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Conservative management of chronic compartment syndrome
Since compartment syndrome of the posterior compartment occurs less frequently than compartment syndrome of the anterior and lateral compartments (Godon & Crielaard, 2005), the conservative outcomes of compartment syndromes in general will be reviewed.
The literature available on the conservative management of chronic compartment syndrome is limited. Most of the conservative approaches or modalities used in the management of CCS are only mentioned and not discussed in detail. The following list is a summary of the various conservative treatment modalities/ approaches mentioned in the literature and which will be discussed in this section: o physical therapy (massage, ultrasound, stretching, heat, cold, myofascial release techniques, whirlpool, electrical stimulations). All of the physical therapy techniques were applied locally to the area of the posterior calf.
o orthotics, modification of shoes, taping
o anti-inflammatory medication, diuretics, steroid injections
o rest, cast immobilizations
o reduced training, different training programmes
o compression, elevation
Schepsis & Lynch (1998) state that once the patient has been diagnosed with chronic exertional compartment syndrome, the only worthy non-operative treatment is the modification of activity. They are of the opinion that if the athlete is unwilling or unable to give up the activity that causes the symptoms, the only other option is surgical decompression by fasciotomy. In their opinion other treatment modalities such as physiotherapy, rest, orthotics and anti-inflammatory medication are of minimal value. Styf (1998) has investigated recurrent exercise-induced pain in the anterior aspect of the lower leg in 98 patients who were clinically diagnosed with chronic anterior compartment syndrome (CACS). Intra-compartmental pressure measurements confirmed the diagnosis of CACS in 26 of the patients. According to the subjective assessment done, all of the 98 patients tried various conservative treatment approaches including rest, reduced training, anti-inflammatory drugs, diuretics, modification of shoes, different training programmes and orthotic applications, as well as physiotherapy that included ultrasound therapy, stretching, local heat and cold. Conservative treatment approaches were only mentioned and not described in detail. According to the patients, none of the previously mentioned treatments had any lasting effect on their symptoms. Davey et al. (1984) postulated that the tibialis posterior muscle is contained in its own osseofascial compartment and might be the site of isolated exertional/compartment syndrome. Part of the study was done on two runners complaining of pain to the posterior- medial aspect of the mid and lower third of the tibia. Both of these individuals had failed to respond to conservative modalities including rest, ice, antiinflammatory drugs, physiotherapy, and foot orthoses. The conservative physiotherapy treatments were not described. The authors concluded that they have found true exertional compartment syndrome to be resistant to anything less than surgical decompression.
According to a study done by Detmer et al. (1985) on patients with chronic compartment syndrome, it was mentioned that:
o 41% had tried orthotics which was considered helpful by 15% of the patients;
o stretching programmes were widely used but were not considered helpful;
o 40% of the subjects underwent physiotherapy; and
o 49% of the subjects had used medication.
A third of the patients described the physiotherapy and the use of medication as being only somewhat helpful while the rest said that they had experienced no measurable relief of their symptoms. In a study done by Martens et al. (1984) nine patients diagnosed with chronic compartment syndrome received conservative treatment consisting of prolonged rest, physiotherapy, anti-inflammatory drugs and stretching exercises of the flexor musclesof the lower leg. According to Martens et al. (1984), none of the conservative treatment methods led to an appreciable improvement. All the patients were forced to limit their sports activities to a certain extent and ended up undergoing a fasciotomy. Although the fasciotomy and its results were described in the study reported, conservative approaches were merely mentioned and not dealt with in any depth. Martens et al. (1984) tried a variety of therapeutic modalities to treat the symptoms of shin splints (which they called medial stress syndrome). According to the authors, aspirin, phenylbutazone, heel-cord stretching, heel-pads and cast immobilizations did not have any lasting effect on the patients’ symptoms. Jackson & Bailey (1975) reported that taping or arch supports yielded no success in patients with CPCS and found that aspirin and local injection of steroids were also not beneficial. According to Garcia-Mata et al. (2001), intermittent massage with specific stretching only serves to lengthen the time before onset of pain in patients with chronic exertional compartment syndrome, but does not cure or prevent the condition. The authors’ mention the effect of massage together with specific stretches only in passing and then go on to describes surgery as a better option for the symptoms. Their study included 23 legs. Twenty-one patients complained of anterior compartment syndrome, one of posterior compartment syndrome and one of both anterior and posterior compartment syndrome. Allen & Barnes (1986) have found with medial tibial syndrome (deep posterior compartment) that the outcomes of both surgical (fasciotomy of the medial border of the tibia) and conservative treatment (physiotherapy, steroid injections to the tibial border and shoe inserts) were poor. The physiotherapy techniques used, or their area of application were not mentioned. Clanton & Solcher (1994) states, that conservative method for treating chronic compartment syndrome, such as ice, medication, shoe modification and orthotics usually provide little benefit. No further description is given with regard to the application of the conservative treatment methods.
