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Exertional Compartment Syndrome
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Exertional compartment syndrome is leg pain that builds during repeated exercise, such as running or cycling, and usually eases within minutes of rest. It mainly affects young, active people and is likely under-diagnosed. Care without surgery is usually tried first, and surgery is an option if it doesn't work. Many people improve, but results vary widely and it isn't certain which option works best. Getting the pain assessed, rather than pushing through it, is the best first step.
What is it?
Exertional compartment syndrome (CECS for short) is leg pain that comes on during exercise and settles soon after you stop. It usually builds gradually while you run, cycle or do other repetitive exercise. The pain usually passes within minutes of resting.
Between workouts, people usually have no symptoms. There is also no nerve or blood-vessel damage and no lasting harm to the muscle.
Your muscles sit in compartments. A compartment is a closed section of muscle wrapped in a tough covering called fascia. The usual explanation is that during exercise the pressure inside a compartment rises higher than normal and takes longer to settle. That squeezes the blood supply, so the muscle is short of blood and aches or cramps. This explanation is still a theory.
Who does it affect?
Exertional compartment syndrome mainly affects young, active people, most often aged 15 to 25. Many are runners or play sport. It is likely under-diagnosed, and how common it is isn't known.
Among people who had surgery for it, most were military service members (54 per cent) or athletes (29 per cent). It isn't clear who is at higher risk. It affects both men and women. So neither sex is clearly more affected, and the age range is wide.
Less is known about how it affects people who aren't athletes or in the military. It may not apply to children, older adults or people who don't play sport.
Signs and symptoms
The pain is often cramping or aching, and it is most often felt in the legs. It usually affects both legs. It may be felt over the front or the front and outer part of the leg.
It tends to start after a fairly steady amount of exercise. Pain often starts after a fairly set amount of exercise, commonly about 20 minutes (anywhere from 15 to 30 minutes). If you keep going, an aching pain may turn sharp.
Once you stop, the pain usually eases within a few minutes. Some people also notice swelling, a muscle that looks visibly bulging, or tingling.
If you get predictable leg pain that eases with rest, see the "When to see a podiatrist" section.
What causes it?
Nobody knows the exact cause of exertional compartment syndrome. It usually shows up in young people who do regular, repetitive exercise such as running or cycling.
The usual theory is about blood flow. During exercise, the muscles may expand and the fascia (the covering around the muscles) may be too tight to allow for it. Pressure then rises inside the compartment and blood flow drops. This view is still unproven.
Several things may play a part: tiny injuries to the muscle, muscle diseases, problems with blood vessels or blood flow, a stiff fascia and muscle growth. None of these has been confirmed as the cause.
No single factor you can fix has been proven. So don't change your shoes, running style or training on a guess that one of them is to blame.
How is it diagnosed?
Your clinician will rely heavily on a detailed history and an examination.
Before your appointment, write down when symptoms start, what brings them on, what eases them, how long they take to settle, whether they happen at rest or at night, and whether they disturb your sleep.
Other causes of leg pain with exercise must be separated out: stress injuries to the bone, muscle pain, nerve compression, and a temporary squeeze on a blood vessel (functional popliteal artery entrapment syndrome, checked with MRI scans). Shin pain (medial tibial stress syndrome) can overlap a lot with exertional compartment syndrome in the deep back compartment of the lower leg. Don't assume it is exertional compartment syndrome.
A pressure test measures pressure inside the muscle compartment before and after exercise that brings on symptoms. A specialist may arrange it if the diagnosis is unclear. It is often called the gold standard, but its cut-off numbers are questioned. Readings in healthy people can overlap with those in people who have it, and pressure varies for other reasons. So it isn't relied on alone.
Treatment
Treatment is advised once the condition is diagnosed. Care without surgery comes first, and surgery is considered if that doesn't work.
Looking after it at home
Ease off the activity that brings the pain on, or switch to something gentler. Rest may ease symptoms, but get a diagnosis and a plan from a clinician rather than relying on rest alone. Check with your GP or pharmacist before taking anti-inflammatory medicines.
Treatment from a clinician
Care without surgery is the usual start. It aims to correct overload from how you move. It often includes changes to your activity, gait retraining (changing how you walk or run, guided by a clinician), shoe changes, orthoses (shoe inserts), taping, massage, stretching and strengthening. It is usually offered for three to six months. It mainly eases symptoms through muscle rest rather than curing the underlying problem.
Ask about a structured gait retraining programme. Don't change your running style on your own, as it isn't clear that it helps. A guided programme to learn to land on the front of your foot (forefoot strike running) looks promising, as it may lower pressure in the leg and reduce pain and disability. This approach is still early, and it isn't yet clear how well each option works.
Agree in advance how long you will trial this care and how you will judge whether it is working.
Other options
Botulinum toxin A is an injection that relaxes the muscle. It can lower pressure in the compartment and ease pain with exercise. Its use is still debated, though it looks promising.
If care without surgery hasn't worked after the trial you agreed, ask for a referral to an orthopaedic or sports medicine specialist.
Surgery
Fasciotomy (surgery to release the fascia) is considered when care without surgery hasn't worked. It is a planned decision after assessment, not an emergency. It has given higher satisfaction and return to activity than care without surgery. How satisfied people are, and how well they return to sport, varies widely after surgery.
Before surgery, ask your surgeon about the outcomes to expect for you, the risks, the recovery time and the rehabilitation.
Recovery
Outcomes vary widely. About a quarter to a third of people return to sport after care without surgery. For some people, resting is often enough for the condition to settle.
Return to activity gradually, under a plan you agree with your clinician. No set return-to-running programme has been established for this condition, so a plan made for you matters.
It isn't clear what stops it coming back, so no prevention can be promised. If you have surgery, report any new symptoms to your surgical team promptly.
When to see a podiatrist
When to book
Book an appointment with your podiatrist if:
- your pain hasn't improved after a few weeks of home care
- your symptoms keep coming back
When to get help sooner
Get urgent medical assessment (see your GP today, or go to an urgent care clinic or the nearest emergency department) if:
- your foot feels very swollen and tight and the pain keeps getting worse, even with pain relief and raising it, after an injury or operation or in a cast: go straight away, without waiting for an appointment
Frequently asked questions
Who should I see first?
Your GP can help work out whether it is this condition or something else, especially if exercise keeps bringing on pain, numbness, swelling or trouble moving a body part. Bring notes on when it starts and how long it takes to settle.
Will I need surgery?
Not necessarily. Care without surgery comes first. Surgery has given higher satisfaction and return to activity, but it isn't yet clear which option works best. Your clinician can talk you through your choices.