Foot Compartment Syndrome: Diagnosis and Management

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Review Article Foot Compartment Syndrome: Diagnosis and Management

Abstract Andrew Dodd, MD Although uncommon, foot compartment syndrome (FCS) is a Ian Le, MD, FRCSC distinct clinical entity that typically results from high-energy fractures and crush injuries. In the literature, the reported number of anatomic compartments in the foot has ranged from 3 to 10, and the clinical relevance of these compartments has recently been investigated. Diagnosis of FCS can be challenging because the signs and symptoms are less reliable indicators than those of compartment syndrome in other areas of the body. This may lead to a delay in diagnosis. The role of fasciotomy in management of FCS has been debated, but no high-level evidence exists to guide decision making. Nevertheless, emergent fasciotomy is commonly recommended with the goal of preventing chronic pain and deformity. Surgical intervention may also be necessary for the correction of secondary deformity.

oot compartment syndrome patients with isolated calcaneal frac- F(FCS) is relatively uncommon.1,2 tures and suspected FCS underwent a Although isolated foot injuries result fasciotomy. in FCS in only 2% of cases,3 ortho- Stiffness, chronic disability, defor- paedic surgeons must remain aware mity, and pain are some of the com- of this clinical entity because it can plications associated with untreated result in negative sequelae. FCS ac- FCS2,4-8,10-13,15,16 (Table 1). Necrosis of counts for <5% of limb compart- the intrinsic muscles of the foot can ment syndrome cases.4 lead to ischemic contractures that Typically, FCS is the result of high- may result in claw toe, hammer toe, From the Section of Orthopaedic energy injuries to the foot such as and pes cavus. Neurovascular injury Surgery, University of Calgary, can also cause chronic pain and an Calgary, Alberta, Canada. crush injuries, Lisfranc fracture- dislocations, midfoot and forefoot insensate foot with secondary neuro- Neither of the following authors nor trauma, and calcaneal fractures.2,3,5-14 pathic pathology (eg, chronic ulcer- any immediate family member has 2,5-8,10,12,13,15 received anything of value from or FCS can also develop after a tibial ation, joint destruction). has stock or stock options held in a fracture secondary to the communi- commercial company or institution cation between the deep posterior related directly or indirectly to the subject of this article: Dr. Dodd and compartment of the leg and the cal- Pathophysiology 7 Dr. Le. caneal compartment of the foot. J Am Acad Orthop Surg 2013;21: The most commonly cited etiology is Compartment syndrome is caused by 657-664 a high-energy fracture of the calca- increasing pressure secondary to neus, which results in FCS in up to hemorrhage or edema within an ana- http://dx.doi.org/10.5435/ 3,10,12,15 JAAOS-21-11-657 10% of cases. However, data tomic compartment bound by inelas- from a study by Thakur et al3 sug- tic fibrous tissue. Pressures rise until Copyright 2013 by the American Academy of Orthopaedic Surgeons. gest that this patient population may capillary perfusion pressure is ex- be undertreated because only 1% of ceeded, resulting in ischemia, soft-

November 2013, Vol 21, No 11 657 Foot Compartment Syndrome: Diagnosis and Management

