Clinical synthesis based on the historical criteria of Pedowitz (AJSM 1990), the two 2012 systematic reviews that challenged their validity (Roberts, Aweid), the diagnostic series of Roscoe (AJSM 2015), the largest series of measurements published to date (Lindorsson, 864 patients) and the review article in the British Medical Bulletin 2026: 55 references checked one by one on PubMed and cross-checked on CrossRef.

What are the fundamentals to know about chronic exertional compartment syndrome?

A muscle compartment is a volume closed off by bone and fascia. During exercise, the working muscle swells. If the container does not yield, pressure rises. That is the theory, it fits in three sentences, and it is probably incomplete: this chapter sets out the anatomy and the population figures, then says plainly what is not known.

Four compartments, only one usually implicated

The leg is divided into four osteofascial compartments, bounded by the tibia, the fibula, the interosseous membrane and intermuscular septa. Each contains its own muscles and its own nerve, and it is that nerve which explains the sensory signs when they are present.

• Anterior compartment : tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis tertius. Deep fibular nerve. It is the stiffest compartment, wedged between the tibia, the fibula and the interosseous membrane.
• Lateral compartment : fibularis longus and brevis. Superficial fibular nerve.
• Superficial posterior compartment : gastrocnemius, soleus, plantaris. Sural nerve (sensory).
• Deep posterior compartment : tibialis posterior, flexor digitorum longus, flexor hallucis longus, popliteus. Tibial nerve.

Involvement is not evenly distributed, and the distribution is known with unusual precision thanks to Campano's systematic review, which pooled 24 surgical series representing 1,596 patients.

Two practical lessons follow. First, if only one compartment were to be explored, it would be the anterior one: it accounts for half of all involvement, and it is also the one whose clinical picture is the most characteristic, with the slapping foot and the loss of dorsiflexion at the end of a run. Second, the deep posterior compartment is the hardest: it is deep, measuring it is technically delicate, and it is the one whose presentation most resembles medial tibial stress syndrome, since it hurts on the same side of the tibia.

Who is affected, and how often

The incidence in the general population is poorly known. The review article in Current Sports Medicine Reports puts forward an estimate of roughly 1 case per 2,000 people per year (Velasco and Leggit, 2020, PMID 32925373). This figure circulates widely and deserves to be handled with caution: it is an estimate quoted in a review article, not the result of a population survey.

The solid figures come from closed populations, where the denominator is known. Among 294 elite cross-country skiers on the French national teams followed from 1994 to 2014, eighteen confirmed cases were identified, giving a prevalence of 6.1 % and an incidence of 13 per 1,000 skier-years, higher in biathletes, with skate skiing and roller skiing as the main triggering conditions (Calvelli, Int J Sports Med 2020, PMID 31935775). The military is the other major source: in Campano's review, 54% of operated patients were service members and 29% were athletes, 83% of them recreational.

These four figures deserve to be read together, because they overturn three received ideas at once.

This is not a man's disease. The systematic review devoted to sex differences pooled 24 studies providing a breakdown: 51% of diagnosed patients were women (Rothman, Phys Sportsmed 2024, PMID 36698053). The contrast with the 70% of men in Campano's surgical series is not a contradiction, it is a recruitment effect: operative series are dominated by military cohorts, which are themselves mostly male. In outpatient practice, the split is even. The same review also finds an unfavourable signal in women: male athletes returned to their sport after surgery more often than female athletes.

This is not an adolescent's disease only. Of 698 patients at a Dutch referral centre, 98 were 50 or older, that is one in seven. These older patients were less sporty (62% did nothing or only walked), had more comorbidities, and above all presented far more often with unilateral symptoms (45% versus 22%). In them, the anterior compartment clearly dominated (82% versus 59%) (de Bruijn, OJSM 2018, PMID 29531960).

It is most often bilateral. Among 155 patients aged 18 or under operated on at a paediatric centre, 131 (85%) had bilateral symptoms requiring release on both sides, 88% were girls, and the main sport was running (25%), football (23%) or field hockey (12%) (Beck, AJSM 2016, PMID 27365374). Strictly unilateral pain in an adolescent should therefore prompt closer attention to other causes.

What we think we know about the pathophysiology, and what we do know

The standard account is a loop: exercise makes the muscle swell, the inextensible compartment does not adapt, pressure rises, capillary perfusion falls, the muscle becomes ischaemic, pain appears, and stopping the effort reverses the process. It is coherent, it is taught everywhere, and at least two findings suggest it should not be taken for granted.

The fascia is not abnormal. Dahl took fascial biopsies of tibialis anterior from six healthy subjects, eleven affected patients and ten affected patients who also had diabetes, then measured stiffness on a tensile testing machine and thickness under the microscope. Neither weight-normalised stiffness nor thickness differed between the groups. The authors conclude that “structural and mechanical properties are unlikely to explain the syndrome” and that the cause must be sought elsewhere (Clin Orthop Relat Res 2011, PMID 21948310). That is an awkward finding for a treatment that consists precisely of opening this fascia.

Ischaemia has not been demonstrated. The 2026 review article explicitly places aetiology among the open questions, in terms that leave no room for interpretation: future research “should address the central question of the aetiology of the symptoms”, the syndrome having “traditionally been seen as a perfusion-related disorder, which remains unproven” (Vogels and Zimmermann, PMID 42478572).

An alternative hypothesis has been explored on a large scale: functional venous obstruction. In 284 patients with exertional leg pain investigated by provocative CT angiography, functional venous compression reproducing the symptoms was found in 91.5% of them, and targeted treatment with botulinum toxin reduced or abolished the symptoms in 79.9% at four weeks (McGinley, Clin J Sport Med 2022, PMID 34009799). The design is a single-centre retrospective series without a control group, the authors' conclusion (“the syndrome results from venous obstruction”) goes beyond what that design allows, and the result has not been independently replicated. It deserves to be known, not to be taught as the mechanism.

