Exertional compartment syndrome can occur in either the superficial posterior compartment, deep posterior compartment, lateral compartment or the anterior compartment of the lower leg. In some cases ECS is seen in multiple compartments in the lower leg. The compartments consist of specific muscles and nerves contained within non-compliant fascial and osseous boundaries⁹. The fascia is a casing of connective tissue that surrounds blood vessels, bones, nerve fibers and muscles holding them in their respective place within the body. Osseous consists of the bone, which is part of the skeletal system. The anterior compartment is associated with specific muscles such as the anterior tibialis muscle, extensor hallucis longus muscle, extensor digitorum longus muscle and the fibularis tertius muscle. The anterior compartment is associated with the deep fibular nerve and the anterior tibial artery as well as vein. These components are affected when pressure levels in the anterior compartment rises, inhibiting prime function of each component it is associated with. The deep posterior compartment is similar to the anterior compartment as it affects muscles, nerves and vasculature. The superficial posterior compartment and the lateral compartment affect both the muscles and nerves, however they do not have an impact on vasculature. The deep posterior compartment affects the specific muscles flexor hallucis longus muscle, flexor digitorum longus muscle, posterior tibialis muscle, and the popliteus muscle. The deep posterior compartment also affects the posterior tibial nerve, the posterior tibial artery and vein and the fibular artery and vein. The superficial posterior compartment affects the gastrocnemius muscle, soleus muscle and the plantaris muscle as well as the sural nerve. The lateral compartment affects the fibularis longus muscle, the fibularis brevis muscle and the superficial fibular peroneal nerve⁹. The entirety of muscles, nerves and vasculature that each of the four compartments affect is what causes this syndrome symptoms to be so intense. The connection of the muscular system and the nervous system highlight why untreated symptoms can be quite dangerous.

The symptoms arise as exercise begins and will intensify during exercise. The time of symptom development is usually five to ten minutes after starting exercise. Symptoms of ECS are throbbing pain, tingling sensation, numbness, swelling and weakness of the affected area. In more severe cases, foot drop is also a common symptom. This is when an individual has difficulty lifting their foot up due to the lack of blood flow and circulation to the foot. These symptoms will subside once exercise is stopped and the individual is at rest. The most affected group of individuals are young athletes involved in high intensity running sports. There are studies that were performed comparing the results of exertional compartment syndrome present in males and females, each study had a slightly different result. In one study 1411 heterogeneous patients who had complaints of lower extremity pain had dynamic intracompartmental pressures performed. Of these 1411 patients within the study, 698 were diagnosed with exertional compartment syndrome. The outcome of this demonstrated a peak prevalence at 20 to 25 years with a higher likelihood in males than females with a bilateral presence¹⁰. Despite this conclusion another study suggested that in the pediatric population that females are at the highest risk of Exertional Compartment Syndrome with a peak age of 16 years old⁹. There has not been extensive research into exertional compartment syndrome, therefore these conflicting conclusions are plausible as new findings are observed in each study due to the lack of detailed knowledge about this syndrome as a whole. An interesting comparison between these studies is that the peak age is above 20 for males, but is lower for females. Another relevant study is not directly related to ECS, but primarily dealt with fascia elasticity. The study concluded that anterior cruciate ligament (ACL) injuries are associated with changes in anterior and posterior cruciate ligament laxity due to changes in body temperature during the menstrual cycle as well as the effect of beta estrogen receptors on the ligaments¹¹. This study also observed plantar fascia in women and men, displaying that estrogen has the same effect on the fascia that it does on the ligaments. This can further support the study concluding the rate of ECS diagnosis is increasing in women with a peak age of 16 because as the menstruation cycle occurs, the elasticity of the fascia changes which can impact ECS as a whole. Women usually get their first period between the ages of 10 and 15, therefore at the age of 16 their menstruation cycles are beginning to become more fixed than irregular. This can contribute to the large diagnosis of ECS in young female athletes during this time period in their lives.

