Posterior Compartment Syndrome

by Hamid L. Sadri, DC, CCSP, ICSSD, CSCS, CKTP, CES, PES

Posterior compartment syndromePosterior Compartment Syndrome is very common in distance training. We see this frequently in the office with our marathon and triathlon athletes. There are two basic types of compartment syndrome: acute and chronic. True acute compartment syndrome is a surgical case and the chronic type can be treated fairly successfully with noninvasive care. I will try and explain what happens in many of the cases we see in our office. Keep in mind, the explanation discussed below is about the non-surgical type.

First off, posterior compartment syndrome of the lower leg consists of two areas, the superficial compartment is the gastroc/soleus complex (Calve muscles) and the deeper compartment consists of the posterior tibialis, Flexor hallicus longus, and flexor digitorum longus. A neurovascular bundle (tibial artery, vein, nerve) lies in-between these muscle layers. With training, these muscles will expand and engorge (fill up) with blood. If the tissue is functioning properly there is no harm done and the tissue will shrink in size shortly after workout. However, with continuous repetitive training, these muscles and the fascia around the muscles will begin to break down (micro trauma) and begin to form adhesions (same stuff as scar tissue). This causes the tissues to lose their elasticity, cause the muscles and fascia to shorten and ultimately cause the tissue to stop functioning correctly. If training continues, the muscles have to work harder, they become hypoxic (have lack of oxygen) and will continue to break down (form more adhesions). As you can see this process will continue until finally your body lets you know something is wrong (calf cramps or severe calf pain). 

Typically with posterior compartment syndrome the tissue fills up with blood, the fascia or surrounding layer of tissue holding the muscles together has become shortened due to the repetitive trauma, and the muscles have no place to expand to so you get severe pain, sometimes diagnosed as shin splints. With shin splints the muscles wrapped in the fascia has no place to expand to so it begins to pull the fascia which is connected to the bones leading to pain in the shins, typically (tibia pain). Usually the symptoms will resolve shortly after workouts.

So now that we know what happens physiologically, what are some precursors to this type of injury? A Compartment pressure check (slit catheter measurement) should be performed for a definitive diagnosis. A gait analysis should also be performed to determine what is going on biomechanically and what muscles and structures are involved. For example, someone who is an overpronator typically toes off on the inside of the foot which will over load the posterior tibialis muscle (the muscle which lies deep in the calf). Running on hills will tend to overload the posterior compartment and will lead to overuse of those muscles. Lack of stretching, and obviously too much training too fast will be another contributing factor.

So once you develop this type of condition what can be done? In our office we use some soft tissue techniques called Active Release Technique (ART) and Graston Technique, which work very well together to resolve these issues in a very short period of time. These techniques are very effective in breaking up the adhesions in the muscles and fascia and restoring proper muscle function and elasticity. It is not uncommon to have a 30-60% improvement in just one treatment and in most cases these issues will resolve in 8-10 visits. Other treatments include massage, ultrasound to help loosen collagen fibers, PT and surgical intervention.

Dr. Sadri has been practicing in Decatur, GA for 25 years and specializes in athletic injuries and rehab. The clinic, 1st Choice Sports Rehab Center, was named “The Best Sports Injury Center in the Southeast” by Competitor Magazine. To subscribe to our newsletter click here. To schedule an evaluation, call 404-377-0011.

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