Chronic Exertional Compartment Syndrome

Runners and other athletes may experience symptoms of leg and foot numbness and pain which comes on during and after activity.  Such symptoms may be frustrating to the athlete as their diagnoses and treatment may be delayed due to the intermittent nature of symptoms.  A patient may see their podiatrist but exhibit no signs and symptoms during the office visit.  

The muscles that control foot and ankle function originate in the leg and are in compartments. Compartments are essentially “sleeves” of connective tissue or fascia that contain muscle groups along with arteries and nerves.  The compartments of the leg are the anterior compartment, lateral compartment, deep posterior compartment and the superficial posterior compartment.

The anterior compartment includes the muscles that dorsiflex or lift up the foot and toes.  It also contains two major nerves and arteries.  The lateral compartment contains two muscles that lift up on  the outside of the foot, that is, evert the foot as well as a major nerve. The peroneal muscles of the lateral compartment also prevent the ankle from spraining. The superficial posterior compartment includes the large calf muscles that define the back of the leg and allow one to push off.  The deep posterior compartment includes muscles that lift up on the arch of the foot or invert the foot and a major artery and nerve that goes to the bottom of the foot.

Anterior compartment:  tibialis anterior muscle, extensor digitorum longus muscle, extensor hallucis longus muscle, deep peroneal nerve, superficial peroneal nerve, anterior tibial artery.

Lateral compartment: peroneus longus muscle, peroneus brevis muscle, deep peroneal nerve, superficial peroneal nerve.

Deep posterior compartment:  tibialis posterior muscle, flexor hallucis longus muscle, flexor digitorum longus muscle, posterior tibial nerve, tibial artery.

Superficial posterior compartment:   Soleus muscle, Gastrocnemius muscle.

Overuse of  the muscle groups can occur with overtraining or with biomechanical imbalances of the foot and leg.  For example, if one has a tight superficial posterior muscle group, then the muscles of the anterior compartment of the leg must work harder to lift the foot, especially on hills or an incline.

Muscles, when overused, may swell while running.  The swelling is contained within the compartment resulting in increased compartment pressure.  The fascia surrounding the muscles has minimal elasticity or expansibility. The delicate nerves in the compartment are sensitive to pressure leading to pain and numbness. Such symptoms generally resolve after cessation of activity but, in some cases, may persist and become severe.  Compartment syndrome of the anterior compartment may lead to foot drop.

Symptoms of chronic exertional compartment syndrome:

  • A feeling of fullness or tightness in the affected limb.
  • Numbness or tingling (paresthesia) in the affected leg.
  • Weakness in the affected leg.
  • Aching, burning or cramping in the affected leg.
  • Visible or palpable area of swelling or bulging due to muscle swelling or a muscle pushing out of the compartment (muscle herniation).
  • Foot drop.



Symptoms of exertional compartment syndrome listed above often follow this pattern:

  1. May begin soon after one starts exercise or after a certain amount of mileage in a runner. Patients may relate symptoms starting at a specific part of their run but that can vary with the rest interval between runs.
  2. Gets worse as the run or inducing exercise activity continues.
  3. Acute symptoms generally subside within 30 to 60 minutes after rest except in severe cases.  Residual symptoms of aching and numbness may linger for a day or two after activity.
Chronic exertional compartment syndrome is also called exercise induced compartment syndrome and generally responds well to conservative treatment.  Conservative treatment need address the cause: overuse, overtraining, incorrect training and, most importantly biomechanical issues.  Dr. Davis, in his San Antonio Podiatrist office often encounters patients who express frustration with their progress in eliminating this issue.  The reason is unresolved biomechanical problems.  A focus on podiatric biomechanics provides the optimal treatment tools.

Risk factors for chronic exertional compartment syndrome:
  • Age.  The condition is most common in athletes under age 35 but can develop at any age.
  • Exercise type.  Exercise that involves high repetitions or repetitive impact such as running.
  • Terrain or exercise surface.  Terrain influences biomechanics.  For example, running on hills necessitates the anterior muscle group lift the foot higher when ascending an incline and additional contraction when descending to prevent the foot from “slapping” ground.  There are two types of muscle contraction – eccentric and concentric contraction.  Concentric contraction involves a muscle contraction in which the muscle shortens, ie, the anterior muscle group when running up a hill.  Eccentric contraction involves muscle lengthening while contraction occurs, ie, running down a hill.  Another example involves running on the beach, along the water line. The foot closest to the water will roll out more or supinate while the foot furthest from the water rolls in more or pronates.  Repetitive excessive pronation places stress on the deep posterior muscle group.
  • Overtraining or mis-training.  Workouts which are too intense or too frequent.
  • Shoegear.  Shoegear need be appropriate for the sport and for one's foot type and mechanics. Fads abound in the shoe industry but serious athletes need seek advise based on sound knowledge of biomechanics. 
  • Drugs and supplements.  Creatinine is a supplement that can increase the water content of muscle and has been suggested as a potential risk in chronic compartment syndrome.  Anabolic steroids can lead to muscle hypertrophy that occurs faster than connective tissue can adapt.

When to seek medical treatment and what to do:

  • Symptoms of unusual pain, weakness, numbness or swelling.
  • Do not try to exercise through the pain as that may lead to permanent nerve or muscle damage.
Exercise induced compartment syndrome may mimic the symptoms of shin splints. There is relationship between the two because shin splints often result from the same type of overuse or problematic biomechanics.

Diagnosis of chronic exertional compartment syndrome can often be accomplished without imaging especially by a podiatrist well versed in biomechanics.  An MRI may be ordered to examine the shape and structure of muscles and rule out stress fracture.   Compartment pressure testing is often utilized in acute compartment syndrome but may be considered in chronic exercise induced compartment syndrome.  It involves insertion of a needle into the compartment attached to a machine which measure compartmental pressure.

Treatment of chronic exertional compartment syndrome is generally conservative focusing on changes in training, shoegear, manual therapy, orthotics and other biomechanical interventions. Surgical treatment may be needed if there is risk of muscle or nerve damage and involves a fasciotomy, cutting the fascia to release presssure or fasciectomy, in which a section of fascia is removed.

For treatment of Chronic Exertional Compartment Syndrome in the San Antonio, TX area, call Ed Davis, DPM, FACFAS. at (210) 490-3668 today!