Compartment Syndrome
Lower LimbOverview
Compartment syndrome is a surgical emergency characterized by elevated interstitial pressure within a closed fascial compartment that compromises microcirculation and tissue function. It can occur acutely following trauma, crush injury, or intensive exercise, or chronically from repetitive overuse. Without rapid decompression, irreversible tissue damage, permanent disability, and loss of limb function can result.
Pathophysiology
Compartments are enclosed spaces bounded by inelastic fascia containing muscles, nerves, and blood vessels. When pressure within a compartment rises above capillary perfusion pressure (typically >30-40 mmHg), microcirculatory compromise occurs. This leads to tissue hypoxia, cellular edema, increased capillary permeability, and a vicious cycle of rising pressure. Prolonged ischemia causes muscle necrosis, nerve damage, and potential rhabdomyolysis with acute kidney injury. The leg has four compartments (anterior, lateral, deep posterior, superficial posterior), each vulnerable to syndrome development.
Patient Education
Compartment syndrome is a medical emergency requiring immediate hospital evaluation if severe pain out of proportion to clinical findings, pain with passive stretch of involved muscles, or neurological changes occur; do not delay seeking emergency care.
Typical Presentation
Site
Anterior or lateral lower leg most common; can affect any compartment (forearm, thigh, buttock, hand, foot)
Quality
Severe, deep, aching pain; burning sensation; progressive tightness and fullness in compartment
Intensity
Severe pain (8-10/10) disproportionate to apparent injury; worsens over hours to days
Aggravating
Passive stretching of muscles in affected compartment (pathognomonic); swelling; elevation may worsen pain; active muscle contraction
Relieving
Early decompression is only effective treatment; elevation and ice provide minimal relief; analgesia often ineffective
Associated
Swelling and firmness of compartment; paresthesias (numbness, tingling) in distribution of compressed nerves; muscle weakness; coldness or pallor; tense, turgid compartment; pain out of proportion to findings; eventual neurological deficit (late sign)
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Pain with Passive Stretch
Procedure
Gently and passively stretch the muscles of the suspected compartment. Lower leg: anterior compartment — plantarflex the ankle and flex the toes; lateral compartment — invert the foot; deep posterior compartment — dorsiflex the ankle and extend the toes; superficial posterior compartment — dorsiflex the ankle with the knee straight.
Positive Finding
Pain far greater than expected from the injury when the compartment's muscles are stretched.
Reference: Olson & Glasgow, 2005, Journal of the American Academy of Orthopaedic Surgeons
Interpretation
Together with pain out of proportion to the injury, one of the earliest signs of acute compartment syndrome. It can be masked by nerve blocks, strong pain relief or reduced consciousness. Suspected acute compartment syndrome is a surgical emergency: call an ambulance. Chronic exertional compartment syndrome in runners is different: pain comes on with exercise and settles with rest, and needs non-urgent referral. A 2002 review of four prospective studies of tibial injuries (Ulmer) found the clinical findings of compartment syndrome were present in only 13–19% of true cases, and absent in 97–98% of people without it. With one finding present the chance of compartment syndrome was about 25%; with three findings, about 93%. A 2023 meta-analysis of seven studies (Lorange et al.) found the chance of compartment syndrome after a positive result was 21% with clinical signs alone, 29% with pressure monitoring alone, and 68% with both together. The abstracts do not give figures for each sign separately, so no figure is shown for this test. Absence of this sign does not rule compartment syndrome out.
Compartment Pressure Measurement (Wick Catheter or Slit Catheter)
Procedure
Hospital procedure. A needle or catheter connected to a pressure monitor is placed into the compartment; after a tibial fracture it is often left in for continuous monitoring.
Positive Finding
Compartment pressure close to the patient's diastolic blood pressure (a small difference between the two).
Reference: McQueen & Court-Brown, 1996, Journal of Bone and Joint Surgery (British)
Interpretation
Supports the decision to perform fasciotomy (surgical release of the compartment), usually alongside the clinical picture. In chronic exertional compartment syndrome, pressures are measured before and after exercise. Not an osteopathic test; the reason to know it is to refer urgently. In 850 people with a tibial shaft fracture who had continuous pressure monitoring (McQueen 2013), the estimated figures were 94% / 98%. These are estimates, and the pressure reading itself helped decide who had surgery, which tends to make a test look better than it is, so no figure is shown. A 2023 meta-analysis of seven studies (Lorange et al.) found the chance of compartment syndrome after a positive result was 29% with pressure monitoring alone and 21% with clinical signs alone, rising to 68% when both were used together. This is a hospital procedure.
Loss of Sensation (Two-Point Discrimination or Light Touch)
Procedure
Test light touch in the areas supplied by the nerves running through the compartment and compare with the other side. Lower leg: anterior compartment — deep fibular (peroneal) nerve, web space between the first and second toes; lateral compartment — superficial fibular nerve, top of the foot; deep posterior compartment — tibial nerve, sole of the foot.
Positive Finding
Tingling, reduced or absent feeling in that nerve's area.
Reference: Olson & Glasgow, 2005, Journal of the American Academy of Orthopaedic Surgeons
Interpretation
Tingling can appear early, but numbness is a later sign that the nerve is starved of blood. Its absence does not rule compartment syndrome out, and treatment should never wait for it. Suspected acute compartment syndrome is a surgical emergency: call an ambulance. A 2002 review of four prospective studies of tibial injuries (Ulmer) found the clinical findings of compartment syndrome were present in only 13–19% of true cases, and absent in 97–98% of people without it. With one finding present the chance of compartment syndrome was about 25%; with three findings, about 93%. A 2023 meta-analysis of seven studies (Lorange et al.) found the chance of compartment syndrome after a positive result was 21% with clinical signs alone, 29% with pressure monitoring alone, and 68% with both together. The abstracts do not give figures for each sign separately, so no figure is shown for this test. Absence of this sign does not rule compartment syndrome out.