The implementation of manual therapy would be highly effective in releasing fascia tension and restrictiveness, as well as decreasing build up of scar tissue post-surgery. Manual therapy is most often performed by physical therapists due to their education and certification for this specific technique. Manual therapy utilizes specific hands-on techniques without the assistance of devices or machines²⁵. The hands-on technique is performed to improve tissue extensibility, increase range of motion of the joint complex, mobilize soft tissues, reduce soft tissue swelling, and change muscle function. Soft tissue within the body include muscles, nerves and tendons which are highly involved and affected in the diagnosis of ECS. Specific techniques performed through manual therapy include applying pressure in order to relax muscle tension, break up scar tissue and fibrous muscle tissue, reduce inflammation and promote circulation²⁵. In this development of protocol physical therapists primarily target the muscle and connective tissue. Pressure to the tissue can help increase blood flow to decrease pain and promote optimal performance. Manual therapy has been concluded to be highly effective in chronic pain and is used to recover functional capabilities due to the release of tension within specific parts of the body²⁶. Another technique involved with manual therapy is known as massaging. A massage is a hands on technique performed on the body in order to relieve pressure and tightness. A specific type of massage physical therapists are able to perform is known as the lymphatic drainage massage that relieves swelling that results from injury²⁷. In exertional compartment syndrome and especially after fasciotomy, during exertion the muscle becomes visibly swollen. After repetitive exercising the compartment and muscle have a difficult time releasing the buildup of fluid and swelling. Therefore, a lymphatic drainage massage can be used to treat the intense swelling that occurs during exertion. This intense swelling can be painful as the build up will begin to block the movement of joints making it more difficult for the individual to perform functions such as dorsiflexion of the ankle. The shin bones are contracted and the ankle joint is flexed during dorsiflexion. To perform this technique physical therapists will elevate the patient’s lower leg then use their hands to massage from the bottom of the affected compartment to the top. This optimizes lymphatic drainage of the build up of fluid and swelling to reduce symptoms. This is highly effective in providing release of discomfort or pain, and significantly improves performance. The combination of these techniques provides health and optimal performance to the patient, improving their symptoms to be less painful and more manageable when undergoing activity.

A subset of manual therapy can be performed through manual use of specific tools. This technique is defined as scraping, which is a treatment using tools enabling clinicians to efficiently locate and treat soft tissue tightness and injury²⁸. The instruments used in scraping break up adhesion and restore normal tissue mobility to correct musculoskeletal issues which may be causing pain. This technique can be applied onto the affected compartment as well as surrounding muscles depending on the patient’s diagnosis. A soothing cream is applied onto the area where scraping will be performed. The scraping treatment can be uncomfortable depending upon the level of tightness within the muscles and connective tissues. It is common for patients to experience discomfort and redness during the treatment, as well as potential sensitivity the day after²⁸. Although it involves minimal discomfort, scraping is a beneficial technique that significantly improves functionality of the body and improves consistent pain. The methods of manual therapy can significantly reduce the overall pain experienced by patients diagnosed with exertional compartment syndrome.

The implementation of mobility stretching would be beneficial in the reduction of ECS symptoms and provide adequate performance in athletics as well as everyday life. Mobility itself is the combination of flexibility and strength, the sum making up your total movement capacity. It is defined as a fitness attribute and the ability to actively extend ranges of motion²⁹. Mobility stretching has multiple benefits such as joint health and longevity as well as greater movement capacity. The protocol development will focus heavily on ankle mobility and hip flexor mobility. The ankle is the first major joint that absorbs shock when an individual’s foot hits the ground while pursuing activity. If ankle mobility is lacking, the initial shock will be absorbed somewhere further up in the body contributing to various pains in the shins, knee, hip and back³⁰. A different joint will be absorbing this shock which it was not designed to absorb and this is dangerous to the health of the compensating joint. Ankle mobility between both ankles should be relatively the same in order to promote equal distribution of the forces and proper balance. If one ankle has more range of motion, the forces will be unequally distributed throughout the kinetic chain causing the body to be unbalanced and forced to compensate³⁰. Poor ankle mobility will affect an individual’s gait which is how an individual walks, as well as their running economy³¹. In athletes diagnosed with ECS prime ankle mobility is critical due to the importance of the ankle joint involved in running. Poor ankle mobility can cause ECS to intensify and athletes to experience greater pain. Implementing mobility stretching for ankle mobility can significantly improve the symptoms caused by ECS through improvement of gait functionality. To introduce ankle mobility to the patient, important exercises are ankle circles that can be performed by using a foam roller that is placed under the ankle. To begin, the patient slowly rotates their ankle in a clockwise direction ten times and then repeats the motion ten times in the counterclockwise direction. The patient should focus on moving the foot and ankle and not engaging their legs. Another important mobility stretch is known as the ankle flexion plantar stretch. The patient begins by sitting on the floor or a table with one leg bent at the knee, with their heel on the floor, and the other leg straight³². A band will be looped around the front of the patient’s foot, then the patient holds each end of the band with their hands. The foot will be pointed slowly forward and then back releasing collected tension. Another important ankle mobility stretch for ECS is ankle flexion (dorsiflexion) which uses a stretch band to flex the ankle by pulling the toes towards the body. The patient will sit on the floor with their legs stretched out in front of them while also having a secured band around a chair leg or a table leg, and then wrap it around one foot. The patient will slowly point their toes upwards towards herself and then return to the starting position. This will increase the mobility the ankle has when lifting the foot up which will be highly beneficial once swelling begins within the compartment, in order to have optimal mobility of the joint.

