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Chronic exertional compartment syndrome (CECS) is a condition that occurs almost exclusively with running whereby exercise increases intramuscular pressure compromising circulation, prohibiting muscular function, and causing pain in the lower leg. Currently, a lack of evidence exists for the effective conservative management of CECS. Altering running mechanics by adopting forefoot running as opposed to heel striking may assist in the treatment of CECS, specifically with anterior compartment symptoms.
The purpose of this case series is to describe the outcomes for subjects with CECS through a systematic conservative treatment model focused on forefoot running. Subject one was a 21 y/o female with a 4 year history of CECS and subject two was a 21 y/o male, 7 months status-post two-compartment right leg fasciotomy with a return of symptoms and a new onset of symptoms on the contralateral side.
Both subjects modified their running technique over a period of six weeks. Kinematic and kinetic analysis revealed increased step rate while step length, impulse, and peak vertical ground reaction forces decreased. In addition, leg intracompartmental pressures decreased from pre-training to post-training. Within 6 weeks of intervention subjects increased their running distance and speed absent of symptoms of CECS. Follow-up questionnaires were completed by the subjects at 7 months following intervention; subject one reported running distances up to 12.87 km pain-free and subject two reported running 6.44 km pain-free consistently 3 times a week.
This case series describes a potentially beneficial conservative management approach to CECS in the form of forefoot running instruction. Further research in this area is warranted to further explore the benefits of adopting a forefoot running technique for CECS as well as other musculoskeletal overuse complaints.
Since the 1970's the popularity of aerobic exercise has increased tremendously.1 Running has long been a primary popular choice of aerobic exercise for many people and boasts several positive health benefits. It can be performed virtually anywhere without any special equipment, can complement most physical training programs, and can improve aerobic endurance with three 30 minute training sessions per week.2 As the number of individuals participating in leisurely jogging and running activities has increased, the incidence of injuries has also increased.3,4
In an effort to prevent, treat, and reduce running injuries, a current trend in rehabilitation has centered on modifying running technique. Several running techniques that have recently gained popularity are Chi Running, Barefoot Running, Evolution Running, and the Pose Method.5–7 These running styles are similar in the sense that they aim to eliminate the initial heel strike at ground contact by promoting a forefoot strike upon impact. While much more research is needed to determine if adopting such a running style can help prevent injuries, several authors have demonstrated that a significant reduction of ground reaction forces can occur if the heel strike is eliminated at initial impact.8–10 Research has not been thoroughly conducted to determine what musculoskeletal conditions would respond favorably or not so favorably to changing running styles. Theoretically, adopting a forefoot running style would be best suited for those conditions that could benefit from reduced ground reaction forces while running (i.e., stress reactions/fractures, anterior knee pain, back pain, etc.). This case series presents preliminary data which suggests that chronic exertional compartment syndrome (CECS) is one musculoskeletal condition that may respond positively to adopting an alternate running style.
CECS is defined as a condition that causes lower leg pain and disability during exercise in the presence of increased intramuscular pressure in a closed fibro-osseous space.3,11,12 This condition is most prevalent in young adult athletes and occurs with increased frequency among members of the military.11,13,14 The exact cause of CECS remains unclear but it is speculated that the pressure increase is due to arterial spasm, capillary obstruction, arteriovenous collapse, venous outflow obstruction, muscle hypertrophy, fascial inflexibility, or a release of protein bound ions.4,11,12,15 The high pressure may cause vascular occlusion and decreased tissue perfusion which may lead to ischemic pain that often occurs bilaterally.16–19 The anterior compartment is the most common location for CECS to occur, with runners accounting for 69% of all cases.14,19 The anterior compartment is bordered by the tibia, fibula, interosseous membrane, and the anterior intermuscular septum. It consists of the tibialis anterior muscle and anterior tibial artery, extensor digitorum longus, extensor hallucis longus, fibularis tertius muscles, the anterior tibial artery, and the deep fibular nerve. Diagnosis of this condition is difficult due to the lack of clinical signs and symptoms. History and physical examination alone are often considered inadequate for the diagnosis of CECS.20 Intracompartmental pressure measurements confirm the diagnosis of CECS and help differentiate it from other conditions causing exercise induced pain.21 Pedowitz et al developed intramuscular pressure thresholds using a slit catheter to further assist in the diagnosis of CECS.18 For those suffering from CECS, running activities present a significant problem. As the compartment pressure increases, a person may develop lower leg pain, sensory abnormalities, and muscle weakness which eventually results in a premature cessation of the activity.4,11–13,20,22–27 Upon cessation of the activity the compartment pressure decreases, pain subsides, and the functional examination returns to “normal”, typically within ten minutes.11,12 Recommended non-surgical management for CECS includes anti-inflammatory drugs, stretching, prolonged rest, decreasing or avoiding the problematic activity, orthotics, and massage.16,20,23,25 None of these conservative approaches have yielded consistently positive long term results; however, no randomized controlled studies exist in the literature to truly investigate conservative management techniques.28 If those with CECS do not desire to modify their activity level, the only effective treatment for this condition is surgical management in the form of a fasciotomy.16,25 While the majority of patients do well following surgery, approximately 3-17% of individuals undergoing fasciotomy experience less than favorable outcomes such as ankle pain, reoccurrence of symptoms, decreased sensation at the incision site, numbness at the lateral leg, hypersensitivity to touch, and paresthesias in the legs.16,19,29,30
One conservative management approach that has not been investigated, but theoretically could assist those with anterior CECS, is altering running technique. Kirby et al found that anterior compartment pressures were significantly influenced by running style, reporting anterior compartment pressures were increased when a heel striking gait pattern was utilized.15 It has also been well documented that forefoot striking as opposed to heel striking causes a decrease in ground reaction forces, stride length, and ground contact time and an increase in step rate.8–10,31–42 To the authors' knowledge, the modification of running technique as an intervention for CECS has not previously been investigated. Incorporating the use of a systematic instructional model, which focuses on landing on the forefoot as opposed to the heel, may assist in controlling the elevation of compartment pressures with running. If successful, this could allow those suffering from CECS the ability to run longer without symptoms and possibly reduce the need for fasciotomy.
