Anterior Compartment Syndrome

Anterior compartment syndrome includes two types of compartment syndrome, which are acute and chronic, such as described below:

Acute compartment syndrome

This condition may follow a direct impact, tear, or contusion to the muscle. It commonly affects athletes, particularly in sports such as running and football. Symptoms include severe pain in the tibialis anterior muscle on the outside of the lower leg. In addition, one possible cause is when blood flow is restored after blocked circulation.

This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. Lying for an extended period of time in the same position can also block blood vessels, although most patients will move in their sleep. Other possible causes of acute anterior compartment syndrome include from fractures, crush injuries, anabolic steroid use, and burns.

Chronic compartment syndrome

Chronic compartment syndrome is caused by exercise and repetitive movements and comes on over a period of time. It is often found in runners, swimmers, cyclists, and other athletes. Symptoms include pain, muscle tightness, numbness, and visible muscle bulging. This type of anterior compartment syndrome usually occurs during or shortly after exercising.

Symptoms that are associated with anterior compartment syndrome include the following:

• Pain – This is the most common sign that people describe as being extreme and out of proportion to the injury. It is worsened by touch, pressure, elevation, and stretching.
• Paresthesia – This is an awkward sensation, such as tingling or pricking, sometimes described as pins and needles.
• Tenderness – The inside of the shin may be tender and painful if pressed or squeezed.
• Tight calf muscles – Athletes may notice their calf muscles are tight.
• Pulse – There may be weak or no pulse from the affected anterior compartment.
• Passive stretch – Muscles lacking in blood are highly sensitive to stretching, therefore, extending the affected shin leads to extreme pain.

Certain risk factors increase your risk of developing anterior compartment syndrome, including:

• Aging – Although anyone can develop anterior compartment syndrome, the condition is most common in male and female athletes under the age of 30.
• Type of exercise – Repetitive impact activity, such as running, can increase the risk of developing anterior compartment syndrome.
• Tightness from bandages / casts – Patients who have anterior compartment syndrome and are currently wearing either a bandage or a cast may have a chance of experiencing a complication of bandages / casts that are applied too tightly, or due to swelling that occurs after casting.
• High-intensity training – Working out with high intensity or too frequently also can raise your chance of developing anterior compartment syndrome.
• Hyperpronate – Excessive pronation refers to when most or all of the body’s weight rest on the inside sole of the foot. Hyperpronation can cause increased eccentric loading of the soleus and tibialis posterior muscles in the calf, which can lead to anterior compartment syndrome.
• Flat feet (pes planus) – Such as people who have hyperpronate, people who have flat feet tend to put more stress on the inside sole of the foot.
• Slightly different leg lengths – A person can have slightly different leg lengths and not be aware of it. A relatively small leg length difference can cause problems in running biomechanics, leading to anterior compartment syndrome or other repetitive use injuries.
• Improper footwear – Running shoes that do not provide enough cushion and support proper foot mechanics may encourage the development of anterior compartment syndrome.
• Run on hard surfaces – Running on hard surfaces, such as concrete sidewalks, increases the impact on the musculoskeletal system and can lead to the condition.

In more severe cases of anterior compartment syndrome, a surgical procedure known as fasciotomy may be required. A fasciotomy surgery is necessary to relieve symptoms and prevent permanent tissue damage in a patient with anterior compartment syndrome. The complications associated with fasciotomy include:

• Pain
• Infection
• Scarring
• Nerve damage
• Muscle damage
• Excessive itching (pruritus)
• The need for future corrective surgeries, which may include an amputation.
• Kidney failure due to a condition known as rhabdomyolysis. Rhabdomyolysis is a condition that involves the breakdown of muscle tissue.

Certain health conditions may increase the risk of complications. It is recommended to talk to your surgeon, before the procedure, if you have certain disease conditions, such as diabetes, or if you are on any medications, such as steroids, aspirin, or blood thinners. Obese people may also be at a higher risk of developing complications after a fasciotomy.

Fortunately, most patients with anterior compartment syndrome never need to go to the doctor for a clearer diagnosis with a standard recovery estimation time of up to 3 months. However, athletes may want to consult with their doctors if their shin pain isn’t relieved after a couple of weeks of resting, icing, and taking over-the-counter NSAIDs, such as ibuprofen. In order to make a diagnosis, your doctor will conduct a patient interview and physical examination and possibly also medical imaging:

Patient interview

Your doctor will ask you many questions, including questions about your regime, what brings on pain and what relieves pain.

