Compartment Syndrome Management?

[jordanloughlin]

Patient is a runner in his 40's with anterior shin pain, which is worse on rest, and better with walking and movement.

He has bilat. overpronated feet, FAROM at ankle which is pain free, but slightly decreased tib ant length, and very bulky calf's. The tib. ant. muscle belly is tender to palpate on deep palpation. Shin tap and stress tests are negative for stress fracture.

So far I have given gastro/soleus stretches, tib ant stretches, and tib post strengthening with little improvement. His is seeing podiatry and is in the process of having orthotics made up.

Any advice would be greatly appreciated!!!

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[ginger]

compartment syndrome is rare and not indicated by his symptoms as described. You do have someone however who will most likely have the consequences of uncontrolled over pronation, which is a stiff lower back. Mobilise L34and 5 to eliminate his referred pain.

[msk101]

HI There,
sounds more like a periostitis at the tibia (pre-stress fracture level) secondary to the poor lower limb biomechanics. Whilst i somewhat agree to treating the lower back i would also advocate for core strength and the podiatric orthoses for foot correction. The tib ant is likely tight in response to attempting to stabilise the foot and ankle as tib post just isn't doing the job well enough or isn't in a biomechanically advantageous position with the pronation to be effective. this person is likely a bulky soleus type runner with either flat foot or heel plant with jogging rather than a gastroc toe planter so soleus stretching is really important - you're on the right track there.
As far as manual treatment goes, it can be bruising but effective to treat the soft tissue of tib ant but more particularly tib post on the posterior medial margin of the tibia.. it's generally knotty and thickened and responds well to deep tissue work and manual massage stretching as well as increasing vascularisation and healing of the chronic periostial inflammation. it is quite painful to treat (along the lines of ITB massage) but can be extremely effective with results within a few sessions if you're on the money. Dry needling the periosteal margins of tib post is also effective in elliciting this response but i find the manual deep tissue work more beneficial.
also it may be worth your patient trying ice massage for themselves after running (polystyrene cup full in the freezer then just peel a layer of the cup off each time you use it and it stops fingers from freezing holding an ice cube!) to minimise acute inflammation and aggravation although taking 2 weeks off running and impact work would be better (they will need to NOT run with new orthoses for at least that long anyway).

Good luck
msk101

[neurospast]

Hello, you got a lot of good advice. In general you do not give enough information to give a proper advice. e.g. if lower back would be involved Slump test (modified) ought to be positive (referred symptoms). In case of local neuro-musculo problems check feeling of periost (stress reaction as is mentioned), do test in movement not static (use hamster belt), do test strength/control of dorsiflexors of foot in general. Check Talar movements, test subtalar movements (both priority definitely when having re occuring ankle injuries). Also to consider; core control (thus correlation with L3-L5), Gluts control/ strength. Psoas-Iliops coordination, Hip flexor length. Etc, etc. I suggest to take a broad look at the problem, to consider the whole of the leg and lower back (can take this upto 1/2 thoracic since movements of lower back eg L3-5 need counter action on thoracic level during movement) as possible cause (or contributing to problem) and look at the whole. The hamster belt and possible a video will help you a lot (video not only foot movement but also up the chain (again til back). My personal best idea is ask the pt how long he has his running utensils, like a tooth bruch people tend to have them far to long or are using a hard brush while the have sensitive teeth and last but not least people tend to buy their running shoes by which one looks smartest, most sexy. So advice to buy with footscan! You might have to go yourself to shops and try out to find which one is most likely the most reliable and not the one which tries to empty the pockets of your client fast in stead of given the appropriate shoes ( in general in Uk 70 pounds, continent 80-90 euro). In case your client tends to run hamster belt only you need to look at his running because a lot of people tend to follow the pace of the belt in stead of having the same pace. when you look closely you will see what I mean. Conclusion use your eyes than your brain!
Hope this will help.
PS since having problems at rest not at movement it is most likely a neuro thing and nothing else. Shin splints , stress syndromes, and Compartment syndromes are all aggravated by movement and relief by rest ( stress # do aggravate during night, use tuning fork on shin to include exclude #)

[jordanloughlin]

Hi Folks,

Thanks for the advice. I have had a good think about his symptoms, I am sure it is compartment syndrome as he initially had pain on exercise, but now, I feel that there is a build up for swelling at rest, and this causes his pain and discomfort. As far as his lumbar spine goes, he does not report any pain or discomfort, and has no risk factors for developing low back pain.

