Click here to view next page of this article

Compartment Syndromes

What we see in sports tends to be related to the chronic compartment syndromes. A little bit of a review, the elevated pressure within a closed fascial space can decrease blood perfusion and compromise the neurovascular structures. The lower extremity is commonly seen in compartment syndromes, there four compartments in the lower extremity and each compartment runs a nerve vessel, both artery, vein and muscle. They are separated by the tibia and fibula. You need to know especially the areas of compartments of the lower extremity, the one that’s most commonly involved is the anterior compartment which is this muscle group that gives you sensation only between the first and second web space of the toe. That’s the only sensory distribution of the anterior compartment for the peroneal nerve. You need to look at that, especially in patient’s that have leg pain.

Pathophysiology, they get swelling, they get edema, the pressure increases, it decreases their circulation, as the pressure continues to rise, you get muscle necrosis, that muscle necrosis causes more swelling as the pressure continues to get even higher, you damage the nerve, the nerve starts to degenerate, you get muscle fibrosis.

This is ischemia, we usually don’t see this in the lower extremity, this is an upper extremity issue, especially in little kids or adults that break their humerus, they pinch off the neurovascular structures of the elbow and you can get devastating hand problems. We are fortunate, in the lower extremity we don’t have this big issue, but if you do get neurological issue with the foot, they will lose some function in their intrinsics of the foot. As I said, in the lower leg, there are four compartments, anterolateral, superficial, posterior and deep posterior, the most important is the anterior, that’s the one that’s most commonly involved with any type of these compartment syndromes. Here is the anterior compartment.

Symptoms. Classic P’s, pain, pallor, pulseless, paresthesias, they have pain to passive stretch of the toe, anything that crosses that compartment if you stretch it or move it, usually it hurts. Hypesthesia, that is usually late, tenderness and tenseness, that’s early. Pain is classic, you have to go looking for it or you’re going to miss it. Physical finding, localized swelling, pain to palpation, pain with passive stretch, decreased two point and light touch sensation, and later on, loss of pulses.

The other thing you get concerned about, especially in runners, are shin splints. Most runners will have them, shin splints is a periostitis, it’s where the periosteum is being pulled off the bone. They usually have pain posterior medial of the tibia, they describe it as a dull, achiness or a soreness. It can be sharp or severe later on. It is usually diffuse, it’s not point specific, that’s how this sort of differentiates itself from stress fractures, in that it is diffuse. The tenderness is usually posterior medial, it can have swelling, sometimes it’s not evident, but they have pain with motion of the foot.

Patellar tendinitis is a common tendon issue that we see, happens at the level of the patella, also called jumper’s knee from repetitive jumping. Usually they have pain at the tendon insertion. Treatment once again, physical therapy, ice, rest anti-inflammatory medicines, patellar tendon straps.

Most patellar tendonitis happens at the inferior pole of the patella, in adolescence they get Osgood Schlatter’s disease which is a traction epiphysitis at the insertion site. These immature patient’s get these traction injuries because of the issue of what’s strongest in their bodies, tendons and ligaments tend to be stronger than bone, so they pull off the tendon from the bone and they get these bony avulsions. Osgood-Schlatter’s disease, the children are a little bit older, mostly boys 10 to 16 years of age once again with jumper’s. They have pain at the insertion site of the patellar tendon where the patella inserts into the tibial tubercle, treat these initially symptomatically with pain medicine, anti-inflammatories, strapping, in severe situations.

Bursitis, multiple bursas throughout the knee, the prepatellar bursa, the infrapatellar bursa, you have bursas around the ITB pes tendons on the medial side, they are gastrocnemius and semi-tendinosis. Bursas are fluid filled sacs, they are there to minimize friction, they can get inflamed, they can get septic, more commonly, the reason for sepsis is usually that there has been intervention, either with a needle or a puncture wound from an abrasion. Patient’s usually present with swelling, erythema, tenderness to palpation, you can treat these with aspirations if you are a little aggressive but you have to be concerned.