How to treat anterior compartment syndrome

Your remedial massage therapist, James Maddock, has done specific training to treat compartment syndromes.

Anterior Compartment Syndrome is a condition affecting the lower leg, typically impacting runners, dancers, and other athletes.[1] There are several other compartment syndromes as well, depending on which part of the limb is affected: lateral compartment syndrome, posterior compartment syndrome, and of course anterior compartment syndrome.

How does it happen?

Anterior Compartment Syndrome most commonly arises when your foot-strike pattern favours the heel, with a ‘lazy’ foot-slap as the front of your foot (forefoot) follows the heel to the ground. The shin muscles must work to decelerate or slow down the foot-slap.

It can also occur when you have repetitive strain injuries. In runners, for example, this most commonly occurs when someone starts running either for the first time, or for the first time in a long time, and goes too hard, too fast. The shin muscles cannot adapt quickly enough to the increased strain, and “shin splints” and/or anterior compartment syndrome (ACS) develop. This is also called chronic exertional compartment syndrome (CECS) [2].

Finally, it also occurs following a high-energy impact, either during a sports event or, for example, a motor vehicle collision.

Over time, these muscles – primarily the tibialis anterior muscle – become weak or dysfunctional. This is especially true if there is also nerve compression as part of the syndrome.

The muscles stress out and become inflamed as they try desperately to do their job. Along with the inflammation comes swelling, pain, and oftentimes redness and tenderness. The discomfort can become quite disabling if not treated early.

As they swell, the four muscles attached to the front of the foreleg (shown below) become constricted within the skin-like compartment of fascia that encapsulates them. With less room to slide and function, their outgoing blood flow reduces, which in turn further swells the compartment is a vicious circle.

This causes quite a lot of pain – especially when exercising.

Medical treatments for ACS/CECS are limited, and most people are simply told that they can not run or exercise on their feet any longer. At all. Ever.

In this article, we briefly discuss options for treatment, both with massage and manual therapy, and beyond.

Who’s a fan of abstinence?

Melbourne is a city of sports lovers. Footy, fun runs, tennis, soccer, hockey and everything else – all are at risk of anterior compartment syndrome. Nobody wants to stop doing something they love, right?

Even so, the first method of treatment is usually abstinence. This never goes down well!

As I have discovered, try telling a passionate runner or tennis player to stop running, forever, and see what they tell you…!

For this reason, I prefer to give them at least a chance with manual therapy assessment and treatment before forever writing off the idea of running around again.


Pain medication is not usually effective at treating the condition[3].

Conventional treatment is to surgically open the compartment to release the pressure followed by specialist physiotherapy or podiatry.

In many cases, symptoms return and some patients might have two, three, or even four surgeries. Even then, the pain may still return.


The standard surgical approach for ACS is called a fasciotomy[4]. It is usually an emergency procedure.

During a fasciotomy, the surgeon puts you under a general anaesthetic, then makes incisions in the fascia compartment that wraps around your muscles, aiming to release the internal pressure and relieve your pain.

However, the usual side effect of this pain relief is the continued inability to do any meaningful exercise, since the muscles rely on the fascia to anchor it to surrounding tissues. without that support, those muscles are unlikely to be able to achieve anything near peak output.

That said, following surgery some people do make good recoveries. The critical component of this is to diligently follow the physiotherapy/podiatry and recovery programs. Those who follow their programs are far more likely to have a better outcome.

What can I do for you?

Manual therapy treatment assesses the relative strength of the calf muscles (which tend to dominate) versus the anterior compartment muscles (which tend to be weakened and overpowered), and aims to re-balance any differences.

Then the job is to reduce the pressure in the anterior compartment by gently stretching the connective tissues, thus loosening the fascia and returning blood flow.

Following that, the client learns the correct corrective exercises that they need to improve foot strike patterns and to maintain the gains we achieve during treatment.

To loosen the fascia, I might call upon techniques and methods such as myofascial release, myofascial cupping, assisted soft tissue manipulation (ASTM) which uses steel tools to gently loosen the tissues, or guided resisted range of motion approaches such as specific assisted stretches.

Your mileage may vary

In full disclosure, this protocol is not always successful. A lot of it depends on your habits and the structural patterns of your body. Certain elements, such as muscle tension, length and strength, can be corrected. We can assess and treat for these aspects.

Certain other elements, such as bone shape or previous surgeries, cannot be corrected with massage therapy.  In those cases, or if the symptoms persist despite massage treatment, a foot specialist such as a podiatrist, sports physio, or orthopedist, would be the next port of call.

Failing that, surgery is the final option.

Further reading

What is remedial massage therapy?

What is myofascial cupping?

What can I expect from a remedial massage appointment?


[1] American Academy of Orthopaedic Surgeons (2009). Compartment Syndrome – OrthoInfo – AAOS. 

[2] Rasul, A. (2017) “Acute Compartment Syndrome Treatment & Management: Approach Considerations, Renal Protection, Indications for Fasciotomy.” Medscape.

[3] Buerba, R.A., Fretes, N.F., Devana, S.K. and Beck, J.J. (2019). Chronic exertional compartment syndrome: current management strategies. Open Access Journal of Sports Medicine, [online] Volume 10, pp.71–79. doi:

[4] Ormiston, R.V. and Marappa-Ganeshan, R. (2022). Fasciotomy. [online] National Institutes of Health. Available at: [Accessed 17 Apr. 2023].