Hip flexor mobility is very important because the hip flexors are key muscles in stabilizing the pelvis and spine. They are able to create stability and are used in explosive movements such as running and jumping³³. If the hip flexors are lacking in mobility this causes destabilization throughout the body by putting weight on different parts that are not equipped to handle the weight. The overuse of muscle groups presents through pain arising in certain areas of the body. Therefore, optimal mobility of the hip flexor muscles is very important especially for individuals and athletes with exertional compartment syndrome. Hip flexor weakness influences how the lower body moves by causing an imbalance of forces throughout the lower-leg muscle groups and contributing to compartment syndrome if mobility is lacking³⁴. To increase hip flexor mobility, including a mobility stretch put in the protocol would be effective. This would involve the patient kneeling down on their left knee and putting their right foot in front of them. Their right hip and knee should make a ninety degree angle. Then the patient would put their left hand on their left hip, gradually pushing their hip forward. Their left hip should end up in front of their left knee³⁵. Another mobility stretch to be performed to increase hip flexor mobility is for the patient to lie back down on an elevated surface, whether that is a couch or clinical table, using a strap looped around their foot of the one leg hanging off of the elevated surface. With their hands the patient will begin to slowly bring their foot and leg towards their head. This increases mobility and releases pressure in the area as the leg is “free floating” in the air during the stretch. Mobility stretching is incredibly important, especially for athletes, because it improves joint health allowing full mobility of joints and muscles to perform their functions correctly. Exertional compartment syndrome symptoms can be reduced significantly with increased mobility of the associated muscles and joints, because it alleviates compression and tightness which are factors that cause the symptom to intensify.

The implementation of corrective strength training into the protocol would significantly improve consistent undesirable effects of exertional compartment syndrome for athletes. Corrective strength training is a technique that combines the understanding of anatomy, kinesiology, and biomechanics to address and fix movement compensations and imbalances to improve the overall quality of movement during workouts and in everyday life³⁶. In this protocol the corrective strength training would primarily focus on strengthening the gluteus muscles, core muscles and hamstring muscles as well as and focusing on increase of overall body strength.

The gluteus, more commonly referred to as the “glutes”, consists of three sets of gluteal muscles originating from the pelvis and inserting into the femur³⁷. The three muscles are the gluteus minimus, gluteus medius and the gluteus maximus. The gluteus minimus is the smallest and deepest in the body compared to the other two gluteal muscles. The gluteus minimus is responsible for abduction of the thigh and stabilization of the hips and pelvis during walking, running or standing on one leg. The gluteus medius is the middle-sized muscle sandwiched between the gluteus minimus and the gluteus maximus³⁷. This muscle is responsible for proper pelvis alignment during different movements and for adequate single-leg balancing. The gluteus maximus is the biggest of the gluteal muscles. This is one of the strongest muscles within the body. The gluteus maximus is responsible for stabilizing the pelvis and helping in hip rotation. It also is responsible for abduction and lateral rotation of the hips but also in hip extension, which pulls the leg backwards³⁷. The glutes as a whole are important for most bodily actions such as walking, running, jumping, or simply rotating your hip joints. The strengthening of gluteus muscles is extremely important due to their contribution to improved balance, posture, muscle performance and lower back support which can reduce the risk of sports-related lower body injuries. If the gluteus muscles are lacking in strength the body will find another muscle to take over it’s role, however it is not that other muscle’s designed role so pain to the lower body will occur. The gluteus muscles are able to work individually and together to stabilize the lower half of the body to increase muscle performance, alleviating swelling and overuse of the lower legs. Therefore, exertional compartment syndrome symptoms can be reduced through the increase of gluteus strength which is able to stabilize the pelvis allowing equal weight on each side of the body as well as adequate performance of each muscle, so that one muscle is not compensating for another. Exercises such as squats, lunges and bridges should be introduced to the patient for the protocol. These exercises promote glute activation which stimulates the increase of glute strength. The squat exercise is very important in strengthening your gluteus muscles as well as the tendons, bonds and ligaments within the leg muscles. The squat exercise is performed from standing straight with feet shoulder width apart, and then lowering down as if the patient is going to sit in a chair, then with their heels the patient will push themselves up to strengthen the legs and come back to the upright standing position. The patient’s core should be kept tight, keeping it engaged, and the patient should display adequate form keeping the shoulders straight with the back stabilized. In addition to strengthening the gluteus muscles, it engages multiple joints associated with the quadriceps, hamstrings, and calves. To perform a lunge the patient’s torso must be kept straight with core tight, as they take a step forward lowering towards the floor as the knee is bent. The thigh of the leg that took the step forward will be parallel to the ground and the leg behind it will have the bent knee pointing towards the floor. The position is a split stance, the knee does not touch the floor which keeps the gluteus muscles engaged. The leg position is alternated between how many lunges the patient performs, such as stepping forward with the right foot first then the second lunge is performed with the left foot stepping forward. It is important to keep this form when performing the lunge exercise to make sure the gluteus muscles are engaged as well as minimal pressure on the knee. The bridge exercise is important because it is able to isolate the gluteus muscles. This exercise is performed by the patient lying on their back on a flat surface, their knees bent upward and shoulder width apart. The patient will then push through their heels to raise their hips off the floor until the hips are aligned with the knees and shoulders and then squeeze the glutes at the top for three seconds. The patient will then lower back to the ground to the start position. Each of these exercises are key for glute strengthening. These exercises are also beneficial for improving exertional compartment syndrome symptoms and pain occurrence. In this protocol, the patient would start off with bodyweight exercises and increase the weight every two weeks or upon evaluation every week. The squats and lunges would use lifting weights to increase weight, but the bridges would use bands. The tightness of the bands exerting pressure to hold the legs together increases as the patient lifts their hips and attempts to keep their feet separated shoulder width apart.

