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BACKGROUND: Bilateral non-traumatic compartment syndrome of the legs is an exceedingly rare presentation that requires emergent surgical intervention. CASE PRESENTATION: We report an unusual case of a 43-year-old man with acute bilateral deep posterior compartment syndrome of the legs with flexor hallucis longus myonecrosis. Despite any clear causative factor, we suggest an etiology based on the unique combination of prolonged creatine supplement use, strenuous exercise, and cocaine use. DISCUSSION AND CONCLUSIONS: The pharmacokinetics of both creatine and cocaine might lead to increased fascial compartment pressures; furthermore, the concurrent use of each substance can potentially cause and exacerbate developing compartment syndrome. The diagnosis of compartment syndrome in the absence of traumatic causes is often delayed and leads to increased patient morbidity. A high index of suspicion and early surgical management is the key for preventing long term adverse sequelae of acute compartment syndrome.
