Open 4-Compartment Fasciotomy for Chronic Exertional Compartment Syndrome of the Lower Extremity

Chronic exertional compartment syndrome (CECS) is an underrecognized cause of lower extremity dysfunction in athletes. Open 4-compartment fasciotomy remains the gold standard for surgical management.

Operative intervention is indicated for patients with clinically and objectively confirmed CECS who fail to respond to conservative management. Contraindications include inadequate nonoperative treatment or unaddressed medical comorbidities. Proper diagnosis requires exclusion of vascular or neurologic causes that can mimic CECS symptoms.

A 2-incision, 4-compartment fasciotomy is performed with the patient supine and a thigh tourniquet applied. Two lateral incisions-1 distal (7 cm, 11 cm from the lateral malleolus) and 1 proximal (3 cm, at the fibular head)-allow decompression of the anterior and lateral compartments under direct visualization. The superficial peroneal nerve is identified and protected throughout. Medially, a 7-cm incision is made 2 cm posterior to the tibial border to decompress the superficial and deep posterior compartments. The saphenous vein and nerve are mobilized anteriorly, and the deep posterior compartment is released by detaching the soleal bridge along the posteromedial tibia.

Postoperative protocols emphasize early range-of-motion exercises and progressive gait retraining, with return to sports typically at 12 weeks. Recent studies demonstrate that 4-compartment fasciotomy allows 64% to 96% of patients to return to function, although recurrence rates approach 45% and revision rates up to 25% have been reported. Wound complications occur in 15% to 25% of cases but are mitigated by meticulous dissection and neurovascular protection.

Four-compartment fasciotomy remains the most reliable treatment for CECS refractory to conservative care. Success depends on comprehensive compartment release and precise identification of neurovascular structures to minimize complications. While most patients achieve meaningful symptom relief and functional recovery, recurrence underscores the importance of surgical precision and postoperative rehabilitation to ensure durable outcomes.

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