The hamstrings consist of a group of three muscles along the back of the thigh of the upper leg. The group of three muscles are the Semitendinous, Semimembranosus, and the Biceps femoris. The Semitendinous muscle is located at the posterior and medial area of the thigh. It also has a long tendon of insertion. This muscle’s function is responsible for the extension of the thigh at the hip, flexion of the leg at the knee and internal rotation of the knee when the knee is flexed³⁸. The Semimembranosus muscle is located on the posteromedial side of the thigh deep to the Semitendinosus muscle and medial to the Biceps femoris. This muscle primarily involves knee flexion, knee internal rotation and hip extension, with a secondary role in providing knee stability³⁹. The Biceps femoris muscle lies in the posterolateral aspect, arising proximally by two “heads” defined as the long head which is superficial and the short head which is deep. The long head of the biceps femoris is responsible for flexing the knee, extending the hip, laterally rotating the lower leg when knee is slightly flexed, assisting in lateral rotation of the thigh when the hip is extended. The short head is responsible for flexing the knee and laterally rotating the lower leg when the knee is slightly flexed⁴⁰. The hamstrings itself are skeletal muscles at the back of the thigh that cross the knee and hip joints. These muscles contribute primarily to functional motion such as walking or jumping. They are also important in athletics as they are a factor helping an athlete achieve speed, power and agility in different sports. Important factors of the hamstrings directly related to exertional compartment syndrome is that they are responsible for executing explosive movements because they shift the load from the knees to the hips⁴¹. In addition, they contribute to the ability to absorb the shock of movements involving high velocity or force, which is abundant in sports. Strong hamstrings are important because if they are weak and tight they will tug on the hip muscles causing them to tip forward, compromising functional movement⁴¹. Therefore, corrective strength training of the hamstrings in athletes with exertional compartment syndrome is important in order to optimize functional ability of the body. To strengthen the hamstrings an exercise that should be implemented into the protocol are single-leg Romanian deadlifts. To perform this exercise the patient will begin standing upright with their knees slightly bent, then raise one foot slightly off the ground extending their leg outwardly behind them. Their core must be kept tight and their back as straight as possible. As their leg is extending outward behind them, their torso will lower until their chest is parallel to the ground. Once, reaching this position be sure the patient squeezes their hamstrings and glutes together as they return to the original position. Another important exercise to strengthen the hamstring is the double leg Romanian deadlift. To perform this exercise the patient will stand upright with a dumbbell of light weight in each hand. The patient’s feet should be shoulder width apart. The patient will begin to move their hips backwards and bend forward from their waist, keeping the dumbbells close to their legs and lowering to the floor. During this exercise it is important that the patient keeps their back straight to avoid injury. Once the dumbbells reach the bottom of the shin height, the patient will begin to straighten their legs while pushing with their heel back to the upright position. In the development of this protocol it is very important to include the hamstrings within the corrective strengthening section, due to their primary roles being involved in functionality of the body. In exertional compartment syndrome there is a lot of pressure on the lower leg, therefore strengthening the hamstrings and being sure the form is correct when doing so will be able to work towards alleviating any extra pressure put onto the lower legs.