Functional anatomy and biomechanical factors
In the literature a number of researchers found a correlation between exercise related leg pain (ERLP) and biomechanical factors (Bennett et al., 2001; Dugan & Bhat, 2005; Hreljac, 2005). Dugan & Bhat (2005) found that foot pronation had a distinct influence on the development of ERLP in athletes. They found that athletes with a history of ERLP had a significant greater foot pronation than athletes without such a history. Excessive pronation is however difficult to define due to the fact that the magnitude of normal foot pronation in a large sample of asymptomatic subjects has never been described (Johanson et al., 1994). Although some research findings contradicts these relationships (Johanson et al., 1994; Lun et al., 2004), these contradictions are probably contributable to the definition of runners and the associated distances run by the different research populations (Hreljac, 2005). Hreljac (2005) however makes a convincing argument for such a correlation based on the increased risks for injury due to increased torque and instability that results from improper biomechanical alignments. In the following section the function of the muscles of all the compartments of the posterior compartment of the lower leg will be discussed in the light of the effect which they have on movement patterns which will be assessed during the gait analysis.
CHAPTER 1: THE SCOPE OF THE RESEARCH
1.1. INTRODUCTION AND BACKGROUND
1.2. THE RESEARCH PROBLEM
1.3. THE RESEARCH QUESTION
1.4. INVESTIGATIVE QUESTIONS
1.5. KEY RESEARCH OBJECTIVES
1.6. SIGNIFICANCE OF THE RESEARCH
1.7. THE RESEARCH PROCESS
1.8. THE RESEARCH DESIGN AND METHODOLOGY
1.9. RESEARCH ASSUMPTIONS
1.10. RESEARCH CONSTRAINTS
1.11. CONTEXTUAL BOUNDARIES
1.12. CONCLUSION
CHAPTER 2: LITERATURE REVIEW
2.1. INTRODUCTION
2.2. RESEARCH METHODOLOGY
2.3. CHRONIC POSTERIOR COMPARTMENT SYNDROME
2.4. KNOWLEDGE OF FASCIA
2.5. THE CONTINUITY OF THE SOFT TISSUE LINKS
CHAPTER 3: METHODOLOGY
3.1. INTRODUCTION
3.2. EXPLORATORY RESEARCH DESIGN
3.3. THE EXPLANATORY RESEARCH DESIGN
3.4. EXPERIMENTAL RESEARCH
CHAPTER 4: RESEARCH RESULTS
4.1. INTRODUCTION
4.2. EXPLORATORY RESEARCH PHASE
4.3. THE DEVELOPMENT OF THE CONCEPT OF CLINICALLY SIGNIFICANT MUSCLES
4.4. THE REVISED THEORETICAL FRAMEWORK
4.5. EXPLANATORY RESEARCH RESULTS
4.6 CROSS CASE STUDY COMPARISON
4.7. EXPERIMENTAL RESEARCH
4.8. RESEARCH VALIDATION
CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS
5.1 INTRODUCTION
5.2 KNOWLEDGE INTEGRATION
5.3. THE RESEARCH PROBLEM
5.4. THE RESEARCH AND INVESTIGATIVE QUESTIONS
5.5. KEY RESEARCH OBJECTIVES
5.6. SIGNIFICANCE OF THE RESEARCH
5.7. THE RESEARCH PROCESS
5.8. THE RESEARCH DESIGN AND METHODOLOGY
5.9. CONTEXTUAL BOUNDARIES AND SHORTCOMINGS
5.10. RECOMMENDATIONS
REFERENCES
