UW HEALTH SPORTS REHABILITATION

Rehabilitation Guidelines Following Compartment

Syndrome Release With Open Fasciotomy
Chronic Exertional Compartment
include leg length differences and Syndrome (CECS) is a painful
malalignment of the lower leg. condition of the lower leg that
Other factors may include: muscle affects many runners and other
imbalances or weakness, lack of athletes involved in repetitive
endurance, decreased flexibility, impact activities. The pain
incorrect movement control patterns associated with this condition is
and training intensity or frequency. thought to be abnormal pressure in the compartments of the lower leg. The lower
leg is comprised of four universally described compartments— anterior, lateral, superficial posterior, and deep
posterior (Figure 1). Bone and connective tissue structures define the various compartments in the lower leg. The
compartments have relatively fixed volumes and surround muscles, arteries, veins and nerves.
The incidence of CECS in those with chronic exercise-induced leg pain ranges from 14-27%. 70% of patients with
CECS in the anterior compartment are runners. The condition is nearly evenly split between males and females.
CECS has been reported in the forearm, thigh, hand and foot. However 95% of cases occur in the lower leg.
Symptoms in both legs occur in 85-95% of those affected.
Compartment syndrome occurs when increased pressure impedes blood flow impairing function of tissues within the
lower leg. Unlike acute compartment syndrome, CECS is non-emergent. CECS is a reversible form of abnormally
increased pressure in the compartment that occurs during exercise/exertion of tissues that are noncompliant with
increased muscle volume during exercise. The exact physiological cause of CECS remains unclear but it is thought
to be multi- factorial. Contributors to CECS may include: increased muscle size, connective tissue thickness or
stiffness, decreased blood flow, and microtraumatic injuries.3 Factors inherent to the individual may
Those affected with CECS often complain of dull, aching, or cramping pain localized to the
Figure 1 Lower leg compartments ​compartment affected in the lower extremity at the same duration of time
(minutes) following the initiation of each episode of exercise. Confirmation of the diagnosis is made with needle
compartmental pressure testing at rest and following exercise. If rehabilitation is unsuccessful, surgical management
may be the treatment choice for CECS in the active population. Specifics of surgical decompression vary, but many
include: open
fascial tissue is cut. A partial fasciectomy describes a procedure in which a portion of the connective tissue/fascia is
removed. Surgical treatment can be performed as an outpatient procedure under local anesthesia. A carefully
planned and implemented rehabilitation program is important for a patient to achieve optimal functional outcomes
post- operatively.
fasciotomies or fasciotomies with partial fasciectomies. An open fasciotomy typically involves 1-2 large incisions
where connective/
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Rehabilitation Guidelines Following Compartment Syndrome Release With Open Fasciotomy

PHASE I (surgery to 4 weeks after surgery)

Appointments ​• Rehabilitation appointments begin within 5 days of surgery and continue 1 time
per week for 4
 visits

Rehabilitation Goals ​• Administer Foot and Ankle Ability Measure (FAAM) both activities of daily living
(ADL) and sport
subscale
• Protection of the post-surgical
compartment
• Minimize postoperative swelling; lower extremity circumference measurements at proximal and distal
incisions. Subsequent measurements should not increase more than
0.5cm per session
• Instruction in safe positioning and limb
self-management
• Restore normal knee and ankle range of motion
(ROM)
• Able to lift leg involved leg in all directions in standing without pain or compensation
• Restore ability to control leg in open and closed kinetic chain
during gait
• Normal gait after 3 weeks of using
boot

Precautions ​• Use auxillary crutches for 2 weeks with non-weight bearing (NWB) status. Week
3 walking boot with weight bearing as tolerated (WBAT) and assistive
device as needed
• Dr. Scerpella patients wear a splint for the first 4-7 days post-operatively while using crutches and NWB
• Avoid any activity which causes increased
swelling
• Avoid any friction on new
scar
• Avoid any impact activity including running, jumping or
hopping

