TIBIALIS ANTERIOR

Origin:
1. lateral tibial condyle
2. proximal 2/3 of anteriolateral surface of tibia
3. interosseous membrane
4. anterior intermuscular septum & crural fascia
Insertion:
1. medial & plantar surface of base of 1st metatarsal
2. medial & plantar surface of the cuneiform
Action:
1. strongest dorsiflexor
2. inverts & adducts the foot
Blood: anterior tibial artery
Nerve: deep peroneal nerve, L4,5,S1

The Tibialis anterior (Tibialis anticus) is situated on the lateral side of the tibia; it is thick and fleshy above,
tendinous below. It arises from the lateral condyle and upper half or two-thirds of the lateral surface of the body of
the tibia; from the adjoining part of the interosseous membrane; from the deep surface of the fascia; and from the
intermuscular septum between it and the Extensor digitorum longus. The fibers run vertically downward, and end in
a tendon, which is apparent on the anterior surface of the muscle at the lower third of the leg. After passing through
the most medial compartments of the transverse and cruciate crural ligaments, it is inserted into the medial and
under surface of the first cuneiform bone, and the base of the first metatarsal bone. This muscle overlaps the anterior
tibial vessels and deep peroneal nerve in the upper part of the leg.
Actions.The Tibialis anterior and Peronus tertius are the direct flexors of the foot at the ankle-joint; the former
muscle, when acting in conjunction with the Tibialis posterior, raises the medial border of the foot, i. e., inverts the
foot; and the latter, acting with the Peroni brevis and longus, raises the lateral border of the foot, i. e., everts the
foot. The Extensor digitorum longus and Extensor hallucis longus extend the phalanges of the toes, and, continuing
their action, flex the foot upon the leg. Taking their fixed points from below, in the erect posture, all these muscles
serve to fix the bones of the leg in the perpendicular position, and give increased strength to the ankle-joint.

Compartment Syndrome
Compartment syndrome is a general term which can cover a variety of different areas in the body but for
this discussion we're going to focus on the anterior compartment of the lower leg as this is the primary
area that would be affected in runners and triathletes. This article will cover what is typically called
Chronic Compartment Syndrome as it is due to overuse and overtraining.
The Anatomy
Muscles are surrounded by fascia which act a lot like a sausage casing, holding things in place. In certain
areas of the body like the lower leg, bones and fascia combine to form well-defined spaces called
compartments. For example, the tibia (shinbone) is bordered by muscles on both sides. The muscles that
run up the outside (lateral) margin of the tibia make up the anterior compartment of the lower leg. This
anterior compartment is defined by the tibia bone on the inside, the fibula bone to the rear, and the crural
fascia surrounding it all. The crural fascia basically wraps the muscles and the bones of the lower leg.
Now, the tibia and fibula are bones so they don't offer a lot of 'give', therefore on 2 of the 3 sides of this
compartment you have very stiff walls.
By definition, compartment syndrome "occurs in anatomic locations that have unyielding, well defined
osteofascial spaces."1 That makes the anterior compartment of the lower leg the perfect place for potential
problems because it is bordered on 2 sides by bone. Furthermore, in some individuals the fascia that
wraps the muscles is very tight, thereby allowing for little or no expansion, complicating the situation even
more. The muscles of the anterior compartment are involved with dorsiflexion (upward movement) of the
foot and toes. Also present in the anterior compartment are the deep peroneal nerve which supplies the
shin and foot and the anterior tibial artery and vein.
What's Going On
During exercise which involves repetitive dorsi- and plantarflexion of the foot (moving the foot up and
down), such as running, swelling can occur in the muscles of the anterior compartment due to increased
blood flow. This can create an increased pressure in the compartment. If the fascia surrounding the
compartment does not stretch enough (remember, the bony walls of the compartment don't give), the
increased pressure will compress the artery and nerve, thereby causing pain or numbness or tingling in
the distribution of that nerve.
Signs and Symptoms

