Physical Therapy Guide to Compartment Syndrome
Compartment syndrome is a serious medical condition that occurs when there is increased pressure in the muscular compartment of the limbs. When this pressure builds, there is restricted blood flow to the involved area that can compromise the health of the muscles and nerves. Compartment syndrome is classified as either acute or chronic. Acute compartment syndrome is a medical emergency, usually due to a traumatic injury, and must be addressed immediately to avoid irreversible consequences, such as limb loss. Chronic compartment syndrome develops over time, usually due to excessive or inefficient exercise exertion. Physical therapy can be effective to help identify the factors that may influence the development of compartment syndrome.
What is Compartment Syndrome?
Our limbs (arms and legs) are divided into compartments that contain different muscles, nerves, and blood vessels. Each compartment is separated by fascia, a thick sheet-like tissue that does not stretch.
Our bodies are able to handle small changes in the pressure levels within these compartments. For example, our tissues may swell slightly after a hard workout or a mild injury. However, when there is excessive swelling within a compartment due to a severe acute injury or chronic overuse, pressure builds within that compartment as the fascia does not expand to accommodate the increased volume. In rare circumstances, this condition can be more than our bodies can handle, and the blood supply to the area is restricted. If the condition persists, the muscle and nerve tissue can be harmed. It is essential to relieve the pressure immediately to avoid permanent damage.
Compartment syndrome is typically classified into 2 categories—acute or chronic—based on its cause and symptoms.
Acute Compartment Syndrome
Acute compartment syndrome (ACS) is a medical emergency. It can develop as early as several hours following a severe injury. If left untreated for even a few hours, irreversible tissue damage can occur. ACS most often develops in the lower leg and forearm.
ACS is typically caused by a serious injury, such as:
- A direct hit or blow to the limb (athletics, a significant fall)
- Crush injuries (motor vehicle accident, work-site injury)
- Highly restrictive bandages
How Does It Feel?
The most common signs and symptoms of ACS include:
- Severe pain in the involved limb that may be out of proportion to the typical response to a certain injury
- Changes in sensation (tingling, burning, numbness)
- A sense that the limb is tight or full (from the swelling and increase in pressure)
- Discoloration of the limb
- Severe pain with stretching of the involved muscle
- Severe pain when the involved area is touched
- Significant pain or an inability to bear weight throughout the involved limb
How Is It Diagnosed?
It is critical that ACS is identified and treated immediately. Following a severe injury, if an individual is showing signs of ACS, the individual should be taken to the emergency room right away for evaluation by a physician. The physician will be able to objectively measure the levels of pressure in the involved compartment. If necessary, surgery will be performed to alleviate pressure in the compartment using a procedure called a fasciotomy. During surgery, an incision is made through the skin and fascia to drain the swelling and relieve the pressure within the compartment. A patient undergoing a fasciotomy will have to spend a period of time in the hospital to ensure that the pressure normalizes and the wound heals properly. Following a fasciotomy, physical therapy is necessary to restore the motion, strength, and function of the limb.
Chronic Compartment Syndrome
Chronic compartment syndrome (CCS) is often referred to as “exertional” compartment syndrome, and is typically caused by exercise that involves repetitive movements, such as walking, running, biking, or jumping. Usually, excessive exercise causes the tissues of the leg to be overworked without time to recover. The development of CCS may be influenced by external factors, such as poor body control during movement, poor footwear, uneven or too-firm training surfaces, or too much training. There have also been cases where excessive steroid use has been linked to CCS.
How Does It Feel?
The symptoms for CCS may be similar to that of ACS, but less severe and not a result of an acute traumatic injury. These may include:
- Pain and cramping in the involved limb that usually worsens with activity and subsides with rest
- Mild swelling
- Pain with stretching
- Numbness or tingling in the limb
How Is It Diagnosed?
Because the symptoms of CCS are similar to many other conditions, it is important that a physician or physical therapist rules out other possible diagnoses, such as tendinitis, stress fractures, shin splints, or other inflammatory conditions. The examination may include the use of diagnostic imaging, such as an ultrasound, x-ray, or MRI to assess the tissues in the painful area.
If CCS is suspected, an individual will likely be referred to a physician for a specific test called the "compartment pressure measurement." This test is only used in cases where CCS is strongly suspected. It is performed in a medical office. During the test, the pressure in the involved compartment is measured before, during, and after exercise. The goal of the test is to reproduce symptoms as they occur during real-life activities. If CCS is diagnosed, your medical team will devise a plan to best treat your specific condition. For more mild cases of CCS, you will likely be referred directly to physical therapy. In more severe cases, individuals are likely to be referred to a surgeon to discuss the option of a fasciotomy.
How Can a Physical Therapist Help?
If you are diagnosed with compartment syndrome, your physical therapist will play an important role in the treatment of the condition, whether it requires surgery or not. Your physical therapist will work with you to design an individualized treatment program based on your condition and your personal goals. Your physical therapist may recommend:
Range-of-Motion Exercises. Restrictions in 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 help restore motion in these joints to minimize undue muscle tension.
Muscle Strengthening. Hip and core weakness can influence how your lower body moves, and can cause imbalanced forces through the lower-leg muscle groups that may contribute to compartment syndrome. Building core strength (in the muscles of the abdomen, low back, and pelvis) is 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 stabilize the hip and knee joints during repetitive leg motions. Your physical therapist will be able to determine which muscles are weak, and provide specific exercises to target these areas.
