Compartment syndrome of the foot is a condition that occurs when there is increased pressure within one of the compartments of the foot. This increase in pressure can cause pain and swelling, and can rapidly lead to tissue death. It’s important to understand and identify compartment syndrome early to prevent complications from occurring.
In this article, we’ll discuss compartment syndrome in detail and how it is treated.
Let’s dive in…
What Are the Two Types of Compartment Syndrome?
There are two types of compartment syndrome: acute and chronic.
Acute compartment syndrome typically occurs after an injury, while chronic compartment syndrome occurs due to overuse injuries.
For this article, we will be discussing the management of acute compartment syndrome.
Anatomy
What Are the 9 Compartments of the Foot?
The foot is anatomically divided into 9 compartments that separate the muscles and vasculature/nerves. This is important to understand because it influences surgical planning if surgery is needed.
The 9 Compartments
Medial compartment: Contains the Abductor hallucis muscle and the Flexor Hallucis muscle
Superficial compartment: Contains the 4 Lumbrical muscles, the flexor digitorum brevis muscle, the flexor digitorum longus muscle, and the medial plantar nerve
Lateral compartment: Contains abductor digiti quinti muscle and flexor digiti minimi muscle
Interossei compartment x 4: Contains the interossei muscles
Adductor compartment: Contains the adductor muscle
Calcaneal compartment: Contains the Quadratus plantae muscle, the posterior tibial artery/vein/nerve, the lateral plantar artery/nerve/vein, and the medial plantar nerve
What Causes Compartment Syndrome in the Foot?
Compartment syndrome is caused by high-impact trauma to the foot. This includes trauma sustained from falls and motor vehicle accidents. This traumatic event causes excessive bleeding and swelling in the enclosed compartments of the foot.
When there is too much pressure in a foot compartment, tissue death can occur. This includes damage to the muscles, blood vessels, and nerves.
Nerve deficits begin within 30 minutes and become irreversible after 12-24 hours. Muscle dysfunction occurs after 2-4 hours of ischemia and becomes irreversible at 4-12 hours (1).
That’s why it is pertinent to address compartment syndrome fairly quickly to prevent lasting foot problems.
What Are the Symptoms of Compartment Syndrome?
There are 6 P’s of compartment syndrome- Pain, Paralysis, Pallor, Pulselessness, Paraesthesia, and Poikilothermia
- Pain: Pain out of portion in the foot that does not get better with rest. This occurs due to increased pressure on the foot nerves. Even pain with passive motion of the foot can cause significant pain.
- Paralysis (the loss of the ability to move the limb), pulselessness (absence of pulses), and paresthesias (abnormal nerve sensation from nerve damage) present late in the disease process as a complication of compartment syndrome.
- Pallor: Pallor (lightening of the skin) can also present as a late finding in compartment syndrome. Foot pulses are often present in early diagnosis of compartment syndrome. However, if it is not addressed, damage to the blood vessels can occur. This can limit perfusion and cause the skin to appear lighter in color.
- Poikilothermia: The presence of coolness in the limb may be present due to increased compartmental pressures.
What You Should Do if You Suspect You Have Compartment Syndrome
If you suspect you have acute compartment syndrome, you should go to the Emergency Room. Avoid icing the foot in case blood flow may be compromised. Avoid elevating the limb as this can cause further blood flow obstruction to the limb.
Try to stay off of the foot using crutches or a knee scooter until you can be evaluated in the Emergency room.
How Is Compartment Syndrome Diagnosed?
Compartment syndrome is diagnosed by a catheter that checks the compartment pressure in the different compartments of the foot. This is done by injecting the various compartments of the foot using saline. Tissue pressure is then recorded.
Watch this video by EM: RAP Productions on how compartment syndrome is measured.
Normal pressure is 0-4mmHg (2). Whereas, in acute compartment syndrome, the pressure may be higher. An intracompartmental pressure of greater than 30mmHg is considered critical and surgery will be needed.
Your doctor will also order labs to check for muscle damage. These labs include serum creatinine phosphokinase (CPK) and the presence of myoglobin in the urine.
X-rays of the foot will be ordered to check for broken bones. In addition, an MRI may be ordered to check for soft tissue damage in the foot.
If your doctor suspects damage to the blood vessels, he/she may order an angiogram to assess the blood flow to the foot.
