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Chronic exertional compartment syndrome

Also called CECS, exertional compartment syndrome, chronic compartment syndrome

Exercise pain and tightness in a muscle compartment of the leg or forearm that eases after stopping. How reviews define it, the debate over pressure tests, who studies include, and what studies of surgery and running-style programmes found.

Region
Lower leg
Muscles
tibialis anterior, peroneus longus, peroneus brevis, soleus, gastrocnemius, tibialis posterior
Updated
October 22, 2026
Reviewed
October 22, 2026 · how entries are checked

What it is

How reviews and a consensus define it

A 2022 expert consensus calls it a disabling overuse injury of the muscle compartments of the arms or legs1. It describes muscle pain with a feeling of pressure or tightness during repeated movement, easing once the activity stops1. A 2020 review defines it as a short-lived rise in compartment pressure during activity8. In that account the fascia, a sheet of tough connective tissue, fails to make room for the rise, and pain follows8.

The 2022 panel of 27 civilian and military clinicians agreed on five features that make it likely1. Two are pain and tightness, each during exercise1.

Why the cause is still argued over

The symptoms are thought to come from a reversible rise in pressure, as swelling muscle expands inside fascia that gives little1. The 2022 consensus paper notes growing evidence that the condition has several causes and is more than a passing pressure rise1. A 2026 review by two authors of that consensus says it has long been seen as a problem of blood flow1,9. The review adds that this remains unproven9.

The four compartments of the leg

The lower leg has four compartments10.

  • Anterior (front): the tibialis anterior, peroneus tertius, extensor digitorum longus and extensor hallucis longus11.
  • Lateral (outer side): the fibularis longus and fibularis brevis muscles, with nerves and branches of two arteries10.
  • Superficial posterior (back, outer layer): the soleus, gastrocnemius and plantaris12.
  • Deep posterior (back, deep layer): the tibialis posterior, popliteus and two toe-bending muscles, the flexor hallucis longus and flexor digitorum longus12.
Engraving of a slice straight across the middle of the lower leg, seen end-on, with every structure labelled. The tibia sits at the top as a thick ring and the thinner fibula lower left; a thin interosseous membrane joins them. In front of the membrane lie the tibialis anterior and the long toe extensors with the deep peroneal nerve and anterior tibial vessels. On the outer side lie the peronaei longus and brevis with the superficial peroneal nerve. Behind the bones are the flexor digitorum longus with the posterior tibial vessels and tibial nerve, and, nearest the skin at the back, the large soleus and the two heads of the gastrocnemius.
Cross-section through the middle of the lower legHenry Gray, Anatomy of the Human Body (1918), Fig. 440. Public domain, via Wikimedia Commons. (source, Public domain)

The 2022 consensus paper says the condition is found mostly in the anterior compartment1. A 2016 systematic review of 1,596 people who had surgery counted which compartments were involved13.

Share of involvement, 2016 reviewAnterior51 %Lateral33 %Deep posterior13 %Superficial posterior3 %
Share of involvement, 2016 review (%). Bars start at zero; the table below gives each value with its source.
CompartmentShare of involvement, 2016 review
Anterior51%13
Lateral33%13
Deep posterior13%13
Superficial posterior3%13

A 2020 review lists conditions considered alongside this one when exercise brings on leg pain8. Among them are muscle strain, medial tibial stress syndrome and stress fracture, a small crack in a bone from repeated loading8. “Shin splints” is one of the two most common names for medial tibial stress syndrome14.

What pressure tests show, and why they are debated

In a 2024 review of 29 studies, 24 identified it with static monitors of compartment pressure15. Pressure is given in mmHg (millimetres of mercury). A 1990 study of 131 people with exercise leg pain proposed three cutoffs, any one of which, with fitting clinical findings, points to it16. They were at least 15 mmHg before exercise, 30 mmHg one minute after, or 20 mmHg five minutes after16.