One clinical observation points to mechanics rather than to simple ischaemia: patients change the way they walk before they feel any pain. Roscoe measured plantar pressures in 20 affected service members and 20 controls, walking and marching in step, before symptoms appeared. Patients brought the foot flat sooner after heel strike, with an area under the ROC curve of 0.75 to 0.77, which the authors call “fair predictive validity”. Their interpretation is a mechanical disadvantage of tibialis anterior (Gait Posture 2018, PMID 29702369). This result matters for what follows: if running mechanics come first, changing them can be a treatment, and not merely an accommodation.

How do you recognise the picture, once you know it?

This is the chapter that makes this article useful. Chronic exertional compartment syndrome is extremely recognisable, provided you have the exact shape of the account in mind. What follows is that shape, broken down into its elements, each with what is known about it.

Five cardinal symptoms, and an order of importance

The literature agrees on five symptoms: pain, a sense of tightness, cramping, weakness and sensory disturbance, appearing on exertion and disappearing on stopping (Ding, J Vasc Surg 2020, PMID 32473344 ; Dunn and Waterman, Clin Sports Med 2014, PMID 25280617). They do not carry the same weight. In de Bruijn's cohort of 698 patients, pain was present in 94 to 96% of patients depending on the age band, and a sense of tightness in 57 to 62% (PMID 29531960). Pain and tightness are therefore the core; the other three are additional arguments when they are there, and their absence rules nothing out.

The word patients use spontaneously deserves attention. “It squeezes”, “it swells”, “it feels as if the skin is going to split”, “it burns” come up more often than “it hurts”. This quality of tightness, distinct from a pinpoint pain, is one of the features that points away from bone straight away.

The reproducible exertion threshold: the most discriminating feature

The patient is able to say at what moment it happens, and that moment does not move. Ten minutes, three kilometres, the second climb of the route. This regularity is no mere comfort detail: it is what distinguishes compartment pain from bone pain, which sets in more gradually and depends above all on the cumulative load of the preceding weeks.

The only direct measurement of this delay comes from an unexpected comparison. Seeking to help vascular surgeons avoid confusing compartment syndrome with arterial disease in patients over 50, de Bruijn compared 43 patients with compartment syndrome and 41 newly diagnosed patients with peripheral arterial disease. The time to symptom onset during exercise was 15 minutes in the compartment group versus 4 minutes in the arterial group (p < 0.01) (J Vasc Surg 2021, PMID 33278541).

What eases with rest, and what does not always ease

The third element of the account is recovery: the patient stops, walks for a few minutes, and it passes. Then they set off again, and it comes back at the same place. This rapid reversibility is what gives the picture its name and separates it from an established tissue lesion.

One should nevertheless resist turning this into an absolute criterion, because the only study that measured it head-on says something else. In de Bruijn's series, stopping the effort relieved all 41 patients with arterial disease completely, without exception, but 73% of patients with compartment syndrome kept some residual discomfort. This result inverts the usual use of the criterion: it is not the disappearance that marks out compartment syndrome, it is the persistence of discomfort after stopping that distinguished it best from arterial disease, with a specificity of 100% and a positive predictive value of 100% in this comparison. Pain persisting beyond 4.5 minutes after stopping had the best sensitivity (95%), for a specificity of 54%.

Two cautions before generalising. First, the population is unusual: patients aged 50 and over on both sides, compared with arterial patients whose median age was 72. Second, the comparison does not set compartment syndrome against medial tibial stress syndrome or stress fracture, but against arterial disease. What the study establishes solidly is that relief which is immediate and complete on stopping points more towards vascular claudication than towards compartment syndrome. What it does not establish is a threshold applicable to the young runner.

Paraesthesia and the foot that gives way

When the affected compartment contains a motor nerve, the story may include a transient neurological component. The most characteristic one involves the anterior compartment and the deep fibular nerve: numbness of the first intermetatarsal space, and above all a foot that slaps at the end of a run, because tibialis anterior no longer controls the lowering of the forefoot. Some patients describe tripping on the edge of a kerb in the last minutes of the outing, never at the start.

The frequency of paraesthesia has been measured in a surgical cohort of 78 legs: 33 patients out of 78, that is 42.3%, reported it (Shankar, Sports Health 2024, PMID 36951383). So it is neither rare nor constant. And this symptom carries a prognostic value that matters for what follows: in that same series, the presence of paraesthesia predicted poorer results after fasciotomy, with more severe rest pain and pain during daily activity, a smaller gain in activity and a lower probability of return to sport. The least favourable subgroup was the one with paraesthesia in the tibial nerve territory.

In other words, a patient who describes pins and needles gives both a diagnostic argument and a prognostic signal. That deserves to be recorded in the notes before, and not after, the surgical discussion.

The one examination sign that has proved itself: muscle herniation

Pedowitz compared, across 131 records, patients whose diagnosis was confirmed by pressure measurement with those in whom it was refuted. The conclusion is striking and has never been contradicted since: the only significant difference found on history and physical examination was the presence of muscle herniations, in 45.9% of affected patients versus 12.9% of the others (AJSM 1990, PMID 2301689).

It is a small subcutaneous bulge, often on the anterolateral aspect of the middle or distal third of the leg, at the point where a perforating branch leaves the fascia, best seen on contraction or after exercise. It is painless in most cases. Looking for it means examining the leg standing, with the dorsiflexors contracting, and not just palpating the patient lying down.

Diagnostic delay, and why it is the rule

In Beck's paediatric series, symptoms had been going on for more than a year in 63% of the 155 patients at the time of surgery (PMID 27365374). This delay is not an accident: it is produced by the very structure of the picture. The patient comes in for a pain they do not have at the time of the consultation, to a practitioner who examines them at rest and finds nothing, with normal plain imaging. Everyone logically concludes that it is something benign, and the most available conclusion is medial tibial stress syndrome.

The practical consequence is simple: it is the history that must be systematic, not the examination. Three questions are enough to point the way:

1. “At what point in the session, exactly?” A precise and stable answer points to the compartment.
2. “What do you have to do to make it stop?” Having to stop, and that being enough within a few minutes, points to the compartment. Having to wait several days points to bone.
3. “Does it come back in the same place if you set off again?” A return at the same threshold, within the same session, is highly suggestive.

