The earliest and most important symptom that occurs in patients with all forms of compartment syndrome, including anterior, is pain, which progresses and becomes more intense over time [13]. Most patients report extreme pain which may be out of proportion to the severity of injury, as the skin overlying the anterior segment ay be intact although under pressure and shows no signs of trauma. Muscle stretching or passive limb movement can exacerbate the pain. In addition to pain, the other symptoms that are encountered include paresthesia, paralysis, pallor and pulselessness, comprising the 5 P's of compartment syndrome. Paresthesia, diminished 2-point discrimination, as well as sensory loss are neurological deficits that are often observed [14], while pale skin overlying the affected compartment is also a hallmark of this condition.

• Pain

  METHODS: Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology. RESULTS: Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. [ncbi.nlm.nih.gov]

• Swelling

  Other common symptoms include excessive swelling that causes the skin to become hot, stretched and glossy. [en.wikipedia.org]

  OLS > Experimental Factor Ontology EFO > EFO:1000808 http://www.ebi.ac.uk/efo/EFO_1000808 Rapid swelling, increased tension, pain, and ischemic necrosis of the muscles of the anterior tibial compartment of the leg, often following excessive physical exertion [ebi.ac.uk]

  ACUTE STAGE SYMPTOMS AND TREATMENT When there is swelling and inflammation in your calf. ACUTE STAGE SYMPTOMS: The acute stage starts the moment an injury occurs and lasts until the swelling and inflammation are gone. [sinewtherapeutics.com]

  This causes bleeding within the compartment and the swelling that follows can cause severe pain and dysfunction of the lower extremity. A muscle tear in the area, causing bleeding and swelling. Swelling of the tissues in the area due to overuse. [metrotownphysio.com]

  Compartment syndrome is a condition in the body where the muscles swell and put pressure on the membrane that houses them, or their ‘compartment’. [ezultrasound.com]

• Weakness

  At follow-up examination 1 year later, no limitation of joint motion nor weakness of the quadriceps were observed. [ncbi.nlm.nih.gov]

  It's always a good idea to have injuries assessed especially if they involve pins and needles, numbness or muscle weakness. [running-physio.com]

  […] ankle inversion, some weakness of plantar flexion 5. compartment pressures. resting > 25, exertional >35 Lateral Compartment Syndrome contents peroneus longus and brevis superficial peroneal nn no major artery. [quizlet.com]

  Subsequently, the pressure within the compartment may increase excessively during activity resulting in a variety of lower leg symptoms such as tightness, pain, weakness, pins and needles or numbness. [athleticedge.biz]

  They also often report a feeling of weakness and, in severe cases, may develop true muscle weakness such as drop foot (slap sign). Less often, patients with CCS report a severe shooting pain. [mdedge.com]

• Inflammation

  ACUTE STAGE SYMPTOMS AND TREATMENT When there is swelling and inflammation in your calf. ACUTE STAGE SYMPTOMS: The acute stage starts the moment an injury occurs and lasts until the swelling and inflammation are gone. [sinewtherapeutics.com]

  Inflammation traps fluid in the area and makes you hurt more, which makes your body create more inflammation that traps more fluid and release more pain enhancing chemicals. [tendonitisexpert.com]

  The danger of compartment syndrome is that it causes swelling and restricts circulation, and ultrasound uses a local heating effect to encourage blood flow and reduce inflammation. This can help relieve pain and speed healing. View Product [ezultrasound.com]

  Ice to restrict fluid formation and elevation for damage should be complemented by aspirin or ibuprofen in one of its forms to minimise inflammation. [runnersworld.co.uk]

  As the name implies, the body becomes overly exherted and can’t repair tissue well enough to prevent increased inflammation and pressure. [draxe.com]

• Disability

  Disability. In the context of health experience a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. ‎ [books.google.de]

  Chronic anterior compartment syndrome can be a disabling injury which may require a fasciotomy, depending upon the severity and duration of the patient's symptoms and the intracompartmental pressures. [ncbi.nlm.nih.gov]

  The article is titled “ Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome .” [runblogger.com]

  This condition can become very serious and disabling. If the foot begins to go numb or have pins and needles in it, go directly to a doctor or hospital emergency room. PREVENTION: Play on a soft surface as often as possible. [metrotownphysio.com]