Table 1 ported high rates of sensory distur- the anatomic compartments of the bance and pain at rest in patients foot using high-resolution MRI. The Potential Complications Associated With Untreated Foot treated for lower limb compartment authors found a 10th compartment Compartment Syndrome syndrome. To our knowledge, no in addition to the 9 compartments studies have examined the prevalence described by Manoli and Weber.26 Chronic pain or natural history of neuropathic The 10th compartment is bounded Insensate foot pain in the setting of acute FCS. by the skin and contains the extensor Foot and ankle stiffness digitorum brevis and the extensor Claw toe deformity hallucis brevis in a newly described Hammer toe deformity Anatomy dorsal compartment. Cavus foot deformity In a cadaver study of the myofas- Neuropathic pain Understanding of the myofascial cial compartments of the foot, Ling Neuropathic ulceration compartments of the foot continues and Kumar8 dissected 13 feet and to evolve. Early reports identified found three vertical fibrous septae in four fascial compartments: medial, the hindfoot that, along with the tissue compromise, and subsequent lateral, central, and interosseous.22-24 plantar aponeurosis, form the com- necrosis followed by fibrosis and Myerson25 described methods for partments of the foot (Figure 1). contracture of the compartment’s surgical decompression of these com- These results were substantially dif- contents.2,4 partments. ferent from those of prior studies. Claw toe is the most common se- Manoli and Weber26 performed in- The septae bound compartments quela of FCS and develops when the fusion studies and reported that the identified as medial, intermediate, extrinsic musculature overpowers foot could be divided into nine ana- and lateral. Skin and subcutaneous the weak or scarred intrinsic foot tomic compartments, with the cen- tissue compose the medial border of muscles, whereas cavus deformity is tral compartment divided into super- the medial compartment. As such, the result of scarred and contracted ficial central and deep central (or only the intermediate and lateral plantar structures.2 In the setting of calcaneal) compartments. They also compartments are rigidly bound by intra-articular calcaneal fracture, increased the number of interosseous fascia on all sides. The authors found claw toe develops after the fracture compartments from one to four, add- no evidence of a thick fascial layer hematoma in the deep central com- ing a compartment for the adductor between the previously described su- partment of the foot raises pressures hallucis muscle. New decompression perficial central and deep central and compresses the medial and lat- techniques using multiple incisions (calcaneal) compartments, finding eral plantar neurovascular bun- were recommended based on the in- only a thin and often incomplete dles.12,15 This results in ischemic increased number of compartments.26 filmy layer of tissue instead. They sult to the interosseous muscles and Guyton et al27 questioned the va- concluded that the intermediate and quadratus plantae muscle, which de- lidity of previous gelatin infusion lateral compartments are the only rive their blood supply from the me- studies in defining anatomic com- compartments that need surgical de- dial and lateral plantar arteries. partments and accurately measuring compression and recommended a Acute compartment syndrome can them without image guidance. The single plantar-based surgical ap- also cause ischemic neuropathy and authors performed infusion studies proach to do so. These findings con- chronic neuropathic pain.17 Periph- using CT guidance with simultane- flict with those of Stotts et al29 who eral nerves may undergo irreversible ous compartment pressure monitor- reported on an isolated medial com- damage after 4 to 6 hours of isch- ing, focusing on the distinction be- partment syndrome in the foot that emia.17 Symptoms of neuropathic tween the superficial and deep required surgical decompression, pain include numbness, spontaneous central compartments. They demon- which suggests that the medial com- pain, allodynia, and hyperalgesia.18 strated active fluid communication partment is capable of developing Neuropathic pain is associated with between the two compartments as pressures sufficient to warrant de- poor general health and a decrease in pressures rose above 10 mm Hg. In compression. many quality of life measurements.19 addition, they commented on the dif- Ling and Kumar8 attempted to Management of neuropathic pain is ficulty of inserting an infusion needle qualify the clinical importance of the difficult and the outcomes are gener- into the superficial central compart- foot compartments with regard to ally poor. Multimodal drug therapy ment even with CT guidance. surgical decompression and con- is often necessary.20 Frink et al21 re- Reach et al28 further investigated cluded that only two rigidly bound

658 Journal of the American Academy of Orthopaedic Surgeons Andrew Dodd, MD, and Ian Le, MD, FRCSC

Figure 1 tense swelling. Other authors agree that although the presence of tense swelling is not necessarily diagnostic, it is suggestive of FCS.11-13,31 Substan- tial pain with passive dorsiflexion of the toes is a common physical finding, but it may be present in the absence of compartment syndrome.1,2,11,13,30 Passive dorsiflexion of the toes decreases the volume of the interosseous compartments, which exacerbates pain.2 Sensory changes can be nonspecific, with the most sensitive findings being decreased two-point discrimination and decreased light touch on the plantar aspect of the foot and toes. Decreased pin-prick sensation is a less sensitive finding.1,2,11,13,30,31 Motor strength and the presence or absence of palpable pulses are poor indica- Illustration demonstrating the anatomic structures of the foot, including the tors of a developing compartment 2 three vertical septae (medial, intermediate, and lateral) that form the two syndrome. Serial examinations are major compartments of the foot described by Ling and Kumar.8 (Reproduced helpful to observe changes in pain with permission from Ling ZX, Kumar VP: The myofascial compartments of patterns and sensory findings.2 the foot: A cadaver study. J Bone Joint Surg Br 2008;90[8]:1114-1118.)

