Diagnostic and therapeutic dilemmas in chronic exertional compartment syndrome

Background: Exercise-induced leg pain is a common and often disabling complaint in young and physically active individuals. Chronic exertional compartment syndrome (CECS) remains one of the most debated diagnoses within this spectrum due to persistent uncertainty regarding its pathophysiology, diagnostic criteria, and treatment strategies. Sources of data: This review draws on the authors’ previous systematic reviews, original cohort studies, international consensus work, and updated PubMed-indexed literature on diagnostic approaches, intracompartmental pressure (ICP) measurement, and treatment outcomes. Areas of agreement: CECS presents with a characteristic pattern of exertional pain and tightness that resolves with rest. Clinical history remains central, supported by a positive symptom provocation test. Conservative management, particularly structured rehabilitation with activity modification and gait retraining, is increasingly considered first-line therapy. Surgical decompression is effective in patients with persistent, typical symptoms who fail conservative treatment and opt for surgical management. Areas of controversy: The diagnostic value of ICP measurement remains highly debated. Common thresholds lack robust validation and show limited sensitivity and specificity, with considerable methodological variability. Additional controversies include heterogeneity in surgical techniques, postoperative care, and the absence of clear criteria for surgical timing. Growing points: Emerging research focuses on alternative diagnostic strategies, including non-invasive imaging, dynamic functional testing, and symptom-based clinical algorithms. Areas timely for developing research: Future research should address the central question of symptom aetiology. CECS has traditionally been viewed as a perfusion-related disorder, yet this remains unproven. Improved understanding of underlying mechanisms is essential, alongside with refinement of conservative treatment, patient selection for surgery, and development of validated diagnostic pathways and outcome measures.