Why is the examination at rest normal, and how do you make the leg speak?

This is the central trap of this condition: the patient comes to see you in exactly the state in which they have nothing. A normal examination is not an argument against the diagnosis, it is an expected consequence of the mechanism. The answer comes down to one principle: do not examine the leg at rest, but after putting it in difficulty.

A normal resting examination is the rule, not the exception

Between two episodes there is nothing to find, and there should be nothing to find. Range of motion is free, manually tested strength is normal, palpation of the muscle belly is painless, neurodynamic tension tests are negative. The only thing that can be picked up when cold is the muscle hernia described above, present in fewer than one patient in two.

This normality has a documented perverse effect: it steers towards a diagnosis that does give something to palpate. Medial tibial stress syndrome offers reproducible pain on pressure over the posteromedial border of the tibia, over several centimetres. The clinician who palpates finds something, and what they find becomes the diagnosis. Yet nothing forces the two to exclude each other: some of the patients managed in a military centre for compartment syndrome also had associated medial tibial stress syndrome, and their conservative treatment gave the same results as that of patients without it (Zimmermann, BMJ Open Sport Exerc Med 2019, PMID 31191976).

The symptom provocation test

The 2026 review article places the provocation test among the few consensus elements: the history “remains central, supported by a positive symptom provocation test” (Vogels and Zimmermann, PMID 42478572). The principle is to reproduce, in the clinic, the effort that triggers the symptoms, then to examine immediately.

In practice, this is done without any special equipment:

• Reproduce the triggering effort, not a generic one. If the patient hurts while running, then they have to run. A treadmill, an outdoor loop, or failing that a sequence of heel raises and resisted dorsiflexion until the symptom is reproduced.
• Go all the way to the threshold. A test stopped before symptoms appear proves nothing. This is the commonest error: the test is interrupted at the first discomfort, whereas the picture reveals itself at the moment the patient says “there, that's it”.
• Examine immediately afterwards. Within the minute, not after undressing and taking the blood pressure.

What to look for in that short window:

1. A compartment that feels tense on comparative palpation, sometimes with a clear difference between the two legs or between two compartments of the same leg.
2. A muscle hernia that becomes visible when it was not visible when cold.
3. A weakness of dorsiflexion, tested manually and functionally (heel walking). Its presence, transient, points strongly to the anterior compartment.
4. Reduced sensation over the dorsum of the foot or the first web space, compared with the opposite side.
5. Reproduction of the patient's own symptom, which is the most important point: they must recognise their pain, not describe a new one.

What the clinical approach cannot do

It is worth being clear about the limits. No clinical test for chronic exertional compartment syndrome has a published sensitivity or specificity. The systematic review devoted to non-invasive diagnostic tools reviewed 25 studies covering 1,257 participants and retained, among the modalities assessed, no tool validated as a substitute for pressure measurement, including a clinical prediction model, present in a single study (van der Kraats, OJSM 2023, PMID 36655016).

The physiotherapist's role is therefore not to make a definitive diagnosis, but to do three things that nobody else will do as well:

• Recognise the pattern in an account that would otherwise be filed as medial tibial stress syndrome.
• Actively rule out the competitors, in particular stress fracture, which allows no delay.
• Start conservative treatment, whose best-documented modality falls squarely within their competence, and which does not require a pressure to have been measured before it can begin. This point is established: in 108 service members, the anterior compartment pressure value was not associated with the outcome of the conservative programme, and the authors explicitly conclude that measurement “can safely be deferred” (Vogels, Arch Rehabil Res Clin Transl 2022, PMID 35282146).

Medial tibial stress syndrome, stress fracture or compartment syndrome: how do you decide?

The two diagnoses made instead are medial tibial stress syndrome and stress fracture. That is no accident: these are the three commonest causes of leg pain in the runner, they affect the same population, and two of them give something to palpate. This chapter separates them on criteria usable in the clinic, then widens out to the rest of the differential diagnosis.

The runner's trio, line by line

Three questions are enough to separate the three entities in the great majority of cases: where, when within the session, and what palpation gives.

Where. Medial tibial stress syndrome hurts over the bone, precisely over the posteromedial border of the tibia, in its distal or middle third. A stress fracture hurts over the bone as well, but at a point, not along a line. Compartment syndrome hurts inside the muscle, at the front or on the outer side in half of cases, in a location the patient points out with the flat of the hand and not with a fingertip.

When. Medial tibial stress syndrome is often present from the warm-up, may ease during the run, and comes back at the end or afterwards. A stress fracture worsens as the session goes on and above all as the weeks go by, with a tolerated load that falls from outing to outing. Compartment syndrome is silent up to a threshold, then becomes intolerable within a few minutes, and that threshold does not deteriorate session after session.

Palpation. This is the most workable criterion. Medial tibial stress syndrome gives reproducible pain on pressure over several centimetres of tibial border. A stress fracture gives pain that is exquisite and focal, over two or three centimetres at most, often with pain on hopping on one leg. Compartment syndrome gives nothing at all at rest.

Sources of the figures quoted in the table: Campano 2016 (PMID 27020462) for the distribution of compartments; de Bruijn 2021 (PMID 33278541) for the delays and the relief on stopping; Pedowitz 1990 (PMID 2301689) for muscle herniations; Ruohola 2006 (PMID 16523142) for the topography of bony lesions. The other rows draw on the review articles on exertional leg pain by Rajasekaran and Finnoff (PMID 26616179) and Burrus (PMID 25157051); the thresholds they contain are clinical landmarks, with no published quantified diagnostic value.

An order of exclusion, not a list

The differential diagnosis does not unfold on a flat plane: some hypotheses cost more than others if they are missed. Stress fracture therefore comes first, not because it is the most likely, but because continuing to run on it can turn a crack into a complete fracture. The order that follows reflects that cost.

Two diagnoses can coexist, and often do

The tree above has a flaw that every tree shares: it suggests you stop at the first positive answer. Two findings argue against doing so.