Manual Therapy. Many physical therapists are trained in manual (hands-on) therapy, using their hands 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.
Modalities. Your physical therapist may use modalities ( e.g., ultrasound, iontophoresis, moist heat, cold therapy) as a part of your rehabilitation program. These tools can help improve tissue mobility and flexibility, and enhance recovery. Your physical therapist will discuss the purpose of each modality with you.
Education. Your treatment will include education about how to safely return to your previous activities, particularly if your condition required a fasciotomy. Your physical therapist may recommend:
- Wearing more appropriate footwear
- Choosing more appropriate surfaces and terrain for exercise
- Pacing your activities
- Avoiding certain activities altogether
- Mastering strategies for recovery and maintenance of good health (e.g., allowing your muscles and joints proper rest time)
- Modifying your workplace to lower risk of injury
How Can a Physical Therapist Help Before & After Surgery?
In the event that your case of compartment syndrome requires surgery (either due to an acute injury or chronic condition), postoperative physical therapy will be essential to a successful recovery. Your physical therapist will be in close communication with your surgeon regarding the nature of your procedure, expected timelines for healing, and your progress during rehabilitation. As a health care team, your providers will develop a plan to ensure your body has adequate time to heal, while incorporating strategies to restore your motion, mobility, strength, and function.
Real Life Experiences
Caleb is a 14-year-old baseball player. One hot summer day, he and his best friend Bobby decided to get in some batting practice at the ballpark down the street. Unfortunately, the batting cages were being replaced, so they decided to practice on the actual field. Caleb offered to pitch first, as he knew Bobby needed more work on his batting to get ready for fall tryouts.
A few hits into the second bucket of balls, Bobby nailed a pitch right back at Caleb. The baseball hit him very hard in the side of his calf. He fell to the ground and was in a great deal of pain. He tried to get up, but had a hard time putting weight on his injured leg. Bobby felt so bad, he carried Caleb home on his back. That afternoon, Caleb started to feel better and was able to limp around the house. However, his leg still hurt a lot, and after dinner, he noticed his lower leg was extremely swollen, tender to touch, and warm. Caleb said that his toes were tingling, and he was having a more difficult time walking because his leg felt heavy and weak. He showed his dad, who immediately recognized that this was no ordinary bruise and took Caleb to the emergency room.
Upon examination by the emergency room medical team, Caleb was diagnosed with acute compartment syndrome. His injury required a fasciotomy to release the compartment and allow the swelling to dissipate so the pressure would decrease. He had surgery that night, and spent several days recuperating in the hospital. Bobby brought him ice cream every day.
One week after he left the hospital, Caleb was referred to physical therapy. His lower leg had lost a lot of muscle mass, his skin was very tight and tender around his incision, and he was still nervous about bearing his full weight on the injured leg. Caleb knew he would miss his fall baseball season, but was hoping to try out for JV basketball that winter. After a comprehensive evaluation, his physical therapist developed a rehabilitation plan based on Caleb's goals, and drew up a timeline for reaching them.
For the next several months, Caleb and his physical therapist worked on restoring motion at his knee and ankle. She gently stretched the muscles of his lower leg, and progressively began incorporating strengthening exercises into Caleb's routine. She also designed a home-exercise program that Caleb followed diligently.
Once he was able to walk normally without pain, Caleb and his physical therapist started working on more advanced strengthening exercises, building up to running, jumping, and "cutting" activities. Toward the end of his rehabilitation, they performed basketball-specific drills. His physical therapist was in constant communication with his surgeon, parents, and coaches to make sure everyone was on the same page regarding his recovery.
Three months later, Caleb attended basketball tryouts and made the JV squad as the starting point guard! Luckily, Bobby made the team, too. Caleb and Bobby were thrilled to be back playing sports together—although Caleb often reminded Bobby that he owed him ice cream for the rest of his life.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with orthopedic or musculoskeletal injuries.
- A physical therapist who is a board-certified specialist or who has completed a residency in orthopedic or sports physical therapy, as they will have advanced knowledge, experience, and skills that apply to an athletic population.
You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with compartment syndrome.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of compartment syndrome. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Irion V, Magnussen RA, Miller TL, Kaeding CC. Return to activity following fasciotomy for chronic exertional compartment syndrome. Eur J Orthop Surg Traumatol. 2014 March 25. [E-pub ahead of print.] Article Summary in PubMed.
Davis DE, Raikin S, Garras DN, et al. Characteristics of patients with chronic exertional compartment syndrome. Foot Ankle Int. 2013;34(10):1349–1354. Article Summary in PubMed.
Gill CS, Halstead ME, Matava MJ. Chronic exertional compartment syndrome of the leg in athletes: evaluation and management. Phys Sportsmed. 2010;38(2): 126–132. Article Summary in PubMed.
McCaffrey DD, Clarke J, Bunn J, McCormack MJ. Acute compartment syndrome of the anterior thigh in the absence of fracture secondary to sporting trauma. J Trauma. 2009;66(4):1238–1242. Article Summary in PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Laura Stanley, PT, DPT, board-certified clinical specialist in sports physical therapy. Reviewed by the editorial board.