The core is usually thought to describe one area of the body, however there are multiple major muscles within the core. The core includes five main muscles such as the pyramidalis, rectus abdominis, external obliques, internal obliques and the transverse abdominis⁴². The two vertical muscles are the pyramidalis and the rectus abdominis. The pyramidalis helps maintain internal pressure in the abdomen and it is small with the shape of a triangle. This muscle is located low in the pelvis area. The rectus abdominis is a pair of muscles going down the middle of the abdomen, stretching from the ribs to the front of the pelvis. This muscle keeps the body stable during any movements. In addition to these two vertical muscles the core consists of three flat muscles that are stacked on top of each other. The external obliques are the external pair of muscles located on each side of the rectus abdominis. These muscles are the largest of the flat muscles and are located underneath the internal obliques and the transversus abdominis. They run from the sides of the body into the middle allowing the torso to twist side to side⁴². The internal obliques are located on top of the external obliques inside of the hip bone. They are also located on the side of the rectus abdominis stretching from the side into the middle. These muscles aid the external obliques in rotation of the torso. The transversus abdominis is located deepest into the body of the flat muscles. Their function is to stabilize the torso and maintain internal abdominal pressure⁴². The core muscles as a whole work to improve coordination, balance and technical skills within athletics. As stated previously with each individual muscle they are able to increase stabilization in the torso and the body as a whole to reduce the risk of injuries. Strong core muscles increase better posture and balance which causes release of pressure on the lower half of the body which is critical to do for exertional compartment syndrome. In addition, if the core muscles are weak an athlete is more susceptible to increased fatigue causing decreased endurance and increase of injuries⁴³. For the implementation of the protocol the patient would be instructed to perform exercises to strengthen and engage the core. An important exercise to increase core strength is a plank. A plank is performed by lying down on the stomach on a flat surface, usually with a mat on the floor. The patient will lift the arms up to be leaning on their lower arm, in which the elbow to the hand will be lying on the floor. The patient will lean on their toes lifting their body off of the mat, with their lower arm still lying flat on the mat. The patient will hold this position for thirty seconds until further progression. Another important exercise is the side plank. Starting on the right side first, lying on the floor with a mat and with the patient’s legs stacked on top of each other. The patient’s right arm will be bent with the lower half of their arm making a ninety degree angle with the rest of their body. The patient will then push up with their right foot and lower right arm to lift their hips off of the mat, therefore the weight is held up by the lower right arm and the right foot. This position will be held for thirty seconds until further progression. Once completed on the right side the patient will switch to the left side, performing the same technique as the right side just with the opposite arm and leg. The exercises are very effective in targeting the entire core, being sure to strengthen each muscle. In workouts for athletes it is often that isolated core exercises will be neglected to focus on full body strength training, which is thought to make the athlete stronger and better. However, neglecting specific isolating core exercise has detrimental effects as the entire body begins to become unbalanced. Therefore, implementing this into the protocol for ECS would be highly beneficial for the athletes affected, as their body will become better balanced and stabilized, relieving and additional stress compensations to the lower half of the body.

The development of a protocol for Exertional compartment syndrome is immensely important, because there is no specific treatment method in order to improve body functionality before or after surgical treatment. Most athletes and patients are treated for the symptoms exertional compartment syndrome produces. The syndrome is not dealt with as a whole. A factor that is not commonly recognized by physicians and physical therapists, due to lack of research, is that the anatomy of the body is completely shifted as exertional compartment syndrome continues to develop. The body begins to compensate in different ways due to the lower leg losing proper functionality. Fasciotomy is performed to correct the direct cause of the syndrome once it becomes incredibly restrictive to everyday activities. However, the anatomy as a whole is still affected by the effects of the syndrome. Therefore, developing a specific protocol combining manual therapy, mobility stretching and corrective strength training can alleviate painful effects induced by exertional compartment syndrome as well as allow optimal return to activities such as sports and intense exercising. The development of this specific protocol can improve everyday life functionality and overall health of the anatomical aspects of the patient.