First, medial tibial stress syndrome and compartment syndrome live side by side. In Zimmermann's military cohort, the 75 patients treated were split into two groups by design: those with an anterior compartment syndrome on positive pressures, and those who had in addition an associated medial tibial stress syndrome. Notable for practice: the outcome of conservative treatment did not differ between the two groups (PMID 31191976). Finding a medial tibial stress syndrome therefore excuses neither looking for a compartment syndrome nor treating running mechanics.

Second, compartment syndrome and popliteal entrapment can coexist. A college football player followed for two years for bilateral exertional calf pain had been diagnosed with compartment syndrome on pressure measurements; persisting symptoms and a suggestive examination led to MR angiography, which showed severe arterial spasm on plantarflexion on both sides, establishing an associated type VI popliteal artery entrapment syndrome. She underwent a popliteal release. The authors draw the lesson that counts: “the successful diagnosis of one condition does not exclude the possibility of a second, independent pathology” (Bellomo, Diagnostics 2024, PMID 39202313).

What each hypothesis weighs in a running population

Two figures give the order of magnitude. Of 154 consecutive service members referred for anterior leg pain and investigated by MRI over five years, 86 (56%) had a bone stress injury, 99% of which were in the tibia and 57% in its distal third (Ruohola, Clin Orthop Relat Res 2006, PMID 16523142). In other words, in a service member in training whose anterior leg pain warrants an MRI, more than half the time the answer is bone.

On the other side, medial tibial stress syndrome is commonplace: the most recent scoping review reports prevalences of up to 69.5% in recreational marathon runners in an Indian study, and incidences of up to 35.7 % in a German study, with considerable heterogeneity between populations (Saad, Cureus 2025, PMID 40171337). These extreme values say above all this: medial tibial stress syndrome is so common that it will almost always be the most likely hypothesis a priori, which mechanically explains why compartment syndrome is missed.

Does pressure measurement really make the diagnosis?

This is the question that has structured the whole field for fifteen years. Intracompartmental pressure measurement is presented everywhere as the reference standard, including in the articles that demonstrate its weaknesses. This chapter sets out where the thresholds come from, what has been held against them, what has been proposed to replace them, and what that changes in the clinic.

Where the 1990 thresholds come from

The three values most departments still use today come from a 1990 article. Pedowitz and colleagues reviewed 131 records of patients referred between 1978 and 1987 for chronic exertional leg pain, of whom 45 received the diagnosis of chronic compartment syndrome and 75 in whom it was ruled out by measurement. They then built criteria from the pressures recorded with a slit catheter in 210 muscle compartments without the syndrome. The result is the triplet that has become canonical: in the presence of concordant clinical signs, a resting pressure of 15 mmHg or more, or a pressure at 1 minute after exercise of 30 mmHg or more, or a pressure at 5 minutes of 20 mmHg or more is diagnostic (AJSM 1990, PMID 2301689).

Two remarks on how these thresholds were built, which explain the whole later debate. First, they are derived from the distribution of subjects without the syndrome, not from a comparison of diagnostic performance against an independent reference standard. Second, the article itself contains a figure that is rarely quoted: at six months to nine years of follow-up, a third of affected patients and more than half of the unaffected patients still reported persistent moderate to severe pain. So the series that founded the criteria already described a population whose outcome was mediocre on both sides of the threshold.

The 2012 challenge, in two systematic reviews

Two systematic reviews were published in the same year, independently, and reached the same conclusion by two different routes.

Roberts and Franklyn-Miller compared anterior compartment intramuscular pressures in healthy subjects, reported in 38 studies, with the diagnostic criteria in use. Their conclusion is unambiguous: apart from the relaxation pressure, “current criteria, held to be the reference standard, overlap the range found in healthy subjects ”. Several studies reported mean pressures that would trigger a positive diagnosis when not one subject reported the slightest symptom. They add that intramuscular pressure varies with many factors other than the presence of the disease, and that these data “have major implications for the ability to use these published criteria” (Scand J Med Sci Sports 2012, PMID 22092446).

Aweid and colleagues, for their part, pooled the values measured in 32 studies, in patients and in controls, at the three classic time points. The result deserves a detailed look, because it is more nuanced than a plain rejection.

The authors' conclusion follows this figure exactly: the pressure criteria in use are “unreliable”, the emphasis must stay on a good history, and if a measurement is taken, it is at one minute after exercise that it should be taken, the only time point where the ranges did not overlap in the studies analysed. They add a rarely quoted operational recommendation: a value above 27.5 mmHg, the highest value recorded in a control across all the studies, combined with a suggestive history, should be considered highly suggestive.

The 2015 proposal: measure during, not after

Roscoe took the problem from the other end: rather than refining a post-exercise threshold, measure continuously during exercise. Forty men aged 21 to 40, twenty with symptoms of anterior compartment syndrome and twenty asymptomatic controls, ran on a treadmill carrying a 15 kg load and wearing identical footwear, with pressure recorded continuously before, during and after.

Three results. First, patients already had a higher pressure on simply moving into standing : 35.5 versus 23.8 mmHg (p = 0.006). Second, the gap widened at the point of maximum tolerable pain: 114 versus 68.7 mmHg (p < 0.001). Third, a threshold of 105 mmHg during the exercise phase gave a sensitivity of 63%, a specificity of 95% and a positive likelihood ratio of 12.5 (95% CI: 3.2 to 49), “consistently superior to the existing criteria” (AJSM 2015, PMID 25406302).

These figures have to be read for what they are. A specificity of 95% and a likelihood ratio of 12.5 make a positive test highly informative: above 105 mmHg under load, the diagnosis becomes likely. But a sensitivity of 63% means that slightly more than one patient in three will fall below the threshold. A negative test rules nothing out. And the confidence interval of the likelihood ratio, from 3.2 to 49, reflects the uncertainty of a sample of forty subjects.

What happened next is worth knowing, because it is rare. The same team followed what became of the patients operated on after being selected on these stricter criteria: 46% improved their occupational fitness grading in the military. The authors say so themselves: these results “lie at the lower end of the range reported in civilian populations” (Simpson, BMJ Mil Health 2020, PMID 30992340). More specific diagnostic criteria therefore did not produce better surgical results, which raises questions about the surgery as much as about the criteria.

