How To Test And Treat Exertional Compartment Syndrome

By Richard Braver, DPM

When patients experience intense pain, a burning sensation, tightness and/or numbness in the lower extremities during exercise activity, and the pain usually resolves quickly once the patients stop the activity, you may be looking at exertional compartment syndrome (ECS). ECS is certainly one of the more confounding conditions as differentiating between the various leg pains can be difficult.
Parasthesia to the anterior leg, ankle or between the first and second metatarsal is indicative of anterior leg compartment involvement. In addition, weakness of ankle dorsiflexion or a drop foot also involves the anterior compartment. If you find parasthesia to the arch or plantar aspect of the foot, that is associated with deep posterior leg compartment involvement. Most of the time, however, numbness is not evident. Approximately 80 percent of ECS cases involve both legs.1
Other physical findings may include mild edema, muscle herniations over the involved compartment and muscle weakness in the specific compartment.
Several studies have been done to understand the pathophysiology of ECS. Mubarak studied acute compartment syndrome and concluded that the blood flow through the intracompartmental capillaries (capillary ischemia) is impeded, but blood flow continues to larger arteries and veins with palpable pulses distally.2 The extent of capillary ischemia in ECS is unknown.
In a subsequent study performed with magnetic resonance imaging, researchers found that ECS is not related to ischemia, but is actually due to increased fluid content (water) within the muscle compartment.3 This can compromise or impair function of the muscle or nerve within a tight and constricted fascial covering.
My personal observations through clinical and surgical intervention are that some individuals are genetically predisposed due to their anatomical muscle composition. Someone who is born with good muscle development/tone may actually wind up with hypertrophic muscle(s) as a result of repeated exercise activities. Muscle volume may expand 20 percent during exercise from both increased capillary infiltration and blood content. Ultimately, this intracompartment swelling increases the pressure within the enclosed compartment.
I believe there’s a similarity between this intracompartmental pressure problem of the leg and that which is present in tarsal tunnel syndrome cases. Here, there is an impingement of a nerve by surrounding hypertrophic muscle(s) or fluids within the medial ankle area. If the athlete persists in playing a sport with the pain, he or she may have the nerve impingement and symptomatic numbness or muscle weakness described above.
This is just one example. There are other differential diagnoses that you should consider when seeing symptoms of ECS (see “Why The ECS Diagnosis Is Often Missed” on page 24).


Good Morning. I was looking for an update on procedures used to treat ECS. I have read a bit about arthroscopic procedures used to effect anterior/laterial releases, that do not require large 15cm incisions and 4-6 week recovery time. Can you please provide some detailed information about these procedures?

We are planning to publish a new feature article, "Current Concepts In Treating Exertional Compartment Syndrome," in our September 2010 issue. Sincerely, Jeff A. Hall Executive Editor Podiatry Today

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