If local treatment fails, then surely it is more appropriate to work upwards to the lower back? He is only a matter of weeks into his treatment.

Thanks,

Jordan

[neurospast]

I am under the impression you do not give us all the information. It seems to trickle in little by little.
Anyhow in case you look into symptoms anterior compartment syndrome, you'll notice problems become worse with exercise. 1 test is actually to let someone run for e.g. 10 minutes and then test the pressure on/in the compartment and compare this with the pressure at rest (which should be much lower. You look at how long it takes before the pressure drops to an acceptable level. If someone has a proper compartment syndrome he will not be able to run painfree because the bloodflow in the compartment is obstructed and thus a built up of fluid will take place the more one exercises. It is very strange if you say that at rest there is a built up of fluid but you state at the same time that movement aleviates the symptoms (a higher pressure at rest would be a very serious thing and you ought to refer him in that casr back to the Gp with view on decompression). I would think that the blood flow in the compartment would increase with exercise and not at rest.
In case someone has a built up of fluid allready at rest the chance this person would be able to walk more than a couple of hundred yards without aggravation is next to zero.
So again Have you put this person on the treadmill or not? Have you at least tested slump or not or is the feedback from the patient "no history of low back pain" (80% of people above 40 years old have or have had a period of back pain! And strangely enough when someone tells me they have no back pain and no history of back pain I prove them wrong in at least 50%. Why? because people do not think of the odd niggle as most of them call it or morning stiffness as a back problem because it simple does nt effect their life in a dramatic way. Also if you ask someone with shin problems about their back they will think you are a complete idiot because they are unable to see the link.
Anyhow see what you can do locally. I advice you to do an internet search on compartment syndrome and its symptoms as well as for an excentric loading programme for dorsiflexors.
If I get this all completely wrong please sned some comments so I can alter my views on compartment syndrome.

[jordanloughlin]

Hi,

I am fully aware of the symptoms or compartment syndrome. Within the scope of a forum, I am presenting the main clinical features of his condition. I was looking for some ideas, and thanks to all who have provided me with them.

I will let you know how I get on. This is not a simple case due to the muddled picture. Best advice I got from another colleague was not to close my mind to the obvious, which is compartment syndrome.

I'll keep you posted.

Jordan

[sarahkelly]

Silly question probabaly but who actaully diagnoses compartment syndrome, do they usually present in outpatisnt departments and get referred so someone to carryout the pressure tests or is that doen by the physio's, and is it the GP who decides who shoudl get surgery/conservative treatement? also alot on this forum is written about anterior tibila compartment syndrome but can it occur in any of the 3 compartments of the leg? Does it ever jsut resolve itself?
thank you, sarah

[jordanloughlin]

Hi Sarah,

GP's in our area tend not to diagnose musculoskeletal disorders as such, unless its obviously a tennis elbow or frozen shoulder etc. They come to outpatients with a mechanical problem, and then if it presents as something clinically, and the signs and symptoms fit, then you treat it as that.

If there is no resolution, then we would send to orthopaedics, and they would arrange for conduction studies etc to confirm. If applicable they would then go down the surgical route.

All 3 compartments can be affected, and it is a syndrome as and as such it is difficult to diagnose the exact structure at fault. Like shoulder impingement sydrome, there is likely to be a general inflammation in that compartment.

It can go away itself with rest, but there is usually an underlying biomechanical problem which is at fault, so it may come back.

Hope this helps.

Jordan

[ginger]

I see most posters here are still fascinated by structures and guided by the pathanatomical model inherent in the 'medical' way of thinking. When pain and apparent interference in normal functions occur they are always associated with a neural irritation somewhere. The logic I apply is that the most likely source of this is the neural interface commonly associated with referred pain events ( which include sympathetic nerve effects). That being the spine. The ubiquitous element in presentations where pain is a major feature is protective behaviour at the spine. As pain is a brain event it will not be possible to figure out wether this symptom is referred or not by considerations of the nature of this person's pain. referred pain is the same as not referred pain. Attempts at reproducing pain by overpressures etc will most often fail and give a false negative reading. The best approach is to assume the presence of a spinal neural component to this ( and other MSK ) problems and a priori go about the business of restoring a non protected , non irritated spinal root to nerves associated with and adjacent to, the complained of area. In most cases in my own approaches to so called 'shin splints' and other running related anterior leg pain, it becomes clear that referred symptoms dominate.