Acute limb compartment syndrome (ALCS) is a serious complication of traumatic injury. Although ALCS can occur in any limb, it most commonly occurs following injury to the lower leg, particularly in fractures of the tibia. Practitioners should recognise and treat ALCS as early as possible to prevent the development of further, potentially serious, complications. Most of the literature recommends that patients at risk of ALCS should be carefully monitored, with a focus on pain as the main symptom. However, patients in the intensive care unit (ICU) who are unconscious or sedated may be unable or unreliable in reporting pain, therefore it is necessary to consider alternative assessments for ALCS. This article provides an overview of the evidence and guidelines in relation to ALCS in the lower leg and how to undertake an effective assessment for the condition in patients in the ICU. This will enable practitioners to make evidence-based clinical decisions to improve practice and patient safety.