the compartment. This increased pressure can lead to tissue ischemia, where the blood supply is insufficient to sustain the muscle and nerve tissues, causing a buildup of metabolic waste products and leading to pain, swelling, and potentially irreversible damage if not addressed promptly.
The condition is not uncommon; nearly 1 in 1000 athletes may develop compartment syndrome during their athletic careers.
Chronic compartment syndrome primarily affects the leg, with over 95% of reported cases occurring in this region. Among the various compartments of the leg, the anterior compartment is the most frequently affected, accounting for approximately 42–60% of cases. Following this, the lateral compartment is affected in 35–36% of cases, while the deep posterior compartment sees involvement in 19–32% of cases, and the superficial posterior compartment is the least affected, with only 3–21% of cases reported.
Who gets compartment syndrome?
Compartment syndrome can affect individuals engaged in various sports, but it is particularly prevalent among athletes who participate in high-intensity or endurance sports such as lacrosse, football, basketball, skiing, and field hockey.
However, it is the endurance runners who are most significantly impacted, accounting for up to 68% of chronic compartment syndrome cases. The repetitive nature of running, especially over long distances, places considerable strain on the leg muscles, increasing the likelihood of developing CCS. Intense exercise, particularly running, has been closely associated with a heightened incidence of chronic compartment syndrome, as the muscles undergo repeated cycles of contraction and relaxation, leading to increased pressure within the compartments.
What happens in each of the 4 compartments of the leg?
The anterior compartment of the leg is home to several critical structures, including the deep peroneal nerve, anterior tibial artery, and key muscles such as the anterior tibialis, extensor digitorum longus, extensor hallucis longus, and fibularis tertius. When pressure within this compartment rises significantly, it can lead to sensory deficits, particularly in the first interdigital space, as well as weakness during movements like toe and ankle dorsiflexion, which can severely affect an individual’s ability to perform daily activities.
The lateral compartment houses the peroneus longus and brevis muscles, the peroneal artery, and the superficial peroneal nerve. Increased pressure in this compartment can lead to notable weakness during foot eversion, which is essential for maintaining balance and stability, as well as reduced sensation in the dorsum of the foot, further complicating mobility and athletic performance.
The posterior superficial compartment comprises the posterior tibial artery, gastrocnemius, soleus, and plantaris muscles, along with the distal segment of the sural nerve. Compression in this compartment can lead to numbness on the side of the foot and in the distal calf, impacting the individual's ability to walk or engage in physical activity comfortably.
The deep posterior compartment contains the tibialis posterior muscle, flexor digitorum longus muscles, peroneal artery, and the tibial nerve. A rise in pressure within this compartment may result in weakness in plantar flexion, which is critical for activities such as pushing off the ground during walking or running and can also cause numbness in the sole, leading to further complications in mobility.
What are the 5 criteria for diagnosis?
Diagnosis of compartment syndrome is based on a combination of clinical criteria that guide healthcare professionals in identifying the condition.
The five key criteria include:
(I) participation in activities that require repetitive activation of the same muscle groups, which often leads to overuse;
(II) the presence of pain during exercise, which may be sharp or cramping in nature;
(III) the sensation of stiffness or tightness during physical activity, which can indicate increased pressure in the compartment;
(IV) the tendency to stop specific activities earlier than usual or to avoid them altogether due to discomfort; and
(V) the manifestation of symptoms induced by provocative activities during a physical examination, which helps confirm the diagnosis.
Treatment Options
When it comes to the management of compartment syndrome, treatment options vary significantly between acute and chronic cases.
Traditionally, surgical intervention has been the standard approach for acute compartment syndrome, with fasciotomy being a common procedure that alleviates pressure and restores blood flow to the affected muscles and nerves.
This method has been associated with better outcomes in terms of recovery and prevention of long-term complications.
However, there is a growing body of evidence suggesting that conservative treatment strategies may be effective for certain cases of chronic compartment syndrome, particularly when identified early.
These conservative approaches may include physical therapy, modifications to training routines, and a gradual return to activity, allowing athletes to manage their symptoms without the need for surgical intervention.
Ultimately, the management of compartment syndrome, particularly in athletes, must be tailored to the individual, taking into consideration the severity of the condition, the specific compartment affected, and the athlete's overall health and activity goals.
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Jorge PB, Toledo MB, Mari FC, Toledo RRF, Lima MV, Sprey JWC. Chronic Compartment Syndrome in Athletes. Rev Bras Ortop (Sao Paulo). 2024 Jul 15;59(5):e650-e656. doi: 10.1055/s-0044-1787766. PMID: 39649060; PMCID: PMC11624925.
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