Later reviews questioned the commonly used cutoffs4,9:

  • A 2012 review of 32 studies found the evidence for them weak and judged them unreliable4. One minute after exercise was the only time point where average pressures in patients and controls (a comparison group without the condition) did not overlap4. Patients ranged from 34 to 55.4 mmHg and controls from 9 to 19 mmHg4. The authors suggested that values above 27.5 mmHg, with a good history, be regarded as highly suggestive4.
  • A second 2012 review, of 38 studies, found that the common cutoffs overlap the pressures seen in healthy people5. Relaxation pressure was the exception5.
  • A 2026 review by two authors of the 2022 consensus says the value of pressure testing remains highly debated, with cutoffs lacking robust checks1,9.

A 2015 study measured pressure during exercise in 40 men exercising on a treadmill with a 15-kg load17. Twenty had symptoms in the anterior compartment and 20 had no symptoms17.

Test sensitivity is the share of people with a condition whom a test picks out. Test specificity is the share without it whom the test rules out. Measured during exercise, pressure gave 63% sensitivity and 95% specificity, higher than existing criteria17. The authors found a cutoff of 105 mmHg during exercise more accurate than the 1990 cutoffs17.

A 2023 review covered 28 studies of tests other than pressure, including MRI (a scan that shows soft tissue in detail)18. It reported promising results but no high-quality checks18.

Who it affects

How common it is

The 2022 consensus paper states that no reliable rates of new or existing cases are available1. A 2023 review says incidence, the number of new cases over a set time, is still unknown in the general population19. A 2024 review links the uncertain prevalence to people managing it alone or changing activity, errors in recognising it, and not seeking care2. A 2023 scoping review of nine causes of exercise leg pain says how common they are is not clear, and calls for better studies20.

Two reviews instead give its share of exercise leg pain2,19:

  • A 2023 review, citing earlier work, puts it second after medial tibial stress syndrome, at 27% to 33%19.
  • A 2024 review estimates that 14% to 34% of exertion leg pain referred to orthopaedic care fits the condition2.

The counts of new cases found here come from US military records3,21. Among US active service members from 2006 to 2011, there were 0.49 cases per 1,000 person-years3. Person-years are people multiplied by the years each was followed. Higher risk went with being older, female or white, holding a junior enlisted rank, and serving in the Army3. A 2024 study of 1,103,417 US military entrants counted 1,947 people with the condition in the lower limb21.

Who appears in the studies

Group studiedWhat was found
1,596 people who had surgery, in a 2016 review of 24 studiesMean age 26.6, 70% men; 54% military members and 29% athletes, most of them recreational13
Patients in a 2024 review of 41 studies51% female22
1,411 people assessed for exercise leg pain at a referral centre, 2018 study698 had the condition; it peaked around age 20 to 25; running and skating were among its predictors23
698 patients at Máxima Medical Center, Veldhoven, in a 2018 studyAbout 1 in 7 were aged 50 or older, mostly with anterior involvement24
155 patients aged 18 or under who had surgery, at one hospital88% female; running, soccer and field hockey were the commonest main sports25

The forearm form

The forearm form is described as rare in the general population but seen in motorcycle racers, climbers and rowers26. A 2025 review of 590 patients with it found 505 were men27.

What studies found

How the evidence stands

A 2020 review of outcomes in any lower-leg compartment found no randomised controlled trials, which assign people to groups by chance6. Another 2020 review found no agreed best approach and no established international guidelines28. That review, of 14 mostly retrospective studies, found too little evidence to favour surgery or non-surgical care over the other28. The 2022 consensus panel reached no agreement on what pressure values add, or on the preferred approach when symptoms persist or return1.

Without surgery

In 12 military men who did not have surgery, each still had typical complaints after a mean of 50 months29. In 16 of their 21 legs, pressure was still at or above the 35 mmHg cutoff29.