What the largest published series of measurements shows

Lindorsson measured consecutively, from 2009 to 2018, the intramuscular pressures of all four compartments in every patient referred for exertional leg pain to a Swedish orthopaedic department. 864 patients: 442 with the diagnosis confirmed, 422 with the diagnosis ruled out. It is by far the largest dataset available, and it lets you see two things at once: that the compartments do not have the same values, and that the extremes overlap.

Two lessons. The first is explicit in the article's title: the posterior and lateral compartments have significantly lower pressures than the anterior compartment, in patients as in non-patients. Applying a single 30 mmHg threshold to every compartment therefore amounts to demanding more of the posterior compartments, and probably to underdiagnosing deep involvement. The authors explicitly recommend lowering the threshold for those compartments.

The second leaps out of the figure: in all four compartments the ranges overlap. A patient with compartment syndrome may have 24 mmHg in the anterior compartment, a patient without the syndrome may have 34. The median separates the two groups very well; the individual case, far less.

What is actually done, and what that implies

Despite fifteen years of challenge, practice has barely moved. Dean's systematic review classified 29 studies by their diagnostic modality: 24 used a static pressure measurement, 5 a dynamic measurement, and only 2 a strictly clinical diagnosis, for a total of 1,270 patients (J ISAKOS 2024, PMID 37778507). Static measurement, the one whose thresholds are most disputed, therefore remains the de facto standard.

The 2026 review article states the end point: “the diagnostic value of pressure measurement remains highly debated. Current thresholds lack robust validation and show limited sensitivity and specificity, with considerable methodological variability” (PMID 42478572).

For a physiotherapist, three practical consequences follow, and they are liberating rather than paralysing.

1. A negative result does not close the case. With a sensitivity of 63% for the best published threshold, one patient in three with a typical account will have a measurement below the threshold. Management does not change for all that.
2. A positive result does not excuse you from the rest of the differential. The football player in the case reported by Bellomo had a positive measurement and an entrapped popliteal artery.
3. There is no need to wait for the measurement before starting. This is established by a study designed for the purpose: in 108 service members who completed a 6 to 12 week conservative programme, the absolute anterior compartment pressure value was not associated with the outcome (odds ratio 1.01; p = 0.64), and the authors' conclusion is that measurement “can safely be deferred” (Vogels, Arch Rehabil Res Clin Transl 2022, PMID 35282146). No acute-on-chronic compartment syndrome occurred in this cohort.

What are the non-invasive alternatives to the needle worth?

Since pressure measurement is invasive, painful and contested, several teams have tried to replace it. Three avenues have been seriously explored: MRI, near-infrared spectroscopy and scintigraphy. A fourth, ultrasound, is more accessible and much less studied. Here is what each has demonstrated, and why none has yet replaced the needle.

MRI after exercise

The principle is simple: if the muscle suffers on exertion, its T2 signal should rise more than that of a healthy muscle. Verleisdonk tested this in 21 patients (41 anterior compartments) and 12 controls, with MRI before and after exercise, then again in 13 patients after fasciotomy. The results are clear: the T2 signal of the anterior compartment rose by 27.5% (range 13.6 to 38.6%) in patients, versus 7.6 % (0-9.1 %) in controls and 4.25 % in their own posterior compartment. After fasciotomy, the rise fell back to 4.1 % (Skeletal Radiol 2001, PMID 11465772).

This result is elegant: the affected compartment stands apart from the healthy compartment of the same patient, from the control, and from itself once operated on. Yet it has two limitations that explain why it has not replaced measurement. The first is logistical: an MRI has to be available immediately after an effort sufficient to trigger the symptoms, which is not the usual organisation of a radiology department. The second is one of performance: when MRI and pressure were compared head to head in a larger population, MRI had comparable sensitivity but a lower specificity at equal sensitivity.

Near-infrared spectroscopy

Near-infrared spectroscopy measures tissue oxygen saturation through the skin, without a needle. Van den Brand showed that affected patients desaturated far more: mean saturation at peak exercise of 27 in patients versus 56 in healthy subjects (p < 0.05), with a swing between rest and peak exercise that was also more marked. The values returned to the normal range after fasciotomy (AJSM 2004, PMID 14977673).

The same team then ran the most useful study in the field: a prospective comparison of the three modalities in 50 patients (100 legs), with the disappearance of symptoms after fasciotomy as the retrospective reference standard. The diagnosis was confirmed in 42 of the 45 patients reviewed, and refuted in 3.

The landmark result is the one in the purple bar: the sensitivity of pressure measurement as measured in this study, 77% (95% CI: 67 to 86), was lower than the 93% the literature credited it with. And spectroscopy, non-invasive, reached 85% (CI: 76 to 92), exactly the earlier estimate. The authors' conclusion is explicit: “the sensitivity of non-invasive near-infrared spectroscopy is clinically equivalent to that of invasive pressure measurements”.

Ultrasound, the most accessible and the least studied

Measuring the thickening of the anterior compartment on ultrasound before and after a run is appealing: the machine is in the practice, the examination is immediate, it costs the patient nothing. A pilot study compared 4 patients and 9 controls after ten minutes on a treadmill. The thickness of the anterior compartment increased by 21.3% versus 6.32% at 30 seconds, 24.6% versus 4.22% at 2 minutes 30, and 24.9% versus 5.08% at 4 minutes 30, all differences significant (Rajasekaran, Clin J Sport Med 2013, PMID 23558330).

Four patients. The authors themselves conclude that “further studies are needed to validate these findings, with the aim of developing ultrasound diagnostic criteria”. Thirteen years on, that validation work has not been published on a scale that makes it usable. It is a lead, not a tool.

The verdict of the systematic reviews

Two reviews took stock a year apart, and they agree.