Compartment Pressure compartments exist, which may sug- high-energy fractures and severe Monitoring gest that the clinical sequelae of FCS crush injuries to the foot are at risk are a result of injury to the medial of developing FCS and should be FCS can be difficult to diagnose 1,2 and lateral plantar arteries and monitored serially. Open fractures based on physical findings; therefore, nerves that traverse the newly termed and wounds do not result in reliable most authors agree that compart- intermediate compartment. More re- decompression of myofascial com- ment pressure monitoring is the most search is needed to confirm or refute partments and the presence or devel- reliable method for objective diagno- these conclusions, including prospec- opment of compartment syndrome sis of FCS.1,2,4,5,11-13,30,32 Myerson1 rec- tive studies comparing the new de- cannot be ruled out in the setting of ommends liberal use of pressure compression technique described by these injuries.1 monitoring because increased pres- the authors with more aggressive re- Pain associated with FCS has been sures often precede clinical signs and leases of all nine compartments of described as a severe, relentless burn- symptoms. Some authors advocate the foot. ing that encompasses the entire liberal pressure monitoring for any foot.12 Determining whether the pain foot trauma with significant swell- 1,30 Diagnosis and Physical is out of proportion to the injury is ing. Benefits of pressure monitor- Examination difficult given the severe trauma typi- ing include the ability to monitor the cally involved.1 Indications of a de- trend of the compartment pressures Although diagnosis of FCS is estab- veloping FCS include progressive and to document adequate decom- lished clinically and follows the same pain despite immobilization of the pression after fasciotomies.1,13 principles as those for diagnosis of foot and increasing analgesic re- In general, absolute compartment compartment syndrome in other ar- quirement.1,2,13 pressures >30 mm Hg are an indica- eas of the body, the signs and symp- In a series of 12 cases of FCS, Fak- tion for emergent decompres- toms of FCS tend to be less reli- houri and Manoli30 reported that the sion.1,2,4,12,30,32 This indication is sup- able.1,4 Patients who present with most consistent physical finding was ported by the findings of Mittlmeier

November 2013, Vol 21, No 11 659 Foot Compartment Syndrome: Diagnosis and Management

Figure 2

Photographs demonstrating the entry points for compartment pressure monitoring of the medial and calcaneal compartments (A), superﬁcial and deep central compartments (B), and lateral and interosseous compartments (C) based on the speciﬁc needle placement landmarks of Reach et al.33 In panel A, for example, the needle entry point to the calcaneal compartment is approximately 60 mm distal to the most prominent aspect of the medial malleolus.

et al16 in a study of 17 patients with measurement of pressures in particu- made to measure this compartment’s calcaneal fractures, 12 of whom had lar compartments or the number of pressure. central compartment pressures >30 compartments that should be mea- Several authors have described mm Hg. Seven of the 12 patients sured.2,11,12 Myerson1 suggested mea- techniques for measuring the pres- with pressures >30 mm Hg devel- suring the central and interosseous sure of the central compartment. oped ischemic contractures, whereas compartments; however this recom- Myerson and Manoli12 describe a 5 with pressures <30 mm Hg did not mendation was based on the four- method that entails entering the skin develop contractures. Serial measure- compartment model of the foot. perpendicular to the foot at a point ments should be performed in pa- More recently, methods for measure- 3.8 cm distal to the tip of the medial tients with compartment pressures ment of 9 or 10 compartments in the malleolus. No specific depth of pene- between 20 and 30 mm Hg.5,32 Sys- foot have been described.2,4,33 Ling tration is given. In a second method, temic hypotension decreases the tol- and Kumar8 suggest that only the in- the entry is made through the skin erance for increased compartmental termediate and lateral compartments just below the base of the first meta- pressures, and pressures within 10 to require pressure monitoring; these tarsal, passing above the abductor 30 mm Hg of the diastolic blood are the only compartments that the hallucis to a depth of 1.5 in.1 In a pressure are an indication for decom- authors recommended decompress- high-resolution MRI study of the pression.2,12 The calcaneal compart- ing. No evidence currently exists to compartments of the foot, Reach ment of the foot consistently demon- substantiate a recommendation on et al33 describe specific needle place- strates the highest pressures; how many compartments’ pressures ment landmarks (Figure 2). When therefore, this compartment should should be measured because a firm entry to the calcaneal compartment always be monitored.2,11,12 Commer- understanding of the number of clin- is required, they recommend a needle cially available digital compartment ically important compartments in the entry point approximately 60 mm pressure monitors have been used in foot is lacking. The calcaneal (ie, in- distal to the most prominent aspect some studies.30,32 termediate) compartment has con- of the medial malleolus, inserted to a Aside from the importance of mea- sistently demonstrated the highest depth of approximately 24 mm.33 suring the pressure of the compart- compartment pressure readings; The authors describe entry points ment containing the quadratus plan- therefore, it is reasonable to suggest and depths for all 10 foot compart- tae muscle, no consensus exists on that an attempt should always be ments.

