Member Case Study: Exercise-Induced Compartment Syndrome

author : AMSSM

comments : 2

If you are one of those athletes, and the compartments don’t easily expand, the pressure within increases with exercise. This can stress the muscle as well as the nerves and blood vessels.

Question from widgeon:
I have a problem with running. The flexor tendons on the front of my shin/ankle/upper foot get extremely tight and painful over the first half hour of some runs. This causes me to walk until they loosen up, then after 10 minutes of running they tighten up again and I have to walk. It goes on for about 30 minutes of running then seems to fade. I’d appreciate any suggestions you might have on what do about this.

Answer from Andrew Getzin, MD:
Your symptoms don’t easily fit into any one diagnosis, although they sound most like exercise-induced compartment syndrome. The muscles, nerves and blood vessels of the lower legs run in 4 tubes, or compartments, that are separated by bone and thick fibrous tissue. When muscles are working, they need more oxygen, so blood flow to the muscle increases by about 20%. The muscles expand, putting pressure on the walls of their compartments. The compartments are semi-rigid and can’t accommodate a large increase in size. Some of us have naturally tighter compartments than others.

If you are one of those athletes, and the compartments don’t easily expand, the pressure within increases with exercise. This can stress the muscle as well as the nerves and blood vessels in the compartments, leading to pain, weakness, numbness, and tingling down into the toes. A brief period of walking can dissipate the pressure and pain that develops with exercise, and athletes often can resume running again during the same training session. However, the onset of leg pain is usually progressive, and athletes begin having pain earlier in their successive training sessions. In my experience, exercise-induced compartment syndrome is most common in individuals who have increased their volume or intensity of running too rapidly.

The initial treatment I recommend is a decrease in your total weekly mileage and intensity by 25% for a few weeks to a month. Consider new running shoes, especially if you’ve run more than 300 miles in them. Physical therapy, focusing on calf flexibility and strengthening (including the core and hip muscles), can be beneficial. Evaluating foot structure and gait is helpful, as orthotics may be valuable. Anti-inflammatories and icing may ease your discomfort temporarily, but won’t cure compartment syndrome.

If your pain persists despite these measures, your doctor may recommend compartment pressure testing. This mildly invasive office-based procedure involves numbing the compartments and then measuring their pressures with a needle manometer before, immediately after, and 5 minutes after exercise. I have people run on a treadmill with an incline until they have reproduced their symptoms. If their pressures are elevated, they most likely would benefit from a surgical procedure that involves cutting the fascia (fibrous tissue) between the compartments to allow more room for the muscles to expand.

Surgical compartment release has a high success rate and can get individuals back to running, often within the month. Your situation is a little atypical because in most cases, the pain during exercise does not improve after 30 minutes of training. Other possible diagnoses include tendonitis, medial tibial stress syndrome, or tibial stress fracture. Medial tibial stress syndrome (MTSS) is an inflammation on the posterior medial aspect of the tibia (shin bone) where the muscle attaches into the bone. This pain is usually diffuse and can be progressive from experiencing pain only after running to ultimately having pain during running that limits one’s ability to run.

Tibial stress fractures are localized microscopic fractures that occur due to repetitively absorbing impact, or ground forces, caused by running. Point tenderness when pressing on the injured area, tenderness at the stress fracture site with jumping on the affected leg, and pain at night over the site are signs of a stress fracture. Both MTSS and tibial stress fractures typically respond well to relative rest with cross training.

Andrew Getzin, MD
(Physician USA Triathlon
Assistant Race Director Cayuga Lake Triathlon
2006 Lake Placid Ironman finisher- 11:04)
Finger Lakes Sports Medicine
2359 N. Triphammer Road
Ithaca, NY 14850

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date: September 3, 2006