How Massage Therapists Can Deal With Compartment Syndrome
The cracking sound echoed through the arena.
He went down to block a shot and when the puck hit him, we knew it was bad.
He couldn’t put any weight on one leg. Once he started to get up a teammate helped him to the bench.
We carried him to the treatment room and started stripping and cutting gear off.
He had severe pain around his shin, where he had blocked the shot. We carefully cut away his shin pads and compression socks.
The area was getting swollen and red throughout his shin. We couldn’t feel a pulse in his foot.
I thought it looked bad, but didn’t realize just how bad. Fortunately I was surrounded by people with more experience who are much smarter than me (yes I know, that’s not difficult to find!). They immediately realized that the player had to go to the hospital.
What I thought was a contusion, could actually have been a life threatening emergency if not handled properly. After things calmed down and we got him sent to the hospital, I asked why this was such a big deal. In unison the team Doctor and head Therapist looked at me and said:
“Compartment Syndrome”
Recognizing Increased Compartment Pressure
When this happened I was still a student and honestly a pretty fresh student Massage Therapist.
I was fortunate enough to be able to start volunteering with a hockey team to get some sports experience. I had never heard the term “Compartment Syndrome” (aka: Volkmann’s Ischemia) at that point, or if I had, I didn’t remember it.
Later in Massage school we briefly talked about it, but more from the standpoint of how to treat it post surgery.
When we learned about it in school, we only talked about Compartment Syndrome happening around the shin. Turns out that it can happen in other compartments as well.
I learned that the forearm is another common place for it to happen because the Athletic Therapist used to quiz me on things like that.
Also, did you know that part of Scaphoid doesn’t have vascular supply, so if it gets broken the bone can die? More things he used to quiz me on.
Anyway, in researching for this article, I came to find out that any osteofascial compartment can have a Compartment Syndrome. Areas with deep fascia that is very strong that enclose compartments can be subject to a Compartment Syndrome.
The most common areas are the flexor compartment of the forearm and anterior tibial compartment of the leg. The hand, abdomen, glutes, thigh and upper arm can also be affected.
Acute Compartment Syndrome is a buildup of pressure in one of these compartments due to an injury. It can be both limb threatening and life threatening if not treated properly and in a timely fashion.
As swelling increases in a compartment, blood flow creates more pressure on the structures inside, causing capillaries to collapse and begins to starve the area of oxygen and nutrients. The nerves can hold up for two to four hours and the muscles can only survive for six hours before becoming permanently damaged.
Photo by: Hernan Pinera
What Causes Compartment Syndrome
There are a number of things that can cause Compartment Syndrome to take place. So having a good knowledge of the mechanism of injury is our biggest help in recognizing what’s going on:
- Traumatic injuries.
- Long Bone fractures.
- Muscles that are badly bruised
- Crush injuries.
- Surgical complications (especially with abdominal areas).
- Anabolic steroids.
- Circulation blockage.
If any of these things have happened and you’re not quite sure if this is a medical emergency, better safe than sorry, have the person sent to the hospital.
But there are some tell tale signs to look for that will help make your decision.
Pain is going to be your first indication that something is wrong. But the pain may not seem to be normal compared to the injury.
- Pain may be more severe than what the mechanism of injury would suggest, especially if there is no broken bones.
- The muscle will feel tight and full.
- Burning/tingling sensations around the muscle.
- Area can become numb (definite sign of a medical emergency).
- The skin in the area can start to become almost shiny with the swelling happening underneath.
- Discoloration.
- Loss of distal pulse.
- Pain at rest, which increases with passive stretching of the muscles.
Now that you’ve established that this is a medical emergency, it can’t be treated the same way you would typically think to do it.
If there is a long bone fracture in place you can’t put a splint in place as you normally would for a fracture. Anything restricting the area must be cut away to allow the area to swell. Putting on a splint or bandage is only going to make the Compartment Syndrome worse.
However any movement is going to aggravate the pain, so you will have to manually support the injured limb/area as best you can with the help of others around you.
If there is no fracture to the area then it can be treated as you would other soft tissue injuries.
Immobilize the limb as best you can (without bandaging it) and apply ice to the area. If possible, elevate the limb above the heart to help decrease circulation to the area.
But the most important thing you can do is call 9-1-1 and get the person to more advanced medical care as soon as possible.
Once in the care of the hospital, surgical interventions will take place in order to relieve the pressure. A “fasciotomy” is performed, where surgeons cut the muscle and fascia in order to back off the pressure and hopefully save the surrounding tissues.
Massage Therapy And Compartment Syndrome
I actually wrote this article with some encouragement from a former student (thanks, Chelsea).
I wasn’t sure what topic to write on and she told me Compartment Syndrome would be a good topic because we didn’t learn a lot about it in college.
Holy was she right!
Just in doing research on this one I came to learn more about the different compartments that can be affected. I had no idea that the glutes, thigh and upper arm were also at risk. Nor did I know much about Chronic Compartment Syndrome and how it is an overuse injury from excessive vigorous exercise.
The biggest takeaways are just to remember the mechanisms of injury that can create a Compartment Syndrome. Much like the player in the story at the beginning, blocking that shot caused a bad bruise that led to Compartment Syndrome of the anterior lower leg. Always be careful and check (especially with traumatic injuries) if there is a long bone fracture or circulation impingement.
As you assess the injured area, look for pain that doesn’t seem suitable to the injury, increases with muscle stretching and burning/tingling sensations around the area. If you follow your First Aid protocols and take things step by step, you should have no problem figuring out exactly what is wrong.
Recognizing all of the above could possibly save a limb or a life, the next time you have to treat a Compartment Syndrome.
Now if I could just get that Athletic Therapist to keep quizzing me on things, I might get a little smarter!
Jamie Johnston
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Thanks! Just the refresher info I was looking for on compartment syndrome.
This, in no way, explains how to deal with the injury as a therapist.
It does from the acute injury standpoint for those working in sports and are required to respond on scene.
So does this mean that massage is contraindicated on the chronic stage of compartment syndrome?
I’m honestly not sure, the little bit I’ve seen on chronic compartment syndrome is when it flares up on an athlete post exercise. Perhaps it would be during a flare up?, but best to check with the patients doctor to see.
If truly interested in learning more about impact/treatment/success etc, engage with an Army, Marine or similar Dr or Physio. Sufferers of ‘Chronic (Exertional) Compartment Syndrome’ (ie: myself) are referred to as ‘dime a dozen’ due to such a regularly presenting condition due to over use. I know that I couldn’t walk myself out of the remote area I had run myself into when both calves blew-out at the same time and anyone touching the herniated area would have been taking their life into their own hands.
Andrew, what happened next?
What would your preferred first response have been?
What emergency treatment did you receive?
What ongoing treatment are you receiving?