660 Journal of the American Academy of Orthopaedic Surgeons Andrew Dodd, MD, and Ian Le, MD, FRCSC

Nonspecific findings on physical treated with fasciotomy, Fakhouri examination contribute to the diffi- Fasciotomy and Manoli30 reported good results. culty in diagnosing FCS. Compart- Decompression was performed When acute FCS is diagnosed, emergent ment pressure monitoring should be through a single medial incision in decompressive fasciotomy should be considered standard for establishing six cases, medial and double dorsal performed to prevent ischemic con- a diagnosis of FCS. Increasing pain incisions in four, and medial plus tracture.1,2,4,5,12,13,25,32 In the setting of and sensory disturbances in a tense, dorsal and lateral incisions in two. swollen foot should prompt mea- lower limb compartment syndrome, Split-thickness skin grafting was nec- surement of compartment pressures. the best clinical results are achieved essary in four cases. At an average when fasciotomy is performed early; follow-up of 21 months, no wound the potential benefits of this proce- infections or wound complications Acute Management dure decrease the longer the decom- were reported. No ischemic contrac- pression is delayed from the time of tures developed; however, eight pa- Initial management of suspected diagnosis.4 The high complication tients had some discomfort and stiff- compartment syndrome entails the rate associated with delayed fasciot- ness in the foot. removal of all restrictive dressings, omy has prompted the suggestion Currently, the three-incision ap- elevation of the extremity to the level that compartment releases should proach is most commonly used for of the heart, and prevention of sys- not be done if diagnosis is delayed decompressive fasciotomy in the temic hypotension as well as serial >8 hours.10,34 However, it is not al- foot2,4,26 (Figure 3). This recommen- examinations and compartment ways possible to know when the ini- dation is based on the nine- pressure monitoring.1,13 If diagnosis tial signs and symptoms of compart- compartment model of the foot de- of FCS is established, urgent decom- ment syndrome arose. scribed by Manoli and Weber.26 A pressive fasciotomies should be con- In a study of 17 patients with medial incision is made starting 4 cm sidered. Although most authors ad- intra-articular calcaneal fractures anterior to the posterior aspect of the vocate the use of acute compartment and 12 with calcaneal compartment heel and 3 cm superior to the plantar releases,1,2,4,5,12,13,25,32 we believe that pressures documented at >30 mm surface of the foot. This incision is this management option remains Hg, Mittlmeier et al16 reported poor carried distally for approximately 6 controversial. To date, no studies outcomes in patients with FCS cm. Through this medial approach, have compared early decompression treated without fasciotomy. Seven of the medial, superficial and deep cen- versus delayed management of FCS, the 12 patients with pressures >30 tral, and lateral compartments are and most recommendations in the mm Hg developed symptomatic released (Figure 3). Two dorsal inci- literature are based on level IV and V plantar contractures, claw toe defor- sions are used, one just medial to the evidence. Complication rates associ- mity, or both. second metatarsal and one just lat- ated with each treatment pathway Myerson32 reviewed the results of eral to the fourth metatarsal to en- are also poorly described in the liter- 14 cases of FCS treated with decom- sure an adequate skin bridge. The ature, making it difficult to compare pressive fasciotomy. In nine cases, interosseous and adductor compart- outcomes. the releases were performed through ments are released through these dor- Early decompression and fasciot- two dorsal incisions; a single medial sal incisions.2,26 omy carries the risk of wound infec- incision was used in five. In three An alternative to the standard tion and the potential need for soft- cases, wounds were closed acutely dorsal incisions was described by tissue coverage. Delayed treatment with split-thickness skin excision Dunbar et al.35 They used a “pie- presumably results in a higher rate of coverage, eight required delayed crusting” technique in which multi- deformity and the sequelae listed in split-thickness skin grafting, and ple stab incisions are made over the Table 1. Chronic pain is a common three (all medial) were closed with intermetatarsal spaces followed by result of high-energy foot trauma delayed primary closure. Only one blunt dissection with a hemostat. and may or may not be related to is- case required a free tissue transfer. At The goal is to reduce the need for chemic insult to the peripheral nerves the latest follow-up, four patients skin grafts, which are often required of the foot. Without high-quality were symptom free and six reported with longer incisions on the dorsum prospective studies, it is difficult to only occasional discomfort in the of the foot. determine whether one treatment foot. Only one patient developed a Ling and Kumar8 recommend a pathway is superior to another; thus, claw toe deformity. plantar-based, single-incision fasciot- further investigation is necessary. In a review of 12 cases of FCS omy. The incision begins 5 cm distal