• Fracture

  We consider ankle arthroscopy to be available for the treatment of ankle fracture with the suspected complication of an intra-articular disorder such as a Maisonneuve fracture. [ncbi.nlm.nih.gov]

  Key words: Femur; Fractures; Tibia View this abstract indexed in MEDLINE: [hkmj.org]

  Major updates keep you up to speed on current trends such as the management of osteoporotic and fragility fractures, locked plating technology, post-traumatic reconstruction, biology of fracture repair, biomechanics of fractures and fixation, disaster [books.google.de]

• Medial Tibial Stress Syndrome

  A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia. [ncbi.nlm.nih.gov]

  If conservative treatment does not seem to be beneficial, visit your family physician and rule out other pathologies that are also commonly found in the lower leg, such as tibial stress fractures, tibial periostitis, or medial tibial stress syndrome. [solescience.ca]

  Also called medial tibial stress syndrome (MTSS) Palpation The client is supine. Place your resistence hand on the medial side of the distal foot. Resist the client from dorsiflexing and inverting the foot. [physio-pedia.com]

  Differential Diagnosis for Exertional Leg Pain Condition Tissue Origin Characteristics Anterior tibial stress syndrome Periosteum • Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise, decreases during training Medial tibial [orthobullets.com]

  It's also seen regularly in the distal medial region of the leg, where it's called posterior shin splints or medial tibial stress syndrome (MTSS). [massagetoday.com]

• Muscle Weakness

  Potential muscle weakness may lead to a 'drop foot.' TREATMENT If the condition is mild, strengthening the muscle in the anterior compartment, as well as the other compartments is helpful. [secure.yoursole.com]

  It's always a good idea to have injuries assessed especially if they involve pins and needles, numbness or muscle weakness. [running-physio.com]

  If you experience decreased sensation, numbness or tingling, or sudden muscle weakness after an injury, our doctors encourage you to go the nearest emergency room. [nyulangone.org]

  They also often report a feeling of weakness and, in severe cases, may develop true muscle weakness such as drop foot (slap sign). Less often, patients with CCS report a severe shooting pain. [mdedge.com]

• Lower Leg Pain

  […] in the lower leg (Blackman, 2000). [thesportsphysiotherapist.com]

  The pain is like delayed onset muscle soreness by coming on hours later, even at rest. 1 Anterior compartment syndrome sometimes occurs as an acute injury from a direct blow to the lower leg. [massagetoday.com]

  Evaluating and treating exercise-induced lower leg pain can be a difficult task for the foot and ankle physician. [podiatrytoday.com]

  Diebal et al. indicate that accepted belief as to the cause of compartment syndrome is “that exercise increases intramuscular pressure, which in turn compromises circulation, prohibits muscular function, and causes pain and disability in the lower leg [runblogger.com]

  The lower leg is the most common site. The cause is usually trauma and the typical presentation includes pain, pallor and paresthesia. [symptoma.com]

• Muscle Strain

  As long as you’ve ruled out other injuries in the same area, tibialis anterior tendonitis or muscle strain doesn’t need to keep you on the sidelines for long. [runnersconnect.net]

  Focal pain in the muscle itself is usually due to muscle strains or tendinopathy. Conversely, if the pain is more diffuse on palpation and located along the posterior medial border of the tibia, it is commonly a result of shin splints. [orthopaedicsone.com]

  This is especially true when the cause of a pain—eg, stress fracture, muscle strain, claudication, neuropathy, or periostitis (shin splints)—are not consistent with the history and examination. [consultant360.com]

  strain in four, and shin pain in three. [josr-online.biomedcentral.com]

• Suggestibility

  The retrospective analysis of the patient's history was suggestive of a predisposition to an exercise-induced compartment syndrome. [ncbi.nlm.nih.gov]

  It is suggested that about 69% of those diagnosed with ACS are runners. [kinetic-revolution.com]

  Diffuse tightness and tenderness over the entire belly of the tibialis anterior that does not respond to elevation or pain medication can be early warning signs and suggestive of Anterior Compartment Syndrome. [en.wikipedia.org]

