Acute anterior thigh compartment syndrome in Premiership rugby
- Christopher Swallow and
- Daniel Walton
- School of Sport and Exercise Science, University of Worcester, Worcester, UK
- Correspondence to Christopher Swallow; c.swallow@worc.ac.uk
Abstract
A case study of acute compartment syndrome in the anterior lateral thigh of a professional Rugby Union Flanker with no history of trauma is presented. The report covers all details from initial occurrence; medical history; investigations and surgical treatment; manual stimulus and rehabilitation; return to play; challenges and considerations—resulting in a positive outcome. Resultant observations/recommendations are that investigations should be swift and carefully considered to facilitate surgical intervention via decompressive fasciotomy as required.
Background
Acute compartment syndrome (ACS) is a condition where the intracompartmental pressure within an osseofascial compartment increases and compromises the circulation and viability of the enclosed tissues.1 The resulting swelling and oedema cause cellular anoxia and tissue damage.2 3 If ACS is not readily diagnosed, capillary perfusion exceeds normal rates which may lead to ischaemia, tissue necrosis2 and disruption of regular neural function.
Commonly, ACS aetiology is associated with compartments of the lower leg and forearm (with or without fractures) following direct trauma.2 However, isolated occurrences to the thigh have been noted2 4–7; even though the thigh contains a larger compartment encapsulated with dilative fascia and the anatomy of the hip naturally facilitates tissue expansion.8 Alternatively, instances of ACS have also been induced by exercise, known as exercise-induced compartment syndrome.9 Athletes may be considered at higher risk of ACS as muscular hypertrophy and increased exercise tissue perfusion9 may reduce the available space within compartments.7 10 In combination with the physical demand and contact nature of sport, this may contribute to sports being the second most common cause for ACS developing.10
The Professional Rugby Injury Surveillance Project (PRISP) report published in 2018/2019 noted that match and training injury incidence continues to grow and was documented at 103 per 1000 hours in fixtures and 2.9 per 1000 hours in training within English Premiership rugby.11 The severity of sustained injuries also rose; with severity determined by a greater number of days lost categorisation (more days=more severe). The biggest rise was seen in severe injuries classified within the >84 days category, which have become more diverse.11 All known ACS occurrences within professional rugby have arisen in the previous 2 years, which have included this subject, All Black Prop Atu Moli and 2019 world player of the year Springbok Pieter-Steph du Toit. However, there have been semiprofessional instances prior to this.2 7 12
Current empirical literature investigates ACS from a mechanical13 and clinical perspective, focusing on semiprofessional occurrences. Therefore, with recent recognised occurrences, it is prudent to discuss educatory details in relation to ACS rehabilitation within a professional sports setting, as documented in this report.
Initial case presentation
We introduce a case of a fit and healthy 29-year-old male professional rugby player (Flanker) with a height and weight of 188 cm and 108 kg. After completing an 80 min fixture on the 28 April 2019, the player developed ACS of the right anterior lateral thigh.
The player was clinically examined following the fixture by two club physiotherapists and a club doctor but could not recall an originating occurrence. The player reported symptoms of intramuscular haematoma including confined swelling and palpatory tenderness on the anterior lateral thigh. He also presented minor discomfort with resisted knee extension and full weight bearing but no reduction in range of movement (ROM); no pain on passive ROM; no distal paraesthesia and no pallor. Following assessment, he completed the ‘Protection, Rest, Ice, Compression and Elevation’ injury protocol, was given analgesia and a compression bandage was applied lightly.
The bandage was removed approximately 1.5 hours later due to pain while driving and the player’s symptoms worsened throughout the evening regardless of therapeutic interventions; hence concerns about ACS were formed. Club doctors decided to admit to John Radcliffe Hospital, Oxford due to exquisite pain/pressure/throbbing which was constant while sitting.
Medical history
The athlete sustained a right Rectus Femoris strain during training 1 month before injury which was managed conservatively; no imaging required. He returned to play within 14 days, with a small reduction in bilateral knee flexion. The athlete also suffered a left Semimembranosus/tendinosis strain 6 months prior to ACS occurrence as well as a surgically repaired left Anterior Cruciate Ligament (ACL) injury 2 years prior. Additionally, the athlete suffered bilateral grade 1–2 Biceps Femoris strains and sustained a left Adductor Longus tendon strain, both approximately 36 months preceding injury.
Investigations
Following admission, a decline in status was observed from initial assessment with pain on passive Quadriceps stretching and reduced knee flexion (less than 30°, pain on straight-legged raise and large suprapatellar effusion noted). An X-ray was instructed to exclude fracture and was negative.
Haematology, coagulation and clinical biochemistry status was normal other than reduced Haemoglobin levels (114 and 94 L) and erythrocyte count (3.75 and 3.03). Neovascular status was present, and the athlete had a blood pressure of 174/70 mm Hg. A decision was made to measure the pressure of the anterior compartment with a central venous pressure transducer with unilateral readings of 90 mm Hg in the affected area compared with 18 mm Hg in the uninjured thigh, confirming ACS.