Physical examination

Pain along the medial tibia is most often present with running and sports but may progress to be triggered by walking as well. Tenderness to Palpation is present along the shin. Tight calf muscles and decreased ankle motion are common.

Medical imaging

X-rays, bone scan, and magnetic resonance imaging (MRI) are often negative with anterior compartment syndrome, but they may help to differentiate shin splints from stress fractures. X-rays may demonstrate some generalized thickening. A bone scan may demonstrate some generalized uptake of the tracer substance used in these scans along a length of the shin, which indicates locations where the bone’s metabolism is increased.

After a diagnosis, physiotherapist may be done. A physiotherapist will determine what risk factors have caused your shin and will teach you how to address those causes. A treatment plan will be developed that is specific to your and what your body needs to recover and to prevent re-injury. Your physiotherapist may recommend the following treatment plans:

Range of motion exercises

Restricting the motion of your knee, foot, or ankle may be causing increased strain in the muscles housed within the compartments of your lower leg. Stretching techniques can be used to restore motion in these affected joints to help reduce undue muscle tension.

Manual therapy

Your physiotherapist may use their hands (hands-on therapy) to move and manipulate muscles and joints to improve motion and strength. These techniques can target areas that are difficult to treat on your own.

Muscle-strengthening

Hip and core weakness can influence how your lower body moves and may cause imbalanced forces through the lower-leg muscle groups that may contribute to compartment syndrome. Building core strength (for example in the muscles of the abdomen, low back, and pelvis) is highly important; a strong midsection allows greater stability through the body as the arms and legs perform different motions.

For athletes engaged in endurance sports, it is important to have a strong core to help stabilize the hip and knee joints during repetitive leg motions. Your physiotherapist will be able to determine which muscles are weak and provide specific exercises to target these areas.

Modalities

Your physiotherapist may use modalities (ultrasound, iontophoresis, moist heat, cold therapy) as a part of your rehabilitation program. These tools may help improve tissue mobility and flexibility and enhance recovery. Therefore, your therapist will discuss the purpose of each modality with you.

Educational advice

Your treatment will include a set of educational advice about how to safely return to your previous activities, particularly if your condition requires a fasciotomy. Your physiotherapist may recommend:

• Wearing supportive footwear.
• Choosing more appropriate surfaces and terrain for exercises especially endurance sessions.
• Limiting your pace in certain activities.
• Avoiding some activities altogether.
• Adapting strategies for recovery and maintenance of good health (allowing your muscles and joints proper rest time).
• Making changes in your workplace to help lower the risk of injury.

Below are a few stretches that will help you prevent anterior compartment syndrome or recover if you’re having shin splint pain:

Soleus calf stretch

First, stand with your hands against a wall or the back of a chair for support. Put one foot behind, then, keep your feet flat and pointed straight ahead. Bend your front knee slightly. With your back heel down, bend your back knee. Hold this stretch for at least 30 seconds, then repeat 2-3 times a day.

Gastrocnemius calf stretch

Stand with your hands against a wall or on the back of a chair for support. Put one foot behind you, then, keep your feet flat and pointed straight ahead. With your back heel down and back leg straight, bend the front knee until you feel a stretch in the calf of your back leg. Keep your back straight throughout the stretch. Hold the stretch for at least 30 seconds, then repeat 2-3 times a day.

Achilles tendon stretch

You can perform this exercise standing on a stair step, a curb, or a step stool. Stand with the balls of your feet on the edge of the stair step. Slowly let one heel hang off the step until you feel a stretch at the back of your leg and the Achilles area. Hold the position for 30 seconds, then repeat 2-3 times a day.

While eating a diet high in anti-inflammatory foods, exercising in a healthy manner, resting enough between workouts, and stretching after workouts can all help lower swelling, these habits still might not be enough to prevent anterior compartment syndrome in some cases.

It’s still a good idea to practice these things anyway since they prevent injuries and pain in addition to lowering the risk for anterior compartment syndrome, but it has already set in, you must start treatments right away. The goal of treating your shin pain at home is to help reduce pressure and improve blood flow to the area that is affected. Therefore, here are a few home remedies that can reduce further symptoms of anterior compartment syndrome:

• Orthotics – Orthotic inserts are soft but a firm foot or heel pads that are inserted into the shoe. When positioned correctly, inserts can correct abnormal foot posture and relieve muscle pain caused by walking and running.
• Limiting your physical activities – especially focusing on low-impact activities such as cycling.
• Pain relievers – Taking pain medications orally such as NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen and naproxen to help reduce swelling and inflammation due to chronic anterior compartment syndrome.
• Ice application – Applying ice packs 15-20 minutes a day to help reduce inflammation.