The purpose of this case series is to describe the outcomes for two subjects with anterior CECS through the implementation of a systematic conservative treatment model focused on forefoot running.
Both participants were given a verbal explanation of the study protocol and provided written informed consent prior to testing. Approval was granted by the Institutional Review Board at Keller Army Community Hospital.
Case 1: A 21-year old female (154.9 cm, 52.6 kg) presented to physical therapy with a four year history of bilateral anterior and lateral lower leg pain that occurred while running. The patient reported leg symptoms while running that began predictably before 0.8 km resulting in pain and tightness, which progressively worsened to include numbness and pressure with pain throughout the exercise. She reported the ability to tolerate the leg pain for several kilometers if running on flat surfaces at a slower pace; however, she could tolerate less than 1 km if she ran up hills. She reported that upon cessation of running her symptoms would completely resolve within 5 to 10 minutes.
The initial physical examination at rest was unremarkable (i.e., full ankle and knee range of motion (ROM) and strength, no tenderness or compartment tightness to palpation, and full functional ability to squat and hop without symptoms). A running evaluation was conducted by real time observation using a commercial grade treadmill (LifeFitness, 97Ti, Franklin Park, IL). The patient ran at a self-selected pace of 11 km per hour, demonstrating a heel striking and over-striding gait pattern. The patient reported an onset of pain in the anterior and lateral aspect of both lower legs after running 3 minutes, at which time an audible and visual foot slap was observed for both lower extremities. After 0.8 km (5 minutes, 10 seconds), the patient reported a 6/10 pain on the left leg (2/10 on the right leg) and requested to end the session. A physical examination immediately following revealed an appreciable firmness and tenderness to palpation in both anterior compartments, and decreased dorsiflexion strength bilaterally (4+/5). Based on history and physical examination, a preliminary diagnosis of leg pain consistent with CECS was made.
The subject returned the following day for the collection of kinematic and kinetic running data. An instrumented treadmill was utilized (Kistler-Gaitway, Zurich, Switzerland) to assess variables illustrating running technique such as; step length, step rate, vertical ground reaction force (GRF), and impulse, (Table 1). Impulse is defined as the product of the magnitude of a force and its time of application. It is specifically the area under a vertical ground reaction force-time curve. In a third visit, pre- and post-exercise intracompartmental pressures of the anterior compartments were measured by an orthopedic surgeon (refer to Tables 6 and 7 for values) using a Stryker Intracompartmental Pressure Monitor (Side Port Needle, Kalamazoo, MI).20,43,44 Positioning of the knee, leg, and foot was standardized for all measurements. Post-exercise pressure measurements were taken at 1 minute following exercise cessation. Due to the elevation in post exercise intercompartmental pressure, the diagnosis of CECS was made by the orthopedic surgeon.
Physical therapy intervention was initiated that focused on modifying the patient's running technique. The patient was instructed in a forefoot running technique on both land and treadmill, with the aim of eliminating the initial heel strike and consequently reducing ground reaction forces.7,45 Training included increasing her running step rate to 3 steps per second and using her hamstrings to pull her foot from the ground versus push her foot from the ground using the gastocneumius.9 A digital metronome (Seiko, DM50S, Singapore) was also utilized to increase step cadence to 180 steps per minute. Focused training drills and exercises consisted of weight shifting, falling forward, foot tapping, high hopping, and running with a specialized belt (EZ Run Belt, Posetech.com) as described by Romanov (Figures 1–5).7,46 The subject also practiced running barefoot with verbal cueing to “run quietly” to eliminate the tendency to heel strike upon ground contact. Feedback was provided using video recorded from a commercial camera (Flip Video, Cisco, California) and placed on a personal laptop computer (MacBook Pro, Apple) to help demonstrate and correct running errors. This instruction was conducted 3 times a week for approximately 1 hour each and took place over the course of 6 weeks. The instruction initially consisted of the training drills listed in Figures 1–5 and then progressed to forefoot running intervals for distances of .25 km with a two minute walking period between intervals. Running endurance was gradually progressed as proper running form was maintained for longer distances between walking bouts. Instruction during the last 3 weeks of training mainly focused on improving running speed and endurance while maintaining proper form during running duration.
