Compartment syndrome in the foot occurs when excessive pressure builds up within one of its compartments. This escalating pressure results in pain, swelling, and in severe cases, tissue death.
Early identification and understanding of this condition are crucial to prevent complications.
This article delves into the causes, symptoms, and diagnosis of foot compartment syndrome as well as the treatment options.
What Is the Definition of Foot Compartment Syndrome?
Foot compartment syndrome is a medical condition characterized by an increased pressure within the confined compartments in the foot. This leads to compromised blood flow and damage to the muscles and nerves within that space.
There are two forms of this syndrome: acute and chronic.
Acute foot compartment syndrome manifests following a traumatic injury, while chronic foot compartment syndrome arises from repetitive strain or overuse injuries.
In this article, the focus will be on understanding and managing 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/tibial vein/tibial nerve, the lateral plantar artery/nerve/vein, and the medial plantar nerve.
What Causes Foot Compartment Pressure Elevation?
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 will occur. This includes damage to the muscles, blood vessels, and nerves.
According to E. Fulkerson in the American Orthopedic Foot and Ankle Society, 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.
That’s why it is pertinent to address foot compartment syndrome quickly to prevent lasting foot problems.
Who is at risk?
While any traumatic injury can lead to compartment syndrome in the foot, certain factors may increase one’s risk. Individuals with a history of severe fractures, especially of the calcaneus (heel bone) or metatarsals, may be more prone to develop this condition.
Those who engage in high-impact sports or activities that expose the foot to potential crush injuries can be at increased risk.
Prolonged compression, such as that caused by tight casts or splints, can also lead to elevated compartment pressures.
What Are the Symptoms of Compartment Syndrome?
- Pain: This is characterized by disproportionate pain in the foot that doesn’t alleviate with rest. The heightened pressure on the foot nerves can result in pain even during passive motion.
- Paralysis: This refers to the inability to move the affected limb.
- Pulselessness: It indicates the absence of detectable pulses in the affected area.
- Paraesthesia: Abnormal nerve sensations resulting from nerve damage.
- Pallor: A noticeable lightening of the skin. In the early stages of compartment syndrome, foot pulses might still be detectable. However, if left untreated, damage to blood vessels can restrict blood flow, causing the skin to pale.
- Poikilothermia: This manifests as coolness in the limb, a consequence of increased compartmental pressures.
Paralysis, pulselessness, and paraesthesia usually present later in the progression of the disease, acting as complications of compartment syndrome.
It’s important to note that early diagnosis and intervention can prevent these complications.
If an individual suspects they are experiencing acute compartment syndrome, it’s important that they seek immediate medical attention in the Emergency Room.
Individuals should avoid icing the foot, as this could compromise blood flow. They should also refrain from elevating the limb, as it might further obstruct blood flow.
Using aids like crutches or a knee scooter to stay off the foot is recommended until a medical assessment can be conducted.
How Are Elevated Foot Compartment Pressures Diagnosed?
To diagnose foot compartment syndrome, medical professionals utilize a catheter to measure the compartmental pressures in various sections of the foot.
This involves injecting saline into these compartments and recording the tissue pressure.
For a visual demonstration on how this measurement is conducted, refer to the video by EM RAP Productions: Compartment Syndrome Measurement.
As noted by E. Konstantakos in The American Surgeon, a normal compartment pressure ranges between 0-4mmHg.
However, during an acute compartment syndrome episode, this pressure will increase considerably. A reading exceeding 30mmHg is deemed critical, necessitating surgical intervention.
In addition to this pressure measurement, a physician will likely request lab tests to determine how much muscle damage is present.
These tests include checking the levels of serum creatinine phosphokinase (CPK) and the detection of myoglobin in urine.
To rule out fractures, x-rays of the foot will be ordered. For further evaluation of potential soft tissue injuries, an MRI may be ordered.
If vascular damage is a concern, an angiogram might be ordered to evaluate the blood flow within the foot.
How Is Compartment Syndrome Treated?
Invasive Open Surgery
When foot compartment syndrome is confirmed, immediate surgical intervention is necessary. The primary goal is to alleviate the excess pressure. This is achieved through an invasive open surgery called a “fasciotomy”.
The muscles of the foot are covered within a layer of connective tissue known as fascia. A fasciotomy involves making surgical incisions to release this fascia, thereby relieving the pressure within the compartments.