Ritchie included 28 studies assessing tests other than pressure measurement: MRI in 8, SPECT scintigraphy in 6, spectroscopy in 4, MRI and spectroscopy together in 1, various modalities in 9. Promising results were reported for MRI, spectroscopy and scintigraphy, but “the diagnostic tools and protocols were varied”, five studies explored these modalities as an adjunct rather than as a replacement, and “high-quality validation studies were absent” (Int J Sports Med 2023, PMID 35649437).

Van der Kraats covered 25 studies and 1,257 participants, assessing the risk of bias with the QUADAS tools. Only four studies had a low risk of bias; 21 were at risk. The conclusion is blunt: “despite the need to replace the controversial use of pressure measurement, our review indicates a lack of validity of all the non-invasive tools discussed as a replacement” (OJSM 2023, PMID 36655016).

Ritchie adds a sentence that shows where the field is heading, and that chimes with the thread of this article: optimising precise clinical criteria based on “the patient's history, physical examination and symptom provocation” could in time “make intracompartmental pressure measurement redundant”. In other words, the most serious lead for replacing the needle may not be a machine, but a better structured history.

What can modifying running technique achieve?

It is the best-documented conservative option, and by a wide margin. It rests on a simple idea: if the compartment suffers because tibialis anterior works too hard to control the foot at every heel strike, then changing the way the foot lands changes the demand. Four independent series have tested this hypothesis, with converging results. Here is what they show, and what they do not.

The founding study: ten patients who were due for surgery

Diebal prospectively recruited ten patients with an established surgical indication for compartment syndrome, and offered them six weeks of forefoot strike retraining before operating. The choice of this population is what gives the study its strength: these are not mild cases, they are patients for whom surgery had already been decided.

Three important results come on top of the four measures in the figure. The vertical ground reaction forces and impulses were significantly reduced, which gives the benefit a plausible mechanism. The global rating of perceived change was between 5 and 7 for every patient, that is between “a good deal better” and “a great deal better”. And above all, at one year the scores were better still than at six weeks, with two-mile (3.2 km) times significantly faster than before the intervention. None of the ten patients was operated on.

What replication confirmed, and at what cost

A case series of ten patients is not enough. Three later studies tested the robustness of the result.

Helmhout repeated the protocol in 19 patients, comparing a centre-based supervised programme with a home programme supervised less intensively. The gains are reproduced: running distance +43 %, post-run pressure −36 %, SANE +36 %, Lower Leg Outcome Survey +18 %, patient-specific complaints +60 %. The global rating of change was between +4 and +5, so “a little better” to “moderately better”, that is more modest than in Diebal's series. Two details matter: the scores were still improving four months after the end of the programme (SANE +48%, patient-specific complaints +81%, perceived change +6, “a great deal better”), and centre-based supervision did no better than the home programme (OJSM 2015, PMID 26665032). This last point is decisive in community practice: the benefit does not depend on specialised facilities.

Breen worked with 10 patients using a slightly different approach, four coaching cues rather than the forefoot strike alone: increase hip flexion, increase cadence, keep the trunk upright, adopt a midfoot strike. At one year, 70% of patients were running without pain, the exertional leg pain questionnaire score had improved by 40.3% at six weeks and by 49.2% at one year, and three of the four cues had produced lasting kinematic changes (Int J Sports Phys Ther 2015, PMID 25709867).

Zimmermann assessed scaling up in a military setting, in 75 patients eligible for surgery. After a programme lasting 145 days on average, centred on retraining running and marching in step, 65% (49 of 75) returned to active duty without surgery, 28% were referred to the surgeon and 7% left the army. Two-year follow-up, obtained in 42 of the 50 patients contacted, shows some erosion: 57% had continued in service without surgery, but among them 57% held a physically less demanding post (BMJ Open Sport Exerc Med 2019, PMID 31191976).

This last nuance is the one to pass on to the patient. A successful conservative outcome is not always a return to exactly the same thing: it is sometimes a return with an adjusted load. That is already considerable against the alternative, but it is not the same promise.

The programme, in the published detail

The published protocols resemble one another closely enough for a common framework to emerge. It is described most precisely in Vogels's cohort: 4 to 6 individual gait retraining sessions over 6 to 12 weeks, with uniform home exercises stressing acquisition of the new technique (PMID 35282146). In this cohort of 108 patients, 69% returned to active duty.

Why it should work

The proposed mechanism stands up and rests on measurements. With a heel strike, tibialis anterior works eccentrically to control the lowering of the forefoot. Roscoe showed that affected patients bring the foot flat sooner than controls, and do so even before pain appears, which he interprets as a mechanical disadvantage of that muscle (PMID 29702369). With a forefoot strike, this braking phase largely disappears, and with it the eccentric demand on the anterior compartment. Alongside the fall in pressure, Diebal measured a reduction in vertical forces and in impulse, which is consistent.

An honest limitation has to be stated: this reasoning explains the benefit well for the anterior compartment. It explains far less well what might be expected in deep posterior involvement, where a forefoot strike increases the demand instead. The published series in any case deal overwhelmingly with anterior involvement. Transposing the protocol to deep posterior involvement is supported by no data at all.

What does not predict the outcome

Two studies have tackled the question of prognosis, and their answer is useful because it is negative.

Meulekamp tested thirteen prognostic factors in 45 service members in rehabilitation: age, body mass index, body fat percentage, self-efficacy, foot malalignment, intramuscular pressure, comorbidities, protein and creatine use, smoking, alcohol, symptom duration, physical demands of the post, length of service. None reached significance (Mil Med Res 2017, PMID 29502519). And Vogels showed that pressure was not associated with the outcome, whereas a low self-assessment score at entry was, unfavourably (odds ratio 0.95; p = 0.01).

The practical conclusion is simple: you cannot select in advance the patients who will respond. There is no profile to whom a conservative trial can be refused on objective grounds. That argues for offering it to everyone, emergencies aside.

What are the real results of fasciotomy, and its failures?

Fasciotomy is presented as the reference treatment, and it works in a majority of patients. It does not work in all of them, its success rates vary enormously from one series to another, and the difference between “returning to an activity” and “returning to their sport” is the one that matters to the patient. This chapter sets out the figures with their spread, because the spread is the information.