Treatment
An emergency fasciotomy was performed with a lateral incision from the Greater Trochanter to the lateral femoral condyle.14 Further incisions were made to the Intramuscular Septum and Fascia Lata, of which there was no evidence of underlying injury.
Significant muscle haematoma was noted to the Vastus Lateralis and Rectus Femoris including visible fibre damage. Nerve stimulation confirmed viable twitches.15 The Adductor compartment was soft with no clinical evidence of ACS, so no incision was made on the balance of morbidity.
The haematoma was released, circa 50 mL expressed, and 2 L of saline were used to wash the area. No necrosis was noted.
Succeeding the initial procedure, the anterior compartment was dressed and left partially open to evacuate further haematoma, mitigate infection and ensure tissue status; a common procedure with ACS.16 Intravenous antibiotics and analgesia (oral Morphine) were also prescribed alongside elevation. Swelling had reduced to a point where full closure using Vicryl 3.0 via the shoelace method16 could be completed 8 days post injury.
The player was discharged 9 days post injury on 7 May 2019 as seen in figure 1, partially weightbearing with an analgesia prescription of Codeine 60 mg, Ibuprofen 400 mg and Paracetamol 1000 mg; to be taken as required within respective guidelines following a wound and dressings check. In addition, a vague return to play (RTP) timeframe was documented around 12 weeks post surgery.
Right anterior thigh when discharged from hospital.
Manual stimulus and rehabilitation
A 16-week structured RTP protocol was devised by the player’s assigned physiotherapist which included timely progressions, allowing objective multidisciplinary management. This protocol was divided into five phases covering the acute recovery and tissue healing; low loading and tissue capacity; moderate to high load and restoration of strength and a return to sport. The goals of each phase are set out in table 1.
Physiotherapist led return to play protocol
Physiotherapist led return to play protocol
Soft tissue therapist manual stimulus protocol for scar healing
Soft tissue therapist manual stimulus protocol for scar healing
Progression between phases was based on meeting objective data. For example, the athlete was required to achieve full and pain free ROM and equal knee extensor strength, as assessed by handheld and isokinetic dynamometry (IKD). Comparisons were made to previous IKD testing following ACL repair from December 2017, seen in tables 2–4, of which a low left-sided Quadriceps and Hamstrings deficit was noted.
Range of motion and peak torque values
Range of motion and peak torque values
Angles at peak torque
Angles at peak torque
Hamstring and Quadriceps concentric and eccentric ratios
Hamstring and Quadriceps concentric and eccentric ratios
Examples of the athlete’s phase four strength and conditioning led reintegration as well as return to performance physical data can be seen in table 5.
Strength and conditioning led physical performance data and session content
| Session date | Session type | Field time | Total distance | Max velocity | Metres per minute | Velocity distance covered (Zone 5—60%–70%) | Velocity distance covered (Zone 6—70%–80%) | Velocity distance covered (Zone 7—80%–90%) | Velocity distance covered (Zone 8—90%–110%) | Velocity number of efforts (Zone 5—60%–70%) | Velocity number of efforts (Zone 6—70%–80%) | Velocity number of efforts (Zone 7—80%–90%) | Velocity number of efforts (Zone 8—90%–110%) | Total player load |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 08/07/2019 | Rehab Running | 0.016041667 | 2220.34009 | 7.3765 | 96.11723 | 212.7 | 9.95 | 0 | 0 | 11 | 2 | 0 | 0 | 206.88322 |
| 09/07/2019 | Rehab Running | 0.020706019 | 1869.93408 | 8.1845 | 62.71439 | 85.04 | 160.21001 | 250.19 | 1.53 | 10 | 10 | 8 | 1 | 160.291 |
| 12/07/2019 | Rehab Running | 0.027534722 | 2468.67407 | 6.2695 | 62.23705 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 222.13034 |
| 16/07/2019 | Conditioning Session | 0.019664352 | 2765.543 | 6.5695 | 70.55760333 | 139.3 | 20.19 | 0 | 0 | 15 | 2 | 0 | 0 | 291.21146 |
| 22/07/2019 | Rehab Running | 0.031400463 | 2270.47314 | 8.3005 | 50.20172 | 91.55 | 104.32 | 139.48 | 8.19 | 13 | 9 | 8 | 1 | 254.01476 |
| 23/07/2019 | Conditioning Session | 0.046215278 | 4380.44807 | 6.4425 | 65.76426167 | 710.79003 | 5.67 | 0 | 0 | 27 | 2 | 0 | 0 | 469.71783 |
| 25/07/2019 | Conditioning Session | 0.037268519 | 4851.0765 | 7.9805 | 115.8409669 | 120.8 | 81.74 | 58.17 | 0 | 13 | 7 | 3 | 0 | 516.04682 |
| 26/07/2019 | Conditioning Session | 0.059618056 | 5605.92528 | 6.2875 | 80.664475 | 321.66999 | 4 | 0 | 0 | 29 | 1 | 0 | 0 | 572.16231 |
| 30/07/2019 | Rehab Running | 0.027685185 | 2134.19507 | 8.4065 | 53.52213 | 162.32001 | 274.98001 | 467.14999 | 13.59 | 20 | 20 | 17 | 1 | 194.19466 |
| 12/08/2019 | Units | 0.039583333 | 1017.40002 | 3.3285 | 17.91875 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 110.34767 |
| 29/08/2019 | Attack Session | 0.056608796 | 4696.32096 | 6.6555 | 74.07377556 | 175.99 | 29.09 | 0 | 0 | 21 | 4 | 0 | 0 | 456.93374 |
| 12/10/2019 | Matchday | 0.043391204 | 4151.31249 | 6.54491 | 66.94654333 | 200.64 | 20.6 | 0 | 0 | 19 | 3 | 0 | 0 | 473.34623 |
Outcome and follow-up
Following a successful 16-week rehabilitation programme, as discussed above, and a subsequent extended 6-week preseason the athlete returned to competitive play on 28 September 2019. He featured in four consecutive fixtures before sustaining a blow to the lateral thigh during the second half of a fixture. On 12 November 2019, a consultation was organised with a specialist orthopaedic surgeon to consider risk factors and agree an RTP following fluid aspiration and the 6–8 weeks rehabilitation programme. Following his return, the player featured in a further eight fixtures to conclude the campaign; amassing a total of 747 min across the back row: one of the most consistent seasons of his career.