  The strength of these results suggests that gait modification could become a first-line treatment in the management of anterior compartment syndrome, and suggests that surgery need not be the fate to which sufferers of this painful condition must succumb [runblogger.com]

• Foot Drop

  One month later, the foot drop, repeat NCS, and CT demonstrated a significant improvement with conservative management. [ncbi.nlm.nih.gov]

  Weakness when trying to pull the foot upwards against resistance which may result in foot drop or a slapping gait. Swelling and tenderness over the tibialis anterior muscle. Pain when the foot and toes are bent downwards. [thewalledcitymarathon.com]

  In severe cases foot drop or a slapping gait may be seen as the athlete cannot properly lift the foot up when walking. [sportsinjuryclinic.net]

  drop, in severe cases, if legs are affected Often occurs in the same compartment of both legs Occasionally, swelling or bulging as a result of a muscle hernia Pain caused by chronic exertional compartment syndrome typically follows this pattern: Begins [mayoclinic.org]

• Irritability

  Anterior Shin Splints And Anterior Compartment Syndrome Shin Splints Anterior shin splints are most often attributed to an overuse or inflammation of the anterior tibialis muscle, but can be due to irritation or inflammation of any of the structures within [sinewtherapeutics.com]

  Nerve irritation that is persistent can happen because of the nerve irritation against the incised fascia. Certain individuals might have mild weakness in the lower part of the leg. [syndrome.org]

  If this Tendonitis dynamic is really bad, and then you irritate it by going for a run or otherwise working it too hard, the body can go into overdrive and pump a lot of extra fluid in the area. This swelling is usually not much of a problem. [tendonitisexpert.com]

  Health Hormones Horseback Riding Human Learning Hydration Hydrotherapy Hygiene Hyperglycemia Hypertension Hypertrophy Hysterectomy Ice Hockey Impingement Syndrome Incontinence Inflammation Injury Prevention Insulin Integrated Training Interval Training Irritable [ptonthenet.com]

  Chronic compartment syndrome occurs because of excessive exercise, where repetitive motion and muscle use cause localized swelling and irritation. Most often, symptoms in the legs are seen with runners and bicyclists and in the arms of swimmers. [medicinenet.com]

• Hypesthesia

  Hypesthesia and painful dysesthesia Prognosis The outcome of compartment syndrome depends on both the diagnosis and the time from injury to intervention. [boneandspine.com]

The diagnosis of ACP almost solely depends on the skill of the physician and the degree of clinical suspicion about this condition. A thorough physical examination should be performed and a detailed patient history should be obtained. Events preceding the development of symptoms and their duration (long standing symptoms are noted in chronic exertional CP), as well as use of anticoagulant medications should be noted. Physical examination can reveal other accompanying findings supporting the diagnosis e.g. signs of trauma. Patients with suspected ACP should be examined several times in a relatively short period to assess potential progression of symptoms and decide on appropriate therapy.

In addition to physical examination, compartment pressure can be determined using various available techniques. If the ACP occurs in the lower leg, a syringe with a pressure monitor is introduced 1 cm medial to the anterior tibial border into the anterior compartment and pressure measurements obtained. The threshold for abnormally high compartment pressure is controversial, and large-scale studies have determined significant overlap between pressure values of actual patients with control subjects [15]. However, values that are an indication for surgical treatment are either 30 mm Hg below the mean arterial blood pressure or 20 mm Hg below diastolic arterial pressure [16], which indicates that arterial blood pressure should be monitored closely as well. If threshold values are reached, immediate surgical treatment should be performed.

Additional diagnostic procedures should include various imaging studies, such as plain radiography or CT scan to assess patients with trauma and identify possible bone fractures or other injuries.

This syndrome can present significant challenges in the diagnostic workup. Since irreversible tissue changes and permanent disability can occur within a very short time, this condition is reported to be one of the most common causes of medicolegal conflicts, especially when there is inadequate medical documentation, failure to conduct serial physical examination as well as follow-up tests [17]. Hence medical personnel should be on a high alert when CS is suspected.