November 2013, Vol 21, No 11 661 Foot Compartment Syndrome: Diagnosis and Management

32 Figure 3 son reported dorsal skin necrosis in one patient, and one patient required a free gracilis tissue flap for coverage. The medial-based fasciotomy incision places the medial calcaneal branch of the posterior tibial nerve at risk of injury; however, the rate of injury has not been documented.2 For management of acute FCS, we recommend the use of the three- incision approach (one medial incision, two dorsal incisions), with a full decompression of all nine compartments performed. Currently, the nine-compartment model of the foot is the most accepted model described in the literature.26 The “pie-crusting” technique described by Dunbar et al35 may provide similar decompression of the dorsal foot compartments with a decreased need for skin grafting. Additional studies comparing this approach and other ap- proaches, such as that described by Ling and Kumar,8 are needed.

Illustration of the feet demonstrating incision sites for a three-incision fasciotomy. The blue panel indicates the level of the cross-section shown in Delayed Management the inset image. Inset, Cross-section of the medial, superﬁcial central, deep central, and lateral compartments. The superior blue arrow indicates the entrance into the deep central compartment. The inferior blue arrow indicates The natural history of nonsurgically the entrance into the medial, superﬁcial, central, and lateral compartments managed FCS includes potential de- (from medial to lateral). (Courtesy of Herman Johal, MD, Calgary, Alberta, velopment of ischemic contractures, Canada.) neuropathy, deformity, and chronic pain.7,36,37 The goal of management is to the posterior aspect of the heel on split-thickness skin graft coverage 5 to achieve a functional, plantigrade, the non–weight-bearing instep and to 7 days after the fasciotomy is per- and pain-free foot.7,10 Lesser toe de- extends 5 cm distally. The authors formed. The medial incision can of- formities, cavus foot deformity, neu- felt that this single incision could be ten be closed primarily or with de- ropathic pain, and ulceration sec- used to decompress the intermediate layed primary closure.2,30,32 ondary to deformity and sensory and lateral compartments, which Complication rates associated with disturbance are common problems they believe is sufficient to decom- fasciotomy for FCS have been re- that must be addressed.7,10,36,37 press the foot. Data are lacking to ported to be lower than those for un- Claw toe, the most common defor- support the use of this approach in a treated FCS.5 Nevertheless, a paucity mity associated with FCS, develops clinical setting. of data exists in the current literature due to intrinsic muscle weakness and Stabilization or repair of forefoot with regard to complication rates of extrinsic muscle overpull. Interosse- and midfoot fractures at the time of both acute fasciotomy and untreated ous muscle injury, denervation, and decompression is recommended to FCS. In their study of 12 cases of ischemic contracture of the quadra- reduce further soft-tissue trauma. FCS treated with fasciotomy, Fak- tus plantae muscle, which inserts Definitive management of calcaneal houri and Manoli30 documented no onto the flexor digitorum longus ten- fractures should be delayed until infections and no wound complica- don, result in hyperextension of the soft-tissue swelling has receded.2,12,30 tions. In his series of 14 feet with metatarsophalangeal (MTP) joints Dorsal incisions commonly require FCS treated with fasciotomy, Myer- and flexion of the interphalangeal