The principle, and its variants

The operation consists of opening the fascia of the affected compartment or compartments, to remove the constraint of the container. It is performed open, through mini-incisions, endoscopically, and, when it fails, as a fasciectomy, that is resection of a strip of fascia rather than a simple incision. The number of compartments opened varies: two (anterior and lateral) or four.

On this last question, Weiss's systematic review compared the two strategies across 7 studies and 194 athletes and service members of mean age 24. Return-to-activity rates were 90 to 100% for two compartments and 50 to 100% for four compartments, with no significant difference, and the authors conclude that the two approaches “appear equally effective”. They immediately add the necessary caveat: every included study carried a high risk of bias, with small samples, selection bias and no uniform outcome measure (J Foot Ankle Surg 2022, PMID 35337738).

Two series nevertheless suggest the opposite, and they need to be known. In 155 adolescents, legs that had only an anterior or lateral release carried a 3.4 times higher risk of reoperation (95% CI: 1.29 to 9.14; p = 0.01) than those in which all four compartments were opened (Beck, PMID 27365374). And in a small series of 21 patients reviewed, 91% of those who had all four compartments released regained their desired level of exercise, versus 66.7 % of the others (Maher, Foot Ankle Spec 2018, PMID 29931999). The debate is therefore not settled.

The figures, and above all their spread

The most complete series, and the most measured

Campano pooled 24 studies bringing together 1,596 patients, with a mean follow-up of 48.8 months. The verdict: primary surgery was a success in about two thirds of young, athletic patients, 84% declared themselves satisfied, 6% had revision surgery and the overall complication rate stood at 13 %, mainly postoperative neurological dysfunction and infections (Arthroscopy 2016, PMID 27020462).

Two thirds success and 84% satisfaction: the gap between those two figures is not a contradiction, it says something important. Patients can be satisfied with a partial improvement. That is exactly what Oliver's mini-fasciotomy series confirms: at a mean of 3.7 years, 30% of patients were asymptomatic and a further 56% reported improved symptoms, with pain during sport falling from 9.1 to 4.7 out of 10. 74% were satisfied and 81% would recommend the operation, while only 64% had returned to their sport (Eur J Orthop Surg Traumatol 2022, PMID 33675406).

The figure to give a runner

If the patient runs, one series deserves to be quoted as it stands. Salzler surveyed 32 runners who had had surgery, at a mean follow-up of 66 months. The results:

• 84 % returned to a sport.
• only 56% went back to running competitively, and among them the mean weekly distance had fallen.
• 28 % turned to a sport without running, 16% of them because of recurrent pain.
• 19 % had a recurrence, and all were reoperated.
• 78.1 % declared themselves satisfied, with pain during activity falling from 7.9 to 1.7 out of 10 (Sports Health 2020, PMID 32163722).

Not all populations are alike. Among 18 elite French cross-country skiers operated on bilaterally, 94% reported no further pain or only sporadic pain and nearly 90% had returned to competition at the same level or higher (Calvelli, PMID 31935775). At the other extreme, in service members, “only about half achieve complete resolution of symptoms and at least 25% are unable to return to full duty” (Dunn and Waterman, PMID 25280617). The same operation, two different worlds.

Complications, and what becomes of the failures

Ding's review gives the most complete ranges: haematoma 2.7 to 22.5%, nerve injury 2.0 to 18.6%, deep vein thrombosis 2.7%, recurrence of symptoms 0.65 to 8.4%, and up to 10.4% revision surgery (PMID 32473344). Oliver's mini-fasciotomy series reports 16% complications, including 11% superficial infections.

When surgery fails, revision is possible and documented. Vogels followed 24 patients, out of 958 assessed for exertional leg pain, who underwent a fasciectomy after a failed minimally invasive fasciotomy. Intraoperatively, the surgeons found fibrous bands, pseudo-fascia or complete fusion of the fascial edges. After rehabilitation, exertional symptom scores were cut to a third, and at a median follow-up of 12 months 79% reported a satisfactory result and 75% had resumed physical activity (Med Sci Sports Exerc 2021, PMID 33731658).

This result throws light on a mechanism of failure: the fascia closes up again. It also justifies not treating a first-line failure as the end of the road.

Surgery versus conservative care: what the direct comparison says

There is no randomised trial comparing fasciotomy with conservative treatment. Ding puts it bluntly: “there is insufficient evidence in the literature to support either conservative or surgical management over the other”, and calls for randomised trials (PMID 32473344). This absence can be measured: on 15 August 2026, a Europe PMC query crossing “chronic exertional compartment syndrome” with the publication type “Randomized Controlled Trial” returns only three records, only one of which is genuinely on the subject, and it compares compartment pressures between two roller-skiing techniques in skiers, not two treatments (PMID 26090709). This is a gap in indexing, which a poorly indexed trial could mask, but the order of magnitude leaves no room for doubt.

A meta-analysis has nevertheless pooled the four comparative cohort studies available. Surgery did better on pain (standardised mean difference −0.46; 95% CI: −0.74 to −0.17; p = 0.002, with low heterogeneity, I² = 13%) and on satisfaction (odds ratio 3.51; CI: 2.19 to 5.60; p < 0.00001). On the other hand, no significant difference in return to activity (odds ratio 3.70; CI: 0.53 to 25.96; p = 0.19), with massive heterogeneity (I² = 88%) (Elsenosy, Cureus 2024, PMID 39759644).

This confidence interval has to be read: from 0.53 to 25.96, it contains both no effect and an enormous effect. Across four non-randomised cohort studies, with 88% heterogeneity, this result allows no conclusion either way. What the meta-analysis reasonably establishes is an advantage for surgery on pain and satisfaction. What it does not establish is an advantage on what interests the runner: getting back to running.

Which modalities, at what level of evidence?

The table that follows ranks each modality by the confidence that can be placed in its effect. A warning is in order before reading it: none of these modalities has been the subject of a published GRADE rating for this condition. The level-of-evidence column is a judgement, built along GRADE lines, with the reason for downgrading given on each row so that the reader can contest it.

