Compartment Syndrome of the Lower Leg
Compartment syndrome of the lower leg occurs in two main forms: acute compartment syndrome (ACS) and chronic exertional compartment syndrome (CECS). Both conditions involve increased pressure within one or more fascially enclosed muscle compartments of the lower leg, which can reduce circulation, cause ischemia, and impair neuromuscular function. The acute form is an orthopedic emergency requiring rapid diagnosis and surgical treatment, whereas the chronic form causes reversible activity-related symptoms but may have a substantial functional impact over time.
Etiology
Acute compartment syndrome most commonly develops after trauma, particularly tibial shaft fractures, but it can also occur after soft-tissue injuries, vascular injuries, burns, drug overdose, or intense physical exertion. The condition is characterized by increased interstitial pressure exceeding capillary perfusion pressure, leading to cellular hypoxia, metabolic acidosis, and ultimately tissue necrosis⁴.
Chronic exertional compartment syndrome (CECS) is not an acutely life-threatening condition but can cause persistent functional limitations. It is typically triggered by repetitive loading, most often in younger, physically active individuals. During exercise, muscle volume may increase by up to 20%, which raises pressure within the compartment. When compartment pressure exceeds approximately 30 mmHg, blood flow can be reduced and ischemic symptoms may occur. The anterior compartment is affected most frequently⁵,⁶.
Epidemiology
CECS appears to be more common than previously assumed and has been reported in up to 33% of patients presenting with exercise-related lower-leg symptoms¹. Acute compartment syndrome is considerably more common in men than in women, possibly because of greater muscle mass relative to fascial volume. Younger patients under 35 years of age are also at higher risk of the acute form, partly because of tighter fascial structures and higher activity levels².
Anatomy and Affected Structures
The lower leg is divided into four compartments: anterior, lateral, deep posterior, and superficial posterior. Each compartment contains specific muscles, nerves, and blood vessels that are affected differently by increased pressure. For example, increased pressure in the anterior compartment can compromise the deep fibular nerve and anterior tibial artery, causing sensory changes in the first web space and weakness of ankle and toe dorsiflexion².
Symptoms and Clinical Presentation
The most characteristic feature of acute compartment syndrome is pain out of proportion to the apparent severity of the injury, particularly pain with passive stretching of the affected muscle group. Other common findings include a feeling of increasing tightness in the lower leg, swelling, and paresthesia. In severe cases, muscle necrosis, sensory loss, paresis, absent pulses, and pallor may develop—the classic '6 Ps': pain, paresthesia, pallor, pulselessness, paralysis, and poikilothermia²,³.
CECS typically presents as exercise-induced pain and tightness that begins after a predictable amount of physical activity and resolves relatively quickly after activity stops. Symptoms are reproducible and predictable, which helps distinguish CECS from several differential diagnoses.
Diagnosis
In ACS, clinical examination is critical. The earliest and most sensitive sign is severe pain with passive muscle stretch. Pulselessness and motor weakness are late, severe findings that may indicate irreversible injury. Intracompartmental pressure (ICP) may be measured serially to monitor progression and determine whether fasciotomy is indicated. A compartment pressure above 30 mmHg, or a delta pressure below 30 mmHg when compared with diastolic blood pressure, is commonly considered critical².
In CECS, diagnosis is usually based on the history and physical examination, although pressure measurements before, during, and after exercise may be required to confirm the diagnosis. MRI or other imaging modalities are primarily used to exclude alternative diagnoses.
Treatment
Acute compartment syndrome requires immediate fasciotomy, a surgical procedure in which the fascia is opened to relieve pressure and restore circulation. Delay can lead to permanent muscle damage, nerve injury, contracture, and in the worst cases amputation². Rehabilitation is necessary after fasciotomy to restore mobility, strength, and function.
For CECS, conservative management is generally attempted first and includes activity modification, adjustment of training volume, gait or movement-pattern changes, and orthoses. If these measures do not provide sufficient relief, surgical fasciotomy may be considered and often has a good prognosis in appropriately selected patients⁷.
Assessment of Acute Compartment Syndrome
In ACS, the classic findings are the so-called six Ps: pain, pallor, paresthesia, pulselessness, paralysis, and poikilothermia. The most reliable early sign is severe pain that is disproportionate to the clinical findings and worsens with passive stretching of the affected muscles. Sensory change between the first and second toes may indicate involvement of the deep fibular nerve in the anterior compartment. Loss of pulse is usually a late sign and is more suggestive of arterial injury than of compartment syndrome itself²,⁵.
Assessment of Chronic Exertional Compartment Syndrome
In CECS, patients often describe a deep, pressure-like pain in the lower leg that is predictably triggered during physical activity, often within 30 minutes, and resolves quickly with rest. Other symptoms may include numbness, weakness, and a sensation of swelling. Ordinary daily activities usually do not provoke symptoms. Examination may reveal reduced range of motion, swelling of the lower-leg musculature, and tenderness. Diagnosis is most often confirmed by measuring intracompartmental pressure before and after activity using a needle-manometer or catheter-based system⁶,⁹.
Treatment of Acute Compartment Syndrome
The only definitive treatment for ACS is urgent fasciotomy, in which the fascia is surgically divided to reduce pressure within the affected compartment and restore circulation. Delayed treatment can lead to necrosis, contracture, neurological injury, and in severe cases amputation. Early intervention is essential to preserve limb function².
Non-surgical immediate measures include removing or loosening constrictive casts or bandages, keeping the limb at heart level to support venous drainage without compromising arterial inflow, and avoiding positions that may further reduce circulation. Analgesia should not delay recognition or surgical treatment of suspected ACS².
Treatment of CECS
Initial management of CECS is conservative and may include activity modification, stretching, orthotic adjustment, and changes in training pattern. In selected cases, medications or botulinum toxin injections have been investigated to reduce muscle tone and pressure. If symptoms remain limiting despite conservative measures, surgical fasciotomy may be considered. Outcomes are good for many patients, although recurrence can occur¹¹.
Physiotherapy in CECS and ACS
Physiotherapists have an important role in early recognition, preoperative management and postoperative rehabilitation. In CECS, the physiotherapist should:
Assess movement patterns and symptom-provoking factors
Modify activity and promote alternative forms of exercise such as cycling and swimming
Use appropriate stretching of affected muscle groups
Provide advice on footwear and training surfaces
Assess the need for orthoses or insoles
Plan a gradual return to sport
After fasciotomy, postoperative physiotherapy aims to:
Limit excessive scar formation and adhesions through appropriate early mobilization
Restore range of motion and strength in the affected musculature
Resume cardiovascular exercise, for example cycling after wound healing
Introduce progressive strengthening once tissue healing allows
Gradually progress toward running and sport-specific training over approximately 6–12 weeks when clinically appropriate
Educate the patient about recovery and prevention strategies
Examples of preventive strategies include matching footwear to activity, choosing appropriate training surfaces, varying training intensity, and allowing adequate recovery. Patients should also be taught to recognize symptoms that may indicate recurrence.
Conclusion
Acute compartment syndrome of the lower leg is a limb-threatening condition that requires urgent surgical intervention. Chronic exertional compartment syndrome is less acute but can cause substantial functional limitation if not addressed. Physiotherapists can contribute to early recognition, conservative management of CECS, and postoperative rehabilitation. Through careful clinical assessment, individualized interventions, and graded functional rehabilitation, physiotherapy can support recovery and reduce the risk of recurrent symptoms.
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