Compartment syndrome is defined as an elevated pressure within a closed muscular compartment that limits vascular perfusion to the contents of that compartment. This ischemia can lead to pain and tissue injury. Compartment syndrome can occur both in the acute and chronic settings. Acute compartment syndrome, which often results from trauma, is characterized by a progressive rapid onset and often requires urgent compartment release. Chronic compartment syndrome, in contrast, is typically recurrent and results from exercise-induced muscle swelling. This swelling can increase the compartment volume by as much as 20% of the resting muscle volume with strenuous exercise.¹ This is referred to as chronic exertional compartment syndrome (CECS).

The most common sites affected by CECS are the leg, thigh, and forearm. The leg has four fibroosseous compartments: anterior compartment (tibialis anterior muscle, extensor hallucis longus muscle, extensor digitorum longus muscle, deep peroneal nerve, anterior tibial artery), lateral compartment (peroneal muscles, superficial peroneal nerve [SPN]), superficial posterior compartment (gastrocnemius and soleus muscles, sural nerve), and deep posterior compartment (tibialis posterior muscle, flexor digitorum longus muscle, flexor hallucis longus muscle, posterior tibial nerve, posterior tibial artery). CECS most commonly affects the anterior and deep posterior compartments of the leg,² with bilateral symptoms reported in 37% to 82% of patients.^{3, 4, 5, 6}

The diagnosis of CECS is made by history, examination, and compartmental pressure measurement. Patients with CECS typically report aching discomfort that occurs with exercise. With persistent exertion, the pain often reaches a level that requires the individual to stop activities. Numbness or tingling can accompany this discomfort as the structures within the compartment experience transient ischemia. Most patients report resolution of symptoms with rest. In the office, the examination may be quite unremarkable unless the patient is asked to replicate the provocative exertion by jogging or running stairs, for example. With exertion, a fullness of the muscle compartment may be present and be accompanied by a decrease in distal sensation. Foot drop on the affected side(s) may also be observed. When concern for CECS exists, invasive compartment pressure measurement is helpful to confirm the diagnosis and determine which compartment(s) is involved. Pressure measurement in each compartment is often taken at rest, 1 minute post exercise, and 5 minutes post exercise. The type of exercise performed may vary and should provoke the patient’s symptoms. The criteria for CECS typically used is a resting pressure ≥15 mm Hg, and/or a pressure 1 minute after exercise ≥30 mm Hg, and/or a pressure 5 minutes after exercise ≥20 mm Hg.⁷

Nonsurgical management of CECS typically requires activity modification such that compartment pressures do not reach a critical level. Many athletes are not willing to accept this and surgical compartment release offers an alternative. Fasciotomy has been shown to be effective in relieving pain and allowing return to activities.^{6, 8, 9, 10} Fasciotomy has been described with different techniques, including open techniques, mini-open techniques, and endoscopic techniques.^{1, 3, 4, 6, 8, 9, 10} An interest in smaller incisions has been brought about by a theoretical decreased risk of wound problems and an interest in improved cosmesis. Some of the smaller incision techniques limit visualization and therefore risk nerve injury. Endoscopic fasciotomy offers an alternative to open procedures and can improve visualization through limited incisions while reducing the risk of wound complications and improving cosmesis.