Botulinum toxin, a lead that deserves a careful reading

The idea is counter-intuitive: deliberately weakening the muscle to reduce the pressure in its compartment. Two studies exist, very different from each other.

Charvin retrospectively followed 16 patients treated first line with botulinum toxin A injections, upper and lower limbs together, median age 25.5 years. 68.75% reported an initial benefit (7 complete, 4 partial), and 8 of the 16 patients were able to resume the triggering activity. Then comes the decisive part: every patient with a partial benefit relapsed, with a median delay of 2.25 months, and 57.14% of those with a complete benefit relapsed, with a median delay of 5 months. Adverse effects were minor and without functional consequences (Clin J Sport Med 2022, PMID 34282061).

McGinley published a much larger series, 284 patients, but in a setting that limits its reach: single-centre, retrospective, without a control group, with a primary outcome resting on imaging and a strong causal conclusion drawn from a design that does not allow it (PMID 34009799).

What can be said to a patient: the toxin may relieve symptoms for a few months, in about two patients in three, and the relief fades. In an athlete, the induced weakness is an effect to be weighed and not a mere side effect, since it is the very mechanism of the treatment.

A shift in the discourse worth noting

In 2014, a reference review on compartment syndrome in the military wrote that “non-operative management is generally unsuccessful, although gait retraining may have benefits in selected individuals” (Dunn and Waterman, PMID 25280617).

Twelve years later, the review in the British Medical Bulletin places among the points of agreement the statement that “conservative management, in particular structured rehabilitation with activity modification and gait retraining, is increasingly regarded as the first-line treatment” (PMID 42478572).

This reversal happened without a single randomised trial being published. It rests on the accumulation of converging series and on the demonstration, in the military, that a structured programme avoids surgery in two patients out of three. It is a low level of evidence that has changed a practice, which happens, and which it is better to know and to say to the patient.

What do real clinical cases teach us?

The four observations that follow are published, indexed cases, quoted with their identifier. None is a reconstructed vignette. They were chosen because each illustrates a different error or decision: the missed diagnosis, the surgery avoided, the second diagnosis hidden behind the first, and the emergency.

An open question, raised by a fifth case

One last reported case deserves a cautious mention. It describes a distance runner who developed a leg compartment syndrome after creatine use, and discusses the risk factors and the differential diagnoses (Bruneau, Curr Sports Med Rep 2025, PMID 40627559). The authors themselves note that research on the relationship between compartment syndrome and supplementation is “sparse”.

A single case establishes no causation, and it would be wrong to draw a rule from it. The reason for quoting it is different: it is a question patients ask, and it is useful to know that it has been raised in the literature, with exactly this level of evidence, that is none. It can be noted in passing that creatine use was among the thirteen prognostic factors tested by Meulekamp, without reaching significance (PMID 29502519).

How do you apply all this in practice?

This chapter condenses the article into a way of running a consultation. It does not replace the previous ones, it orders them: what you ask, what you do, what you refer on, and what you tell the patient.

First consultation: the history makes the diagnosis

Five questions, in this order, frame the essentials:

1. “At what point in the session, exactly?” A precise and stable moment points to the compartment. Pain present from the outset points to bone or tendon.
2. “Is it always at the same moment?” Reproducibility is the most discriminating feature of the picture.
3. “How would you describe the sensation?” Tightness, swelling, burning, cramping point to the compartment. Pinpoint pain on the bone points elsewhere.
4. “What do you have to do to make it stop, and how long does it take?” Stopping and waiting a few minutes points to the compartment. Waiting several days points to bone.
5. “Does it come back at the same point if you set off again in the same session?” A return at the same threshold is highly suggestive.

Two further questions deserve to be asked routinely, for their prognostic and safety value: “do you get pins and needles or a numb patch?” and “does the foot give way, or slap, at the end of a run?”.

Examination: at rest, then after provocation

What you start without waiting

If the account is typical and no red flag is present, conservative treatment can begin immediately. Pressure measurement is not a prerequisite: it does not predict the outcome of the programme and can be deferred safely, which has been demonstrated in 108 military patients (PMID 35282146).

The programme, as described in the published work:

• Format : 4 to 6 individual sessions spread over 6 to 12 weeks, supplemented by home work. Centre-based follow-up did no better than home follow-up in the only published comparison.
• Content : switch to a forefoot or midfoot strike, increased cadence with reduced stride length, upright trunk, increased hip flexion.
• Gradual build : the transition is spread over six weeks in every protocol. That slowness protects triceps surae and the Achilles tendon, whose load mechanically increases.
• Outcome measurement : distance run without pain before and after, and a self-reported score. The published work uses the SANE, the Lower Leg Outcome Survey or the patient-specific complaints scale. A systematic review of the questionnaires available for exertional leg pain concluded that the Lower Extremity Functional Scale was the best validated, ahead of the medial tibial stress syndrome score and the questionnaire dedicated to exertional leg pain (Castillo-Domínguez, Medicina 2022, PMID 35888560).

When to refer, and to whom

• As an emergency : pain that does not ease on stopping, a tense compartment, a sensorimotor deficit setting in. Acute-on-chronic compartment syndrome until proved otherwise.
• Without delay : suspected stress fracture, particularly at a high-risk site, or a background of low energy availability.
• Promptly : vascular signs in the provoked position in a young athlete, for dynamic vascular imaging.
• After failure of the conservative programme : refer for discussion of a pressure measurement and a possible fasciotomy. Three months of a well-run programme is consistent with the published protocols, which last 6 to 12 weeks.

What to tell the patient, in figures

Patients ask for probabilities. Here are four, with their source, that can be given without overstating in either direction.

Three sentences to avoid, because they are not supported by what we have read:

• “The pressure measurement will say whether you have it or not.” With a sensitivity of 63% for the best published threshold, it will not say so in a third of cases.
• “It is the fascia that is too tight, the operation corrects that.” Neither the thickness nor the stiffness of the fascia differs from that of healthy subjects.
• “After the operation, you will run as before.” Slightly more than one operated runner in two returns to running, and often with a reduced volume.

Frequently asked questions