Muscle Weakness (Strength Testing)
Procedure
Test the muscles of the suspected compartment against light resistance: ankle and toe dorsiflexion (anterior), foot eversion (lateral), ankle and toe plantarflexion (posterior). Do not test forcefully; pain may limit effort.
Positive Finding
Weakness of the compartment's muscles beyond what pain explains.
Reference: Olson & Glasgow, 2005, Journal of the American Academy of Orthopaedic Surgeons
Interpretation
A late sign: muscle and nerve are already being damaged. Waiting for weakness delays treatment. Suspected acute compartment syndrome is a surgical emergency: call an ambulance. A 2002 review of four prospective studies of tibial injuries (Ulmer) found the clinical findings of compartment syndrome were present in only 13–19% of true cases, and absent in 97–98% of people without it. With one finding present the chance of compartment syndrome was about 25%; with three findings, about 93%. A 2023 meta-analysis of seven studies (Lorange et al.) found the chance of compartment syndrome after a positive result was 21% with clinical signs alone, 29% with pressure monitoring alone, and 68% with both together. The abstracts do not give figures for each sign separately, so no figure is shown for this test. Absence of this sign does not rule compartment syndrome out.
Pulselessness (Distal Pulses)
Procedure
Palpate the dorsalis pedis and posterior tibial pulses and compare colour, temperature and capillary refill with the other foot.
Positive Finding
Absent or weak pulses below the swollen compartment.
Reference: Olson & Glasgow, 2005, Journal of the American Academy of Orthopaedic Surgeons
Interpretation
Pulses are usually still present in compartment syndrome, because the pressure in the compartment rarely rises above arterial pressure. A normal pulse must never be used to rule it out. Absent pulses suggest an arterial injury or very late compartment syndrome: call an ambulance.
Tense, Swollen Compartment (Clinical Palpation)
Procedure
Gently feel each compartment of the injured limb and compare with the other side.
Positive Finding
A tense, swollen, woody-hard compartment.
Interpretation
Supports compartment syndrome, but judging tension by feel is unreliable and a normal feel does not exclude it. With severe pain and pain on passive stretch, call an ambulance.
⚠ Red Flags
- •Severe pain out of proportion to clinical examination findings
- •Pain with passive stretching of muscles in affected compartment
- •Acute onset following trauma, crush injury, or intensive exercise
- •Progressive neurological symptoms (paresthesias, numbness, weakness)
- •Absent or diminishing pulses - a LATE and unreliable sign. Distal pulses are usually PRESENT in acute compartment syndrome, because compartment pressure rarely exceeds systolic arterial pressure. Palpable pulses therefore do NOT exclude the diagnosis. The diagnosis rests on pain out of proportion to the injury and pain on passive stretch of the compartment; waiting for pulselessness means waiting until muscle is already necrotic.
- •History of rhabdomyolysis or dark urine suggesting myoglobinuria
- •Signs of systemic toxicity (fever, hypotension, altered consciousness)
- •Any suspicion of compartment syndrome requires immediate referral to emergency department for compartment pressure measurement and possible surgical fasciotomy
⚡ Yellow Flags
- •High pain catastrophizing related to fear of permanent disability or limb loss
- •Anxiety about surgical intervention and recovery timeline
- •Previous trauma with delayed seeking of medical care
- •Occupational demands creating pressure to continue activity despite symptoms
- •Difficulty accepting need for complete activity modification during acute phase
- •Unrealistic expectations about return to sport or full function timeline
Osteopathic Techniques
Refer first
Acute compartment syndrome is a surgical emergency: without treatment it leads to muscle ischaemia and necrosis. Send to emergency care. Chronic exertional compartment syndrome needs referral too: rest, activity modification, stretching and physiotherapy are generally ineffective, and fasciotomy is the surgical option.
- Reference bookTorlincasi et al. · StatPearls 2023
- Reference bookChandwani & Varacallo · StatPearls 2023
Rehabilitation Exercises
Ankle plantar flexion and dorsiflexion (supine, gravity-eliminated)
Ankle inversion and eversion (seated, gravity-reduced)
Calf muscle stretch (standing wall or step stretch)
Anterior tibialis stretch (kneeling toe-under stretch)
Ankle dorsiflexion with resistance band (seated)
Ankle plantarflexion with resistance band (seated)
Ankle inversion and eversion with resistance band (seated)
Single-leg calf raises (holding support)
Standing balance on affected leg (near wall or support)
Gait training with normalized stride mechanics
Stationary cycling (pain-free resistance and duration)
Gradual return to running with interval progression (after clearance)
Referral Criteria
- •Suspected acute compartment syndrome: IMMEDIATE referral to emergency department for compartment pressure measurement and surgical evaluation
- •Severe pain disproportionate to clinical findings with risk factors for compartment syndrome
- •Progressive neurological deficit (weakness, sensory loss) suggesting nerve compression
- •Signs of systemic toxicity or rhabdomyolysis (myoglobinuria, acute kidney injury)
- •Chronic exertional compartment syndrome refractory to conservative management: refer to orthopedic surgeon for consideration of fasciotomy
- •Post-fasciotomy with delayed wound healing, signs of infection, or excessive scar tissue formation: refer to orthopedic surgeon or wound care specialist
- •Chronic compartment syndrome with significant functional limitation: refer to sports medicine physician or orthopedic specialist for management optimization
- •Any case where compartment pressure measurement is indicated: requires hospital-based orthopedic evaluation