662 Journal of the American Academy of Orthopaedic Surgeons Andrew Dodd, MD, and Ian Le, MD, FRCSC joints. Less commonly, hammer toe locity studies can help distinguish be- Amputation can serve as a salvage can develop in the setting of ischemic tween ongoing nerve compression option in cases of severe deformity, contracture in the interosseous and and static ischemic nerve injury. In pain, and ulceration. Poor vascular lumbrical muscles.36,37 Cavus defor- cases of nerve compression, neuroly- supply may also play a role in the mity is also common, occurring as a sis of the tibial nerve and its distal choice of amputation over recon- result of fibrosis and contracture of branches may be helpful.36,37 struction.10,36,37 We do not consider the plantar intrinsic muscles and soft Management of claw toe deformity amputation a failure of treatment. tissues.10,36,37 Additional sequelae in- is based on whether the deformity is For a functionless, insensate foot clude neuropathic changes, neuro- flexible or rigid. Flexible deformities with the sequelae of ulceration and pathic pain due to ischemic nerve in- are passively correctable at the inter- infection, amputation is an effective jury, nerve compression symptoms phalangeal and MTP joints, whereas management option. from fibrosis and contracture, and rigid deformities are not. Flexible de- insensate areas of the foot with sub- formities can often be managed with sequent ulcerations.7,36,37 flexor tenotomies and extensor ten- Summary don lengthening. Flexor-to-extensor tendon transfer (Girdlestone-Taylor FCS is an uncommon diagnosis, ac- Management of Sequelae procedure) also can be used, al- counting for <5% of limb compart- 4 Associated With FCS though we infrequently perform this ment syndromes. A high index of sus- procedure. In cases of rigid defor- picion for FCS must be maintained in Nonsurgical mity, which are far more common the setting of a high-energy injury to Nonsurgical management of complica- than flexible deformities, arthrodesis the foot (eg, severe crush injury). Phys- tions associated with FCS is most likely is recommended.7,10,36-38 We recom- ical examination findings may be un- to be successful in patients with mild, mend proximal interphalangeal ar- reliable for diagnosis; therefore, com- flexible deformities with no neuropa- throdesis with MTP arthrotomy or partment pressure monitoring is thy or static neuropathic symp- even a metatarsal shortening osteot- essential. Controversy exists regarding toms.36,37 Toe deformities and cavus omy, if necessary. This is often sup- acute versus delayed management of foot deformity may initially be man- plemented by extensor tendon FCS, and further research on the out- aged with passive mobilization and lengthening and flexor tenotomies. comes of acute fasciotomy versus de- stretching. Shoe wear modification (eg, Initially, cavus deformity associ- layed management is necessary. Acute deep toe box) is also recommended. ated with FCS should be managed management, if chosen, typically con- Custom orthotics may be beneficial for with soft-tissue procedures (eg, plan- sists of emergent decompressive fas- management of cavus foot deformity. tar fascia release, long flexor tendon ciotomies using a three-incision tech- In insensate areas of the foot, appropri- lengthening or release, scar tissue ex- nique. Reconstruction options include ate skin care to avoid pressure ulcers is cision) followed by osteotomies or deformity correction, nerve decompres- also important.7,36,37 selective arthrodesis, if necessary. In sion, and, in severe cases, amputation. cases of cavus and concomitant claw Further research is also needed to de- Surgical toe deformity, extensor digitorum termine the optimal decompression technique to avoid chronic FCS, which In patients with more advanced de- longus tendon transfer to the meta- can result in deformity, dysfunction, formity, progressive neuropathic tarsal necks addresses both deformi- and chronic pain. symptoms, or failed nonsurgical ties. If the correction is inadequate, a treatment, surgical intervention may forefoot or midfoot dorsal closing wedge osteotomy or arthrodesis may be indicated. Soft-tissue procedures, Acknowledgments osteotomies, arthrodesis, and ampu- be considered.36 At our institution, tation are options that should be we proceed with soft-tissue balanc- The authors would like to thank considered depending on clinical cir- ing before any bony procedures. If Herman Johal, MD, for the artwork cumstances. Correction of deformity soft-tissue procedures do not provide he contributed to this publication. and maintenance of the correction adequate correction, we perform are the goals of surgical interven- dorsal closing wedge osteotomy tion.36,37 Progressive neuropathic through the midfoot. In the setting of References symptoms may indicate ongoing degenerative changes, deformity cor- nerve compression in contracted fi- rection with midfoot or hindfoot ar- Evidence-based Medicine: Levels of brotic tissues. Nerve conduction ve- throdesis is most effective. evidence are described in the table of

November 2013, Vol 21, No 11 663 Foot Compartment Syndrome: Diagnosis and Management contents. In this article, references 3 13. Shereff MJ: Compartment syndromes of calcaneal compartment. Foot Ankle the foot. Instr Course Lect 1990;39:127- 1990;10(5):267-275. and 5 are level II studies. References 6, 132. 16, 21, 30, 32, and 34 are level IV 27. Guyton GP, Shearman CM, Saltzman 14. Chambers L, Hame SL, Levine B: Acute studies. References 1, 2, 4, 7, 9-14, CL: The compartments of the foot exertional medial compartment revisited: Rethinking the validity of 17-20, 29, 31, and 35-38 are level V syndrome of the foot after playing cadaver infusion experiments. J Bone basketball. Skeletal Radiol 2011;40(7): Joint Surg Br 2001;83(2):245-249. expert opinion. 931-935. 28. Reach JS Jr, Amrami KK, Felmlee JP, References printed in bold type are 15. 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664 Journal of the American Academy of Orthopaedic Surgeons