Pain induced only by athletic activity and often at a specific point in the workout
Pain and tightness in the shin, located along the outside (lateral) edge of the shin bone
Decreased sensation on the top of the foot in the area above the second toe (the big toe is toe
#1)
Weakness may be noted on toe extension and dorsiflexion of the foot
Tingling into the toes may be present
Decreased dorsalis pedis pulse may be noted by a trained practitioner.
Symptoms characteristically disappear quite rapidly once activity ceases

Triathletes may experience symptoms with cycling if they are pulling up on the pedals, or during running.
Symptoms may be more noticeable while trail running because you need to lift the toes more to clear
obstacles such as roots or rocks. I have experienced symptoms during the final miles of the bike in
Ironman races and I've attributed that to the anterior shin muscles getting tired during the swim from
kicking, followed by a long ride which also worked the same muscles. By the end of the bike, I was having
pain and pins and needles in my toes. Thankfully, it did not present a problem once the run started.
What To Do About It
If you have been experiencing symptoms of anterior compartment syndrome your first approach to
treatment should be to stretch the anterior muscles of your shin. This can be done kneeling on the ground
with your toes pointing behind you and the top surface of your foot flat on the ground. Then you can 'sit'
down on your heels and lean your body backwards over your feet. You should feel the front of your shins
stretching.

Massage is also a useful approach to treatment because if the muscles are chronically tight they will be
more prone to swelling.

Shin Splints
The term "shin splints" is the name used for pain at the front of the lower leg. The most common cause is
inflammation of the periosteum (the fibrous bone covering) where muscle fibres are attached to it. Sometimes the
pain of "shin splints" may be due to stress fractures of the tibia, usually two or three inches above the bony part of
the ankle. Shin splints are usually an overuse injury, caused by repeated pounding on hard surfaces that occurs in
sports like running, basketball and indoor football.

What are the symptoms?

Pain and sometimes swelling in the shin area are the typical signs of shin splints. Sometimes you may notice bumps
over the shinbone. If this pain is ongoing, you may be suffering from a stress fracture, so it is important to get your
leg checked out by a GP or a sports injury specialist. It is worth noting that X-rays do not show stress fractures at the
time of injury. However, four weeks later, healing bone may be seen at the site of the fracture.

How should it be treated?

Visit your doctor if you suspect shin splints - it may be that you are suffering from a stress fracture. If it is found that
you do have shin splints, the following treatments options are:

taking time off from the sport or lowering your participation. Normally you will need to rest from the
activity for a significant length of time - often two weeks to two months
taking an anti-inflammatory medication such as ibuprofen
applying ice-packs, warm soaks, or a protective wrap to the skin to reduce swelling. Don't apply ice directly
to the skin, always use an ice pack wrapped in soft material
changing to another, low-impact exercise such as swimming to maintain fitness while the shin splints heal

Compartment syndrome
All muscles are surrounded by a protective sheath and sometimes, due to overtraining or injury, the muscle becomes
too big for its sheath. The resulting increased pressure in the sheath causes pain and swelling around the muscle.
When this happens, it is called compartment syndrome. A common compartment syndrome to occur in footballers is
that of the tibalis anterior - the big muscle on the outside of the shin. This injury is known as anterior compartment
syndrome.
Two types of contusion injury can occur:
Acute anterior compartment syndrome- syndrome is usually caused by a muscle tear or an impact. This causes
bleeding and swelling inside the muscle compartment. The syndrome can also be caused by overuse of the muscle.
Chronic anterior compartment syndrome- may occur as the result of overuse and overdevelopment of the muscle
during training, or the over-expansion of the blood vessels during exercise, which causes the muscle to swell and put
pressure on the surrounding sheath.

What are the symptoms?

Acute injury
Severe pain in the muscle on the outside of the lower leg, which worsens on movement
Weakness when trying to pull the foot upwards against resistance
Swelling and tenderness, particularly after exercise
Pain when the foot and toes are bent downwards
Chronic injury
Pain goes after a short rest but comes back again during exercise
Difficulty in lifting the toes and foot up
Pain when pulling the toes and foot downwards

How should it be treated?

