Clinical consensus on diagnosis and treatment of patients with chronic exertional compartment syndrome of the leg: a Delphi analysis

Key points

1. 01Five key diagnostic criteria were agreed: repetitive activity involvement, pain during exercise, tightness during exercise, premature cessation of activities due to pain, and symptoms reproducible on provocation during examination.
2. 02Consensus was reached that gait retraining (88%) and cessation of provoking activities (71%) are valuable conservative treatment components.
3. 03Surgeons agreed on incision size and location for anterior, lateral, and combined compartment fasciotomy.
4. 04No consensus was reached on intracompartmental pressure (ICP) cut-off values, patient positioning during measurement, or whether ICP is essential when clinical criteria strongly suggest the diagnosis.
5. 05No consensus on postoperative weight-bearing restrictions, timing of return to sport, or management of recurrent or residual disease after surgery.

How it was conducted

Design

Three-round electronic Delphi consensus analysis

Panel

27 international civilian and military healthcare providers (sports medicine physicians, surgeons, physiotherapists, clinical researchers)

Consensus threshold

70% positive or negative agreement per question or statement

Rounds

Round 1: 28 questions; Round 2: 22 questions; Round 3: final clarification round; rounds 2 and 3 completed by 24 members (89%)

Scope

Diagnosis and management of CECS of the leg in both recreational athletes and military service members

Literature search period

January 1970 to May 2020 across PubMed, EMBASE, Web of Science, Cochrane, CENTRAL, Emcare

What they found

• Pain during exercise agreed as essential diagnostic clue: 25/27 (93%).
• Tightness during exercise agreed as essential: 24/27 (89%).
• Specific symptom location agreed as conditional: 27/27 (100%).
• Activity modification agreed as conditional: consensus reached (exact n not stated in extracted text).
• Provocative activity involving repetitive muscle activation agreed as conditional: 24/24 (100%).
• Signs and symptoms agreed as essential aspects of diagnostic workup: 23/26 (88%).
• ICP measurement agreed as conditional for diagnosis: 22/27 (82%).
• ICP measurement at 1 min post-exercise agreed as most meaningful timing: consensus reached (exact proportion not stated).
• Bilateral ICP measurement of symptomatic compartments agreed: 17/24 (71%).
• Medial approach for deep posterior compartment measurement agreed: 21/24 (87%).
• Ultrasound-guided tip placement required for deep posterior compartment: 17/24 (71%).
• Supine positioning for ICP measurement did not reach consensus: 16/24 (67%), below the 70% threshold.
• Pedowitz criteria used by majority: 13/24 (54%); locally established cut-off values used by 9/24 (38%).
• Treadmill symptom provocation test agreed as conditional diagnostic test: 21/27 (78%).
• Most panel members do not use imaging (CT, MRI, radiograph) to confirm CECS: 23/24 (96%).
• Gait retraining agreed as valuable conservative component: 23/26 (88%).
• Cessation of provoking activities agreed as valuable: 17/24 (71%).
• Anterior compartment fasciotomy via single 2-cm incision agreed safe and effective: 10/12 surgeons (83%).
• Lateral compartment fasciotomy via two 5-8 cm incisions agreed: 11/12 (92%).
• Combined anterior and lateral compartment fasciotomy via single 4-6 cm incision agreed: 10/12 (83%).
• Deep posterior compartment via medial large incision agreed: 11/12 (92%).
• Standardized postoperative rehabilitation protocol agreed: 21/24 (88%), but permissive vs. unrestricted weight bearing split 67% vs. 33%.
• Standardization of outcome measures agreed: 24/24 (100%).
• Return to previous sports level agreed as outcome parameter: round 1 23/26 (89%), round 2 22/24 (92%).
• Global Perceived Effect scale agreed as outcome parameter: round 2 19/24 (83%).
• No consensus on management of recurrent disease; fasciotomy for recurrent anterior compartment preferred by only 3/23 (13%), fasciotomy with partial fascia removal by 12/23 (52%); variation was similar between surgical and non-surgical panel members (p values not significant).

Limitations

• Panel selection depended on authors' scientific network and subjective judgment, introducing potential selection bias; 18% of invitees were excluded for technical reasons.
• Delphi methodology yields level 5 evidence (expert opinion) only and does not replace original empirical research.
• The 70% consensus threshold lacks a validated scientific rationale.
• The panel was predominantly European (67%) and civilian (70%), limiting generalizability to other geographic and military contexts.

Why it matters

For patients

Athletes or active individuals with exercise-related leg pain can expect clinicians to use a five-item symptom checklist as the starting point for diagnosis, but should be aware that pressure measurement protocols and post-surgery rehabilitation remain unstandardized.

For clinicians

This Delphi output provides a practical five-criterion clinical diagnostic framework and agreed surgical incision guidance for CECS fasciotomy, while highlighting that ICP cut-offs and postoperative rehabilitation protocols urgently need prospective validation.

For readers

The study represents the first expert-consensus attempt at simple CECS guidelines, filling a gap where randomized controlled trials are absent and existing evidence is mostly level 3-4.