Background & Etiology
The ankle is made of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body. It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to and react quickly to changes in environment and walking surface.
Bones and Joints
There are three bones that come together to form the ankle joint. The tibia and fibula (lower leg bones) end in prominences called the malleoli. The malleoli create the bony prominence seen on either side of the ankle, these are called the lateral malleus and medial malleolus. The ankle is made up of two joints, the inferior talocrural joint and the subtalar joint.
The inferior tibiofibular joint is located between the large bone of the lower leg (tibia) and the smaller fibula, which then attach to the talus bone of the foot to form the talocrural joint. The talocrural joint is sometimes called the true ankle joint and is responsible for dorsiflexion and plantar flexion (up and down) movement of the foot. The joint between the tibia and talus bears the most of our body weight.
Beneath the talocrural joint is the subtalar joint. The subtalar joint is located between the talus bone and calcaneus or heel bone. This joint is responsible for ankle inversion (turning in) and eversion (turning out).
Running between the tibia and fibula is a fibrous membrane called the interosseous membrane. This membrane joins the tibia and fibula all the way up the lower leg extending toward the knee. At the upper end, near the outside of the knee, is the superior tibiofibular joint.
Any restriction or dysfunction of these joints can produce symptoms in the ankle. The bony joint surfaces all have articular cartilage that covers the ends of the bones. The articular cartilage has a smooth and shiny surface, which allows the ends of the bones to slide freely over each other.
Compartment Syndrome and Muscles
Muscles can be subject to compartment syndrome, which is increased pressure in the muscles that is trapped by the fascia that surrounds the muscles. The fascia is designed to act as a sheath, keeping muscles, nerves, and blood vessels together. Therefore, it does not stretch or expand readily. Compartment syndrome is a serious condition that can cause irreversible damage if not treated properly.
Anterior Compartment Syndrome
The anterior compartment of the lower leg includes four muscles, the tibialis anterior, the extensor hallucis longus, the extensor digitorum longus and the peroneus tertius. Any of these muscles can experience a build up of pressure that leads to Anterior Compartment Syndrome. When there is too much pressure in a muscle, the blood flow becomes disrupted, which can cause necrosis (death) of the tissue to the muscles and the nerves that serve the affected muscle. Anterior Compartment Syndrome can be either acute or chronic.
- Acute: This type of compartment syndrome is considered a medical emergency, and is typically caused by a severe traumatic injury. Without treatment it can cause permanent damage to the affected muscles.
- Chronic: This type of compartment syndrome is also called exertional compartment syndrome. It is typically not viewed as a medical emergency, but is still a serious condition. Chronic Anterior Compartment Syndrome is most often caused by “overdoing it” while participating in athletic activities.
The common causes of Anterior Compartment Syndrome are:
- A traumatic impact that causes bleeding within the compartment and subsequent swelling
- A muscle tear that causes bleeding in the compartment
- Over use injuries that eventually lead to swelling common in runners or sports that involve running.
- A badly bruised muscle
- Reestablishment of blood flow after circulation has been blocked for some time
- Anabolic steroid use
- Constriction of the leg, for example by bandages or casts that are too tight
The common symptoms of Anterior Compartment Syndrome are:
- Tenderness of the lower leg muscles, particularly over the tibialis anterior
- Pain that does not respond to typical pain reliving medication
- Excessive swelling
- Skin around the affected area will become hot, stretched, and may appear glossy
- A feeling of paresthesia, tickling or numbness in the skin with no apparent cause
- Pain and difficulty running, walking for extended periods of time, and walking down inclines
The treatment for Anterior Compartment Syndrome will vary based on the severity and pathology of the condition. Acute Anterior Compartment Syndrome is an emergency and patients should be taken to the emergency room as soon as possible. For chronic conditions a physician or Physical Therapist will look for any biomechanical dysfunction in the way your walk to run to correct any problems with simple changes like the use of orthotic devices. The use of modalities, soft tissue massage, stretching and site specific strengthening is also indicated. For severe conditions, surgery to make a hole in the muscle sheath to make room for the swelling may be necessary.
Physical Therapists are professionals, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client. Common interventions in the treatment of Anterior Compartment Syndrome include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage, manual stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the ankle and muscles.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the ankle and effected muscle.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity, and improve movement technique and mechanics (for example, running, jumping, kicking, or stepping) in daily use of the involved lower extremity.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation at the ankle.
- Home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Physical therapy for compartment syndrome must remain conservative at the onset, to avoid making the condition worse and to protect the muscle if surgery was necessary. Emphasis will be on rest, protection, and increasing the blood circulation for healing. Following the surgeon’s timeline and protocol, a program of progressive weight bearing, stretching and strengthening will be initiated.
Procedures that your physician may recommend and perform in addition to physical therapy may include:
- REST and ICE
- The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs)
- Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises
- Surgery to correct underlying pathology or the cause of the compartment syndrome
If repair and treatment are initiated immediately, individuals with Anterior Compartment Syndrome generally do well. Factors that can affect recovery, particularly after a surgical procedure are:
- Age: Older individuals are generally weaker and take longer to heal affecting the functional outcome.
- Strength: Individuals who are strong and in good condition prior to the injury generally do better following surgery.
- Tissue: Tissue quality prior to the surgical repair will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will interfere with the healing process.