Acute injury
Rest until the pain has gone
Your doctor may prescribe anti-inflammatory medication
Your sports injury specialist may prescribe range-of-motion exercises to rehabilitate the area
You will need to elevate the leg to heart level (but no higher)
Your doctor may measure the pressure of your compartment
You may need an operation called a fasciotomy. This involves cutting open the sheath to allow the muscle
to expand
Chronic injury
Rest until the pain has gone
Your doctor may prescribe non-steroidal anti-inflammatory medication (NSAIDS)
Your sports injury specialist may prescribe range-of-motion exercises to rehabilitate the area
In the longer term, you'll need to modify your activity levels - perhaps cross-training to use different
muscles
You may need special footwear/orthotics
Sports massage may be advised
Occasionally you may need a fasciotomy

Compartment Syndrome: What It Is, What To Look Out For And How
It Is Treated
The muscles in our limbs are split into sections or compartments bound by strong and relatively unyielding
membranes of fibrous tissue (deep fascia), which also attach to bone, in effect wrapping up the different muscle
groups. Every compartment has a blood and nerve supply. Compartment syndrome arises when the pressure inside
this enclosed space increases.
Although legs, feet and arms can all be affected by compartment syndrome, with sports-people you are most likely
to come across it in the lower leg. There are two forms, acute and chronic, and the sports therapy professional needs
to be aware of both. Chronic compartment syndrome is often overlooked as a possible cause of muscle pain;

Chronic compartment syndrome

Going under the name of chronic exertional compartment syndrome (CECS), this overuse condition mainly affects
active, athletic people. It is characterised by muscle pain that repeatedly occurs with vigorous exercise and subsides
with rest. The pain gradually worsens as exercise continues, ultimately restricting performance. There will often also
be swelling and abnormal sensations in the affected limb during and immediately after exercise.
Chronic exertional compartment syndrome (CECS) can affect athletes of any age, including adolescents. Anyone
whose sport involves a lot of running or jumping, or indeed long-distance walking, may be at risk. It usually occurs
in the lower limb, where there are four tightly packed muscle compartments. Of these it is most commonly the
anterior compartment containing the tibialis anterior muscle, that succumbs. The thigh and foot are also vulnerable.
However compartment syndrome is not exclusive to the lower leg. You may come across compartment syndrome in
an arm in a weightlifter, sport climber or motorcyclist; in these instances the flexor forearm compartment is usually
involved.
Muscle weakness of the affected limb may be a feature of these episodes and gradually increasing fullness (literally
denseness, crowding or swelling) is a frequent complaint. Pain increases both on passive stretching and active
contraction. The athlete may also complain of paraesthesia (pins and needles). In general symptoms disappear within
an hour of stopping the activity but recur when exercise resumes.
Thus the clinical features of chronic exertional compartment syndrome (CECS) are only evident immediately after
exercise, and the nature and location of signs and symptoms will depend on the compartment affected.

As with any compartment syndrome, symptoms are the result of the structures within a closed myofascial
compartment being compressed by increased pressure; but beyond this we dont really know what causes Chronic
exertional compartment syndrome (CECS), or what predisposes individuals to it. During exercise, muscle bulk
increases by up to a fifth and it may be this expansion, plus repeated muscle contraction, that increases the
intracompartmental pressure to a level which causes transient ischaemia and deoxygenation.
An alternative explanation is that muscle tissue, damaged by repetitive hard surface exercise, releases protein-bound
ions which increase cell leakage, provoke oedema and so decrease blood flow within the compartment.
Table 1: Lower leg compartments
Compartment
Major nerve supply
Anterior

Deep peroneal

Lateral
Deep posterior
Superficial posterior

Superficial peroneal
Posterior tibial
Sural

Muscles involved
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneal longus, brevis, tertius
Tibialis posterior, long flexors, soleus
Gastrocnemius complex