Discussion
Occurrences of ACS within sport are rare.2 10 There is a paucity of examples associated with the anterior thigh2 4–7 and none previously of a professional rugby player which have been published within empirical research. Commonly, previously published cases investigate ACS from a mechanical12 and clinical perspective. However, they do not prepare professional athletes nor educate relevant professionals regarding suitable guidelines related to RTP; rehabilitation; tissue healing; complications/challenges or outcomes.
Empirical research emphasises the importance of early and effective diagnosis associated with ACS. Nevertheless, there appears to be no published consensus regarding this process either with or without fracture.2 15 23 Traditionally, observing indicatory symptoms such as the ‘six P’s’ (pain, pressure, pulselessness, paralysis, paraesthesia and pallor) would confirm diagnosis. However, confirming/verifying ACS can be complicated when considering the rapid progression of symptoms, preceding factors and location and invasiveness of devices measuring intracompartmental pressure.2 As found in this case, some or all observable symptoms can be absent, but ACS be present.24 In addition, research suggests that instances of ACS without fracture are more likely to have delayed diagnosis.15 Therefore, repeated examination and pressure monitoring in suspected cases should be undertaken during hospital admittance.12 15
Intracompartmental pressure thresholds have been commonly accepted as accurate triggers for intervention. Either having an ΔP of between 20 and 30 mm Hg or a difference in compartment pressure and perfusion pressure of greater than 30 mm Hg would be diagnostic indicators for surgical intervention. However, discussion of thresholds in the anterior thigh is not encompassed in the existing research.2
Severe consequences can develop should ACS not be recognised and treated rapidly. Such consequences may include necrosis caused by ischaemia; thereby subjecting the patient to higher risk of infection and potentially fatal complications.15 25 There is also no clear timeframe within literature to determine retrospectively when ACS should have been diagnosed. This is crucial as fasciotomy outcomes can be affected by the intervention timeline,12 26 with research indicating that sequalae was more common in those cases which were missed or delayed. Noted symptoms include ongoing pain; motor weakness and altered tissue sensations including paraesthesia and dysesthesia.27 In this instance, acute tissue alterations were present throughout the stages of tissue healing but have since subsided.
In 13% of fasciotomies,26 two divisions of the Fascia Lata were required to adequately release intracompartmental pressure. In addition, once healed, tissue herniation through the defect Iliotibial band may further reduce the strength of natural protective mechanisms.26 As such, it is reasonable to hypothesise the athlete concerned in this case study may be more prone to repetitive haematomas of his lateral thigh muscle. This is a common match injury detailed within five of the last six PRISP reports and having an occurrence rate of 4.0 per 1000 hours.11 Furthermore, the physical nature of rugby and the performer’s musculoskeletal adaptations suggest that training and/or playing modifications may need to be discussed between performers, medical/performance personnel, and coaches to successfully prevent recurrences. Suitable considerations may include a supportive guard to wear during training and fixtures and limiting the amount of contact training.
Learning points
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Early and effective diagnosis of acute compartment syndrome (ACS) is imperative, especially without fracture when occurrences relate to sport.
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Comprehensive return to play rehabilitation programmes, including input from various support personnel mitigate reinjury and facilitate athletes to return suitably to professional sport following ACS.
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Return to play in professional sport should consider athletes musculoskeletal adaptations, sporting and positional demands as well as sequalae. Long-term performance modifications should be highlighted and discussed.
Ethics statements
Patient consent for publication
Acknowledgments
Harry Sharman provided GPS analysis details relating to athlete physical loading and rehabilitation. Aman Shergill assisted with GPS data table interpretation. Chloë Morris and Ricky Shamji provided language editing support and proofreading.
Footnotes
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Contributors CS and DW: study conception; CS: procured investigational details from the relevant parties; CS conducted the literature search; CS and DW wrote the manuscript; CS has primary responsibility for final content. Both authors reviewed and approved the final manuscript.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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