Suggested Therapeutic Exercise ​• Passive range of motion (PROM) of ankle starts 5 days post op once
transitioned
to walking
boot
• Quadriceps
sets
• Leg lifts for hip
strength
• Elevation, compression and icing, as needed, for swelling
control
• Active muscle pumping for swelling
control
 • Gentle distal-to-proximal massage to assist with venous return and
swelling

Cardiovascular Exercise ​• Upper body circuit training or upper body ergometer (UGE), as able
• Begin with 5-10 minutes, 1-2 times/day, and progress
as able

Progression Criteria ​• Patient may progress to Phase II after meeting Phase I goals

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621 SCIENCE DRIVE • MADISON, WI 53711 ​■ ​4602 EASTPARK BLVD. • MADISON, WI 53718
Rehabilitation Guidelines Following Compartment Syndrome Release With Open Fasciotomy

PHASE II (begin after meeting Phase I criteria, usually 3-4 weeks after surgery)

Appointments ​• Rehabilitation appointments are 1 time per week on average

Rehabilitation Goals ​• Lower extremity circumference within 1 cm of uninvolved side

• Incision well
healed
• Minimize muscle atrophy and flexibility deficits in involved
compartment
• Single leg stance control with eyes
open
• Full flexibility/mobility of
gastrocnemius/ankle
• Maintain motion and strength of uninvolved muscle groups, as well as cardiovascular endurance
• Perform active or gentle resisted exercises of the hip of the operated lower extremity and resistance
exercises of the upper extremities
• Proper lower extremity control and alignment with no pain during functional double leg squats
• Non-antalgic gait on level surface with full weight bearing and no
assistive device
• 8 point (or greater) improvement on ADL portion of the
baseline FAAM
 Precautions ​• Avoid over-stressing new scar formation by avoiding any friction over tissue (as
per Phase
I)
• Avoid post-activity swelling by limiting prolonged weight bearing activity as appropriate; if swelling occurs,
manage with rest, ice, elevation and compression (as per Phase I)
• Avoid eccentric
loading

Suggested Therapeutic Exercise ​• Scar massage/mobility and

desensitization
• Gentle stretching and nerve mobilizations to tissue in involved
compartment.
• No cross friction massage over
incision
• Progress open kinetic chain ankle strengthening, as
tolerated
• Balance and proprioception exercises: progression of bilateral to unilateral balance activities first on a level, firm
surface, then on a soft/unstable surface
• Gait drills: begin with sagittal plane and progress to frontal and
transverse planes

Cardiovascular Exercise ​• Upper body circuit training, UBE (as per Phase I)
• May begin stationary bike if wound is
healed
• Begin treadmill or track walking if wound is healed; progress time and speed, as able
• May swim or water walk if wound is FULLY
healed

Progression Criteria ​• Patient may progress to Phase III if Phase II goals are met

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621 SCIENCE DRIVE • MADISON, WI 53711 ​■ ​4602 EASTPARK BLVD. • MADISON, WI 53718
Rehabilitation Guidelines Following Compartment Syndrome Release With Open Fasciotomy
PHASE III (begin after meeting Phase II criteria, usually 6-8 weeks after surgery)

Appointments ​• Rehabilitation appointments are once every 7-10 days

Rehabilitation Goals ​• Prevent post-operative recurrence of symptoms with all activity

• Tolerate 15-30 minutes of continuous aerobic activity without the onset of symptoms/pain
• Reinforce self-monitoring and review signs of recurrence and
complications
• Norman (rated 5/5) ankle strength and
pain free
• Proper lower extremity control and alignment and no pain with single leg functional movements
including squats and lunges
• No residual swelling 12-24 hours following all physical activity (including impact exercises)
• No pain 1-2 hours following physical activity (including impact
exercises)

Precautions ​• Avoid friction over scar tissue (as per Phases I and II)
• Avoid post-activity swelling (as per Phases I
and II)
• No strenuous activity until wound is fully
healed
• No running until 8 weeks post-operative (patient should be advised by sports rehabilitation provider or
physician prior to initiation of any running)
• Avoid pain with any exertional
activity