Diagnosis
Physical examination at rest often provides little helpful information: you are unlikely to see any abnormalities
unless examining immediately postexercise. It is vital to take a careful history, including training regimes. You will
need to establish the specifics of the pattern of pain: how long after the start of exercise and at what intensity it sets
in; how and when it eases off again.
Passive stretching of the involved muscle after exercise may increase your clients pain. Over time you may notice
muscle atrophy, and the client may report tenderness and increased tension in the involved compartment. But be
careful with differential diagnosis: tenderness directly over the tibia is more likely to be a stress fracture, tibialis
posterior tendinitis or periostitis.
Coupled with a careful history, the gold standard for chronic exertional compartment syndrome (CECS) diagnosis is
to measure the pressure within the affected compartment, first at rest, then at several points while exercising, and
finally 5, 10 and 20 minutes after exercise. It is very important that symptoms are elicited during this process and
measurements taken at intervals until the symptoms subside. This is usually an outpatient procedure, requiring the
insertion of a pressure probe into the affected compartment.
Several non-invasive forms of investigation have been assessed for reliability of diagnosis, including MRI,
tomographic imaging and spectroscopy, but all have been shown to have inadequacies.

Treatment
In the first instance a change of training regimes or complete rest may resolve the symptoms, especially if the
diagnosis is made early.
Chronic exertional compartment syndrome (CECS) is usually not identified early, and each successive episode of
inflammation and irritation will cause the compartment fascia to thicken and become fibrotic, making it increasingly
unlikely to be able to return to its normal state of yield, even with rest. Although there have been reports of
successful conservative treatment, massage and physiotherapy alone are rarely satisfactory.

Compartment Syndrome - Anterior (Anterior shin splints)

What is a Anterior compartment syndrome?
Anterior compartment syndromes arise when a muscle becomes too big for the sheath that surrounds it causing pain.
The big muscle on the outside of the shin is called the tibialis anterior and is surrounded by a sheath. This is called
the anterior compartment of the lower leg. Compartment syndromes can be acute or chronic.
Acute anterior compartment syndrome can occur as a result of:
An impact which causes bleeding within the compartment and therefore swelling.
A muscle tear which also causes bleeding.
Over use injury which also causes swelling.
Symptoms of anterior compartment syndrome include:
A sharp pain in the muscle on the outside of the lower leg, usually the result of a direct blow.
Weakness when trying to pull the foot upwards against resistance.
Swelling and tenderness over the tibialis anterior muscle.
Pain when the foot and toes are bent downwards.
What can the athlete do?
Rest, but try to exercise your upper body or cycle if it is not painful.
Apply ice and compression for 20 minutes at a time.
See a sports injury professional who can advise on rehabilitation.
What can a sports injury specialist or doctor do?
Prescribe anti-inflammatory medication e.g. ibuprofen.
Correct any biomechanical disfunction with orthotic devices.
Operate. They could make a small cut or two in the muscle sheath to allow the muscle to expand out.
Chronic anterior compartment syndrome can occur as a result of:
Over use and over developing the muscle through training.
At rest the blood vessels are not at capacity. During exercise these blood vessels fill up much more and
expand putting pressure on the sheath.
The sheath becomes inelastic and unable to expand.
Symptoms include:
Pain which increases during exercise which eventually makes running impossible.
Pain goes after a short rest but comes back again during exercise.
Difficulty in lifting the toes and foot up.
Pain when pulling the toes and foot downwards.
What can the athlete do?
Rest until there is no pain.
Apply sports massage techniques to increase the elasticity of the muscle sheath.
Apply heat and use a heat retainer.
See a sports injury specialist.
What can a sports injury specialist or doctor do?
Prescribe diuretics and anti-inflammatory medication.
Analyse your training methods, running gait and types of shoe to determine any contributory factors.
Use sports massage techniques to stretch the muscle sheath.
Operate. They could make a small cut or two in the muscle sheath to allow the muscle to expand out.