Introduction: Chronic exertional compartment syndrome (CECS) is a recognized cause of activity‑related leg pain, most commonly reported in young athletes. However, long‑standing cases that persist for decades and present in middle‑aged individuals are uncommon and may lead to delayed or challenging diagnosis. This report describes a rare case of CECS with an unusually prolonged clinical course and underscores important diagnostic considerations.

Case Presentation: A 53‑year‑old man presented with a 37‑year history of severe bilateral anterior leg pain provoked by running, physical exertion, and deep squatting. The symptoms were associated with visible, reducible fascial herniations over the anterolateral compartments of both calves. The patient reported partial symptom control through a consistent warm‑up routine before activity. Clinical evaluation and intracompartmental pressure measurements supported the diagnosis of CECS. Following unsuccessful long‑term conservative management, the patient underwent bilateral anterior and anterolateral compartment fasciotomies, resulting in adequate compartment decompression.

Conclusion: This case illustrates that CECS may remain unrecognized for many years and can present later in life. Visible fascial herniations may serve as an important clinical indicator, and individualized conservative measures may provide temporary symptom relief. Nevertheless, surgical decompression remains an effective treatment option when conservative strategies fail.