Suggested Therapeutic Exercise ​• Lower extremity stretching and nerve mobilizations as appropriate (as per
Phase II)
• Lower extremity myofascial stretching/foam
rolling
• Progression of lower extremity closed chain functional strengthening including lunges, step-backs and
single leg squats
• Progress heel rise to single
leg
• Progress gait
drills
• Initiate plyometric exercises (with focus on lower extremity control and alignment at hip, knee and ankle) at 7
weeks. If no increased swelling, can initiate agility ladder impact. Then
begin with 2 feet to 2 feet (jumping) progressing from 1 foot to other
(leaping) and then 1 foot to same foot (hopping); and focus on proper
landing/deceleration mechanics
 Cardiovascular Exercise ​• Initiate or progress swimming or water walking if wound is fully healed (as per
Phase
II)
• Progress walking time and speed (as per
Phase II)
• May begin elliptical trainer, as
tolerated
• Light jogging can be initiated at 8 weeks; initially begin on level surface while avoiding hills and speed work;
runners should consider interval training involving walking; progress jog
interval times, incline, and speed as appropriate for return to
sport/activity goals; and for those returning to multi-planar sport, consider
progression of multiplanar activity

Progression Criteria ​• Patient may progress to Phase IV after meeting Phase III goals

4 ​UWSPORTSMEDICINE.ORG
621 SCIENCE DRIVE • MADISON, WI 53711 ​■ ​4602 EASTPARK BLVD. • MADISON, WI 53718
Rehabilitation Guidelines Following Compartment Syndrome Release With Open Fasciotomy

PHASE IV (begin after meeting Phase III criteria, approximately 8-12 weeks after surgery)

Appointments ​• Rehabilitation appointments are 1 time every 2-3 weeks

Rehabilitation Goals ​• Administer ADL and sport subscales on the FAAM prior to discontinuation of
rehabilitati
on
• 9 point (or greater) improvement on the sport subscale portion of the baseline FAAM
• Proper dynamic neuromuscular control and alignment with eccentric and concentric multi-plane activities
(including impact) for return to sport/work, without pain, instability or
swelling
• Within 90% of pain free plantarflexion and dorsiflexion
strength

Precautions ​• Avoid pain with any exertional activity

• Avoid post-activity swelling (as per Phases I, II
and III)

Suggested Therapeutic Exercise ​• Biomechanical assessment of specific sport activity with video analysis as
needed
 (running, biking,
etc.)
• Instruct in proper return to activity progression (incremental running,
biking, etc.)
• Progressive strengthening exercises using higher stability and neuromuscular control with increased loads,
speeds and combined movement patterns; begin with low velocity, single
plane activities and progress to higher velocity, multi-plane activities. Begin
with forward and backward, progress to side-to-side, diagonals and
transverse plane movements
• Integrate movements and positions into exercises that simulate functional activities and initiate sport-specific
training with low-intensity simulated movements

Cardiovascular Exercise ​• Replicate sport/work specific energy demands

Progression Criteria ​• Patient may return to sport/work if they have met the above stated goals and have
approval from the sports rehabilitation provider or
physician
• Precautions to reduce the risk of re-injury when returning to sports or high- demand activities, as
appropriate. For collision/contact sport, may consider protective
padding over area of scar tissue

These rehabilitation guidelines were developed collaboratively by UW Health Sports Rehabilitation and the UW
Health Sports Medicine Physician group.
Updated
2/2018

5 ​UWSPORTSMEDICINE.ORG
621 SCIENCE DRIVE • MADISON, WI 53711 ​■ ​4602 EASTPARK BLVD. • MADISON, WI 53718
Rehabilitation Guidelines Following Compartment Syndrome Release With Open Fasciotomy

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6 ​UWSPORTSMEDICINE.ORG
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Call your health provider immediately if you think you may have a medical emergency. Always seek the advice of your physician or other qualified health provider prior to starting any
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