When the diagnosis of ACS is based on concrete findings, immediate surgical treatment is indicated for almost all patients [18]. Initial decompression and complete fasciotomy is performed. This comprises of removal of overlying fascia surrounding the compartment. Depending on the severity of trauma, bone reposition or grafting may be performed along with ligation or suturing of blood vessels and debridement of necrotic tissue. In most cases of ACP involving the lower leg, removal of all four fascia is recommended to improve treatment outcomes. Various surgical approaches exist when it comes to management of ACP in the arms and legs and either one or more incisions are made. In some cases, skin grafting may be recommended, so that the effects achieved by fasciotomy are maximized.

This condition should be treated as an emergency, as extensive tissue necrosis and irreversible injury can occur if it is not diagnosed and treated early. With early therapy patients have an excellent prognosis [11], and only a minority of patients may have residual complaints. Without treatment, however, the condition may result in paralysis, or in some cases, limb amputation. Some studies have established that almost 75% of limb amputations occurred because of delayed treatment or incomplete fasciotomy [12].

The causes of anterior compartment syndrome may be divided into those causing acute and those causing chronic or exertional forms of the syndrome. Trauma is the most common cause of acute compartment syndrome and includes injuries from motor vehicle accidents, fractures, contusions or crush injuries [3]. Acute CS can occur after surgical repair of vascular injury. This is associated with reestablishment of blood flow and subsequent increase in local pressure. Prolonged limb immobilization by casts or bandages can also cause increase in local pressure. On the other hand, chronic forms of CS is seen in athletes, in whom prolonged activity leads to compression of local tissues with strenuous muscle activity. Muscle hypertrophy can also be a contributing factor to its development [4].

The anterior compartments of the body that may be affected include:

• Lower leg - Includes tibialis anterior, extensor hallucis longus and extensor digitorum longus muscles, the tibial artery and vein and the deep peroneal nerve.
• Thigh - Contains sartorius and all four parts of the quadriceps muscle, together with the femoral artery and nerve.
• Arm - Biceps brachii, brachialis and coracobrachialis comprise the muscular components of the anterior compartment of the arm, together with the brachial artery and the musculocutaneous nerve.
• Forearm - Contains 8 muscles, 5 in the superficial layer (flexor carpi radialis, flexor carpi ulnaris, flexor digitorum pronator teres and palmaris longus) and three in the deep layer (flexor digitorum profundus, flexor pollicis longus and pronator quadratus), while the nerves that pass through the anterior compartment include the anterior interosseus nerve (a branch of median nerve) and ulnar nerve.

Data regarding the incidence and prevalence of CS is significantly related to traumatic events, since the vast majority of cases occur under these circumstances. Prevalence rates of CS in terms of specific compartments currently do not exist. It is estimated that around 18% of all tibial fractures eventually progress to CS, with virtually all requiring surgical treatment [5]. Other studies found an incidence of only 1.2% for similar type of injury [6]. CS is estimated to occur in approximately 6% of all foot injuries following motorcycle accidents [7]. Regarding chronic forms of CS, about 14% of patients who had lower leg pain due to unknown cause were found to have chronic CS [8].

The pathogenesis of ACS starts with alterations in normal blood flow, usually as a result of trauma. Several theories exist regarding the initial events that occur after trauma, but vessel injury leads to extravasation of blood into the interstitium, leading to edema [9]. Continuous pooling of blood and fluid in the interstitium occurs because of increased capillary permeability as well, since it is stimulated by sudden oxygen deprivation of local tissue. Once the interstitial pressure exceeds the diastolic pressure, tissue perfusion is affected adversely. In an attempt to provide oxygen and nutrients to ischemic and hypoxic tissues, the circulatory system further increases the permeability of capillaries. However, this creates a vicious cycle and eventually leads to severe acidosis and ischemia.

Initially, it was established that 5-6 hours are sufficient for development of irreversible muscle damage, but recent experiments have shown that as little as 3 hours are sufficient to cause significant damage [10]. Because of extensive muscle necrosis, significant amounts of myoglobin are released and may rapidly cause kidney injury. For these reasons, clinical suspicion and an early diagnosis may lead to significantly better patient outcomes.

Because the majority of events that trigger this condition are unexpected, prevention is rarely possible. However, in case of chronic exertional compartment syndrome affecting the anterior segment, with recurrent pain, an early diagnosis may significantly reduce the amount of damage to local tissues.

