The pathophysiology behind acute compartment syndrome is generally ignored by treating physicians. Pressure and subjective signs like pain have been used as surrogate measures of pathology progression in the affected compartment. Due to incomplete understanding of local and systemic physiological changes that occur with increasing pressure in the compartment, both surgical and nonoperative procedures have not been optimized. A recognized progression of the pathological changes has been elicited. Local necrosis, fluctuating pressure gradients and reperfusion injury all play a part in the condition. Ongoing physiological cascades then progress to overall muscle death, nerve injury, and systemic manifestations that are reversible or treatable in some cases.