Exertional Compartment Syndrome


Compartment Release




Increased pressure within a closed fibro-osseous space




Seen in athletes, associated with repetitive exertion






1.  Anterior compartment

- anterior tibial artery

- deep peroneal nerve


2.  Lateral compartment



3.  Superficial posterior

- sural nerve


4.  Deep posterior

- posterior tibial nerve

- posterior tibial and peroneal artery




During strenuous exercise, muscle can swell up to 20 x resting size

- 20% increase in volume

- fixed compartment size

- increased pressure / decrease inflow


Becomes insufficient to meet metabolic needs

- develop pain


Fascial defects

- 40% in exertional compartment syndrome patients

- 5% in normal population

- 1-2 cm 

- junction of anterior and lateral compartments

- often at exit of SPN

- with swelling, fascial edge may compress SPN


Incompletely understood phenomenon




Anterior compartment > lateral compartment

> deep posterior compartment > tibialis posterior compartment




Stress fractures

Muscle strain

Nerve entrapment

Spinal stenosis




Insidious onset of pain after certain period of exercise

- ache to sharp pain

- predictable and reproducible time and level of exertion

- localised to specific compartment


May get transient numbness or weakness in compartment


Site is tender at time

- may have concomitant muscle herniation thru fascial defect

- may feel increased tension




Rule out stress fracture


Bone Scan


May show diffuse uptake along tibia in some cases

- lack of uptake rules out stress fracture




Fascial defect with muscle herniation


Fascial Defect


Compartment Measures



- Too difficult to measure during exercise

- measure before and after exercise

- needle manometry / catheters

- may need ultrasound to accurately insert into deep posterior or tibialis posterior


Diagnostic levels

1. > 15 before exercise

2. > 30 1 minute post exercise

3. > 20 after 15 minutes




Non Operative


Reduce activity

- NSAIDs and orthotic shoes

- not often tolerated by athletes


Surgical Decompression


Compartment Release




Depends on compartment involved

- usually anterior / lateral




Schmitz et al Int J Sports Med 2004

- open release in 56 patients

- 87% good results


Can get wound issues


Wound Issue Compartment release




Wittstein Am J Sports Med 2010

- endoscopic release in 14 legs in 9 patients

- 8/9 able to resume previous level of sport

- no NV injuries

- haematomas in 2