How Is Compartment Syndrome Treated?
Once compartment syndrome is diagnosed, surgery is needed to release compartment pressures via a fasciotomy. The foot muscles are surrounded by fascia (connective tissue).
A fasciotomy is a surgery that releases the fascia to relieve pressure in the compartments.
Surgery would be done in the operating room under anesthesia. If you have elevated pressures in multiple compartments in the foot, your surgeon will make incisions in various areas of the foot to be able to access the compartments and perform a fasciotomy.
The wounds are generally left open, with a return to the operating room required in 5-7 days to close the wound. Occasionally, skin grafts may be needed if the wound cannot be closed. Diligent wound care will be required after surgery.
In many cases, there may be broken bones in the forefoot and midfoot. Your doctor will likely stabilize these fractures during the same surgery.
In the case of extensive fractures like calcaneal (heel bone) fractures, your doctor will likely perform the fasciotomy first, and secondarily repair the heel fracture in 5-7 due to swelling and risk for hardware infection.
How Long Is Recovery From Compartment Syndrome Surgery?
Complete recovery after compartment syndrome surgery in the foot can take anywhere from 3-4 months. This is due to foot fractures that often accompany compartment syndrome. Bone healing takes 6-8 weeks minimum. You will need to stay off of your foot in a cast or splint for 6-8 weeks, followed by gradual weight bearing for 4 weeks in a cast boot, and physical therapy for another 4 weeks before transitioning into athletic shoes.
What Happens if Compartment Syndrome Goes Untreated?
Untreated compartment syndrome can cause lasting damage to the tissues and neurovascular structures in the foot.
Some long-term effects of compartment syndrome in the foot include:
- Hammertoes and claw toes (due to damage to the muscles)
- Neuropathy (due to damage to the nerves)
- A high-arched foot
- Drop foot
- Increased sensitivity to pain signals
- Cramping
- Ulceration from foot deformities
- Chronic pain
Conclusion
Compartment syndrome is a serious condition and should be addressed quickly. If you sustain a severe foot injury, you should go to the Emergency department to be evaluated. Your physician will recommend surgery if needed to relieve pressure in the compartments of the foot. This will prevent further damage from occurring.
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References
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- Frink, M., Hildebrand, F., Krettek, C., Brand, J., & Hankemeier, S. (2010). Compartment syndrome of the lower leg and foot. Clinical Orthopaedics and Related Research®, 468(4), 940-950.https://link.springer.com/article/10.1007/s11999-009-0891-x
- Ojike, N. I., Roberts, C. S., & Giannoudis, P. V. (2009). Foot compartment syndrome: a systematic review of the literature. Acta orthopaedica Belgica, 75(5), 573.https://www.researchgate.net/profile/Peter-Giannoudis/publication/40648106_Foot_compartment_syndrome_A_systematic_review_of_the_literature/links/553e49070cf210c0bda93756/Foot-compartment-syndrome-A-systematic-review-of-the-literature.pdf
- Ziv, I., Mosheiff, R., Zeligowski, A., Liebergal, M., Lowe, J., & Segal, D. (1989). Crush injuries of the foot with compartment syndrome: immediate one-stage management. Foot & ankle, 9(4), 185-189.https://journals.sagepub.com/doi/abs/10.1177/107110078900900407
- Lutter C, Schöffl V, Hotfiel T, Simon M, Maffulli N. Compartment Syndrome of the Foot: An Evidence-Based Review. J Foot Ankle Surg. 2019 Jul;58(4):632-640. https://pubmed.ncbi.nlm.nih.gov/31256897/
- Garcia, R. (2020, April). Acute Compartment Syndrome of the Foot: A Literature Review. The Northern Ohio Foot and Ankle Journal, 1(1). https://www.nofafoundation.org/user/files/pdf/Acute%20Compartment%20Syndrome%20of%20the%20Foot%20A%20Literature%20Review.pdf
- Laverdiere C, Montreuil J, Bouklouch Y, Lorange JP, Dion CA, Harvey EJ. Predictors of Foot Acute Compartment Syndrome: Big Data analysis. J Foot Ankle Surg. 2022 Mar 24:S1067-2516(22)00090-4.https://pubmed.ncbi.nlm.nih.gov/35473922/
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