Compartment syndrome (CP) is a term that describes pressure changes in various compartments leading to extensive tissue necrosis and irreversible injury to local structures. Anterior compartment syndrome (ACP) implies that this condition occurs within the anterior compartments of the body. The lower leg is most commonly affected. The anterior compartment in the leg includes tibialis anterior, extensor hallucis longus and extensor digitorum longus muscles, both tibial artery and vein and the deep peroneal nerve. Anterior compartments of the thigh, arm and forearm can also be affected [1], while some compartments of the hand and foot could be potentially classified into this group of disorders as well. ACP can be either acute or chronic and different causes are responsible for the two forms. Acute ACP is in most cases caused by trauma, including fractures and motor vehicle accidents, while the chronic form is primarily seen in athletes, in which persistent repetitive muscle activity leads to intracompartmental pressure elevation [2]. This form is also known as chronic exertional compartment syndrome and is most commonly seen in runners with lower leg involvement. Certain predisposing factors have been identified, such as muscle hypertrophy, concomitant bleeding disorders and use of anticoagulant therapy. Although the exact mechanism of how CP occurs is unknown, the presumable theory is that the increase in intracompartmental pressure results from bleeding and consequent edema, which results either from indirect vascular injury or from increased permeability of the capillaries due to oxygen deprivation. In either case, a vicious cycle of ischemia and tissue hypoxia occurs, which leads to acidosis and severe tissue necrosis within hours after onset. Because irreversible tissue injury can occur within a few hours, an early diagnosis can prevent permanent damage and even limb amputation in some cases, which is why attending physicians should always exclude this condition during physical examination and workup. The initial presentation of ACP is severe pain, accompanied by pallor of the overlying skin. Neurological deficits, including sensory loss and paresthesia are often present. Patient history is a vital component of the diagnostic workup and information regarding recent trauma or other factors that can provoke ACP may provide significant clues. The diagnosis is based on clinical grounds, with serial examinations, along with invasive measurement of compartment pressures to confirm the diagnosis. Treatment principles include fasciotomy of the affected compartment, together with other necessary measures. This condition should be considered a medical emergency and the time of initiation of therapy significantly influences patient outcomes.

Anterior compartment syndrome is a condition that implies very large sudden increase in pressures of certain parts of the body,leading to extensive tissue damage. For this reason, it is considered to be a medical emergency. Virtually all muscles in the body are, along with the accompanying blood vessels and nerves, are grouped into "compartments" which are created by a layer of connective tissue called the fascia. This tightly encloses the muscles and vessels. In the setting of trauma, which is the most common cause of this syndrome, injury to blood vessels leads to bleeding into the compartment in which the vessel is located. This results in swelling followed by increase in pressure. This pressure disables normal oxygen and nutrient transport to desired tissues, leading to hypoxia and cell death if left untreated. In the case of anterior compartment syndrome, the anterior (or front) compartments can be affected, specifically the front portions of the arm, forearm, thigh and lower leg. In addition to trauma, other factors may predispose individuals to this condition, such as use of anticoagulant drugs, immobilization due to previous trauma with casts or splints and certain surgical procedures that involve restoration of blood flow. A particular form of this syndrome, called chronic exertional compartment syndrome is seen most commonly in athletes who run. This includes recurrent development of symptoms after vigorous muscle exercise. The initial presentation of patients starts with appearance of severe pain at the site of injury, and becomes progressively worse. In addition to pain, symptoms include reduced sensation, pale skin overlying the affected compartment, while paralysis may ensue if treatment is delayed. The diagnosis of anterior compartment syndrome needs to be performed urgently and almost exclusively relies on the ability of the physician to clinically recognize the condition. Since irreversible injury may occur within hours of onset, an initial diagnosis can be made after series of physical examinations performed in a short period of time. Patients may provide significant information such as recent trauma or history of similar symptoms which may further support the diagnosis. To confirm the diagnosis, a syringe is introduced into the affected compartment to measure compartment pressure. Once the diagnosis is established, immediate surgical treatment is indicated. It comprises of removal of fascia that covers the affected compartment. This procedure is known as fasciotomy. Improper or delay in treatment may lead to paralysis and even limb amputation as a result of severe and irreversible muscle damage. This condition should be suspected in all patients who experience recent trauma and complain of severe localized pain.

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