This surgical procedure is carried out in an operating room under anesthesia. Should there be elevated pressures across multiple foot compartments, the surgeon will make separate incisions in the affected regions of the foot to release the pressure.
Post-fasciotomy, the incisions are typically left open. A follow-up visit to the operating room is scheduled within 5-7 days for wound closure.
In certain scenarios, where direct wound closure isn’t possible, skin grafts may be used. After the procedure, diligent wound care becomes an important part of the recovery process.
It’s worth noting that foot compartment syndrome can occasionally coincide with fractures, especially in the forefoot and midfoot regions. During the fasciotomy, the surgeon will likely address and stabilize these fractures.
However, in instances of more extensive fractures, like those of the calcaneal (heel bone), a two-stage approach might be performed.
The initial stage involves the fasciotomy, while the subsequent repair of the heel fracture is deferred by 5-7 days to manage swelling and minimize the risk of hardware infection.
What Is the Recovery Process Like After Surgery?
Following a surgery to address foot compartment syndrome, full recovery typically spans 3-4 months.
This extended duration often results from the presence of foot fractures that often coexist with compartment syndrome. Fractured bones themselves require a minimum of 6-8 weeks to heal.
For the initial 6-8 weeks, it’s advised to keep weight off the foot, using aids like a cast or splint. This is followed by a 4-week phase of gradually reintroducing weight onto the foot while wearing a protective cast boot.
An additional 4 weeks of physical therapy aids in regaining strength and mobility, after which one can transition back into regular athletic footwear.
Rehabilitation and Post-Surgery Care
After surgical intervention for foot compartment syndrome, rehabilitation plays an important role in restoring the foot’s function and preventing potential complications. Physical therapy introduces targeted exercises to strengthen the muscles and improve mobility. Techniques such as massage, electrotherapy, and hydrotherapy can be beneficial in reducing swelling and enhancing circulation.
How Can You Prevent Compartment Syndrome?
To decrease the risk of developing foot compartment syndrome, individuals should review and adopt specific techniques and preventive measures. For athletes and those engaged in exercise routines or other physical activities, wearing appropriate footwear that offers adequate support and cushioning is crucial.
Regularly inspecting the feet for any signs of swelling, pain, or changes in color can assist in the early detection of acute compartment syndrome.
Should one experience a foot injury, it’s vital to seek medical attention immediately to ensure that complications like acute or chronic compartment syndrome have not set in.
Management post-surgeries or procedures that require casting is critical. It’s important to ensure the cast is not too tight.
Reporting any discomfort without delay can prevent the onset of both acute and chronic compartment syndromes in the foot and ankle.
What Happens if Compartment Syndrome Goes Untreated?
If compartment syndrome in the foot is not addressed immediately, it can cause harm to the tissues and the nerves/blood vessels within the foot.
Potential long-term complications of untreated compartment syndrome are listed below.
- Development of hammertoes and claw toes resulting from muscle damage.
- Neuropathy, a condition stemming from nerve damage.
- Development of a high-arched foot.
- The onset of drop foot.
- Heightened sensitivity to pain.
- Frequent cramping.
- Ulcerations due to deformities in the foot.
- Persistent pain.
When Should You See a Health Care Provider in Their Office?
If an individual suspects they have compartment syndrome, it’s important to see a healthcare provider without delay. The condition is characterized by persistent and intense pain in the foot that doesn’t alleviate with rest, and pain often feels out of proportion to the injury sustained.
Early signs include a tight or full sensation in the foot, numbness, and difficulty moving the affected area.
As the condition worsens, there may be noticeable changes in skin color, temperature, and the absence of a pulse in the affected foot. Given the rapid progression of compartment syndrome, where muscle and nerve damage can become irreversible within a matter of hours, any delay in seeking medical attention can have serious, long-term consequences.
If these symptoms are observed or even suspected, it’s critical to get to an Emergency Room or consult with a foot care specialist immediately to prevent permanent damage.
Conclusion
In conclusion, compartment syndrome in the foot is a rare but life- and limb-threatening condition that requires immediate access to medical management. Given its nature as a surgical emergency, understanding the details surrounding its causes, symptoms, and treatment is crucial for both patients and healthcare providers.
Recent cases reveal the critical importance of timely intervention. Whether encountered in an office setting or after a traumatic event, the foot should always be viewed with a critical eye, ensuring that foot compartment syndrome doesn’t go unnoticed.
With the right approach and knowledge, potential foot ankle complications can be effectively addressed.
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