A 2016 review of non-surgical options for the leg found seven articles, each a case series or a case report30. A case series reports on patients with no comparison group. Several studies have tested changes to running style, a form of gait retraining (changing how a person walks or runs)31,32:

  • In a case series of 10 candidates for surgery, 6 weeks of forefoot-landing training was followed by lower post-run pressure and longer running distance31. No patient needed surgery over one year of follow-up31.
  • In 19 people, a 6-week forefoot running programme was followed by 36% lower post-run pressure, with no significant difference between centre and home settings33.
  • Of 75 Dutch military patients eligible for surgery, 65% initially returned to duty without it after a gait retraining programme32. About two years later, 57% of those who answered a survey were still on duty without surgery32.
  • A study took 108 Dutch military members with chronic exercise leg pain who completed gait retraining and met its criteria34. Of these, 69% returned to duty, and anterior pressure was not linked with outcome34.

Botulinum toxin is a drug that weakens or relaxes a muscle it is injected into. In a case series of 16 people with front or front-outer leg symptoms, exertional pain went away after injection in 1535. The injected muscles lost some strength in 11, without loss of function, the authors report, over up to 9 months35. In a retrospective study of another 16, with the arm or leg affected, 11 reported early benefit, but symptoms often returned36.

Surgery compared with non-surgical care

Fasciotomy is surgery that cuts through fascia. The studies comparing it with non-surgical care are not randomised trials. They are summarised below6,37:

  • A 2020 review of 68 reports found 85% satisfaction and 80% return to activity after fasciotomy, against 47% and 50% without it6. Its studies were few and low-level6.
  • The same review found return to activity more often after surgery, except in one study of army personnel that favoured gait retraining6.
  • A 2024 meta-analysis of four cohort studies found more pain relief and higher satisfaction after fasciotomy37. Return to activity did not differ significantly, and results for it varied widely between studies37.
  • In one cohort followed for at least two years, 81% of 73 people rated fasciotomy a success38. Of 27 who continued non-surgical care, 41% rated it a success38. Pressure values did not correlate with outcome38.

Results after surgery

A 2016 review found first surgery on the leg succeeded in about two-thirds of patients, and 84% were satisfied, at short- to mid-term follow-up13. A 2020 review lists the harms reported28:

  • haematoma (a pocket of blood in tissue), 2.7% to 22.5%28;
  • nerve injury, 2.0% to 18.6%28;
  • deep vein thrombosis (a blood clot in a deep vein), 2.7%28;
  • symptoms returning, 0.65% to 8.4%, with up to 10.4% needing a repeat operation28.

For the deep posterior compartment, a 2014 review of 131 patients found success rates of 30% to 65%39. A 2020 review found more complications and recurrences in military than in civilian patients6.

How much fascia to open is also unsettled. A 2022 review of 7 studies of athletes and military personnel found two- and four-compartment fasciotomy about equally successful40. Yet each study had a high risk of bias40. A 2016 review states that open surgery is the main technique, and that how it compares with endoscopic (keyhole) methods is not known13.

A randomised trial of two cutting tools

A 2021 trial gave 50 people with anterior symptoms in both legs a different fasciotome, the cutting tool, on each leg7. Patients did not know which leg had which device, but the surgeons did7. The devices did not differ in complications or symptom relief7. The authors had developed one of them, FascioMax (van Straten Medical), and declared no conflicts of interest7. They note that small differences may have been missed7.

Connections

In the leg, the condition is most often found in the compartment of the tibialis anterior1,41. The lateral compartment holds the peroneals10. The back compartments hold the soleus, the gastrocnemius and the tibialis posterior12. The 2022 consensus account places swelling muscle inside fascia that gives little1.

Medial tibial stress syndrome, commonly called “shin splints”, is one condition considered alongside this one8,14. In a 1982 study of 12 patients with it, pressures in the back compartments were not raised42. Those authors concluded it is not a compartment syndrome42.

Running was among the predictors at the referral centre, and among the commonest sports in the under-18 surgical series23,25. The forearm form involves compartments usually described as superficial volar, deep volar, lateral and dorsal26. Volar means on the palm side. The forearm flexors and forearm extensors pages cover it more fully26.

Chronic exertional compartment syndrome involves the compartment of

Chronic exertional compartment syndrome involves

Chronic exertional compartment syndrome also occurs in the compartments of

Chronic exertional compartment syndrome is compared with

Chronic exertional compartment syndrome is common in

Sources

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Every source the library cites

Changes

  • First published.