At 6 weeks post-intervention, the physical examination, including intracompartmental pressures, and the kinematic and kinetic treadmill measurements were repeated. The physical examination was unremarkable before and after running. The patient ran 5 km (26 minutes, 18 seconds) on the treadmill without any pain complaints; treadmill testing concluded at a predetermined distance of 5 km. The force plate treadmill measurements and the pre- and post-intracompartmental pressures of the anterior compartments are presented in Table 1 and Figure 6. She also completed a global rating of change (GROC) score at that time, rating herself as a 6 (a great deal better). A follow-up questionnaire was completed at 7 months, at which time the subject reported the ability to run 12.87 km (including) hills without an increase of leg symptoms and she reported that she was training to run a marathon.
Case 2: A 21-year old male (172.7 cm, 97.4 kg) presented to physical therapy with complaints of bilateral anterior and lateral lower leg pain while running seven months status post two-compartment (anterior and lateral) right leg fasciotomies (to correct CECS). He stated that his pre-surgical symptoms returned on the right leg within two months following surgery and now has a new onset of pain and tightness in the left leg. The patient reported that his left leg was now worse than the right, and his overall pain caused him to stop running after approximately 5 minutes. He verbalized concern that he may need a surgery on the left leg. He reported complete reduction of symptoms within 5 minutes of rest.
Similar to the first case, the physical examination was unremarkable at rest. However, this patient had noticeably hypertrophied lower legs (calf musculature). A running evaluation, utilizing visual analysis, was conducted on a commercial treadmill at a self-selected speed of 10.5 km/hr, during which he demonstrated a heel striking gait pattern. After running for 2 minutes, 30 seconds, he reported pain and tightness in the right anterior and lateral lower leg. After 0.81 km (5 minutes, 14 seconds), the subject noted the onset of pain and tightness on the left side. After 1.56 km (9 minutes, 11 seconds), a foot slap was observed on the left side at which time he requested to stop the activity. Physical exam immediately following revealed an appreciable firmness and tenderness to palpation in both anterior compartments. He complained of pain in the legs with resisted dorsiflexion (5/5 strength) and with full passive plantar flexion. Kinematic and kinetic data was gathered along with pre- and post-exercise intracompartmental pressures of the anterior compartments (Table 2 and Figure 7). The patient was diagnosed with CECS by an orthopedic surgeon and the intervention of modifying his running technique was initiated.
The running instruction and training mirrored that provided during case one, emphasizing a forefoot running pattern, increasing the step rate to 3 steps per second, and use of the hamstrings to pull his foot from the ground while running.7
After 6 weeks, the physical examination, intracompartmental pressures, and instrumented treadmill measurements were repeated. The physical examination was unremarkable before and after running. The patient ran 4.02 km (21 minutes, 8 seconds) on the treadmill without complaints of leg pain; however, the test was discontinued due to complaints of left foot arch pain. A subsequent physical exam of his foot and ankle was unremarkable. The kinematic and kinetic measurements and the pre- and post-intracompartmental pressures of the anterior compartments are provided in Table 2 and Figure 7. He also completed a GROC score at that time and rated himself as a 7 (a great deal better). After 2.5 months he reported he was able to run 6.43 km without pain. On a follow-up questionnaire at 7 months he reported running distances of 6.43 km pain-free 3 times a week.
This case series presents two subjects with CECS whereby altering running mechanics to a forefoot striking technique was the primary intervention. The subjects had favorable results which allowed them to return to pain-free running activity without surgical intervention. The change in running technique was demonstrated by increased step rate and decreased impulse, GRF, and step length (Tables 1 and and2).2). Post-exercise compartment pressures were lower by as much as 30% in some cases (Figures 6 & 7). In addition, these two subjects, who could not run over 1 km without severe symptoms prior to the intervention, could now run 4 and 5 km with minimal difficulty.
Successful rehabilitation for CECS has historically been challenging. Physical therapists typically perform patient examinations looking for impairments that can be addressed through therapeutic exercise, various modalities, or manual therapies. CECS is a unique condition whereby it is commonly very difficult to find impairments related to a patient's symptoms. Although research is certainly limited, this is potentially one reason why attempts at non-surgical management with anti-inflammatory drugs, stretching, prolonged rest, decreasing or avoiding the problematic activity, orthotics, and massage have largely proved unsuccessful. In these two cases, the selected intervention was not based on any specific impairment observed or measured during the physical examination. Rather, it was based on observing a heel striking gait pattern with running and the theory that decreasing anterior compartment muscle activity could potentially be beneficial for this condition.
There are several possible reasons to explain how the forefoot running training technique may assist those with CECS. Gershuni et al and Tsintzas et al found a significant increase in the anterior compartment pressures of healthy individuals in the full ankle dorsiflexion and full knee extension positions.47,48 The position of full knee extension coupled with full ankle dorsiflexion is consistent with the typical heel strike technique used by runners at initial contact. In addition to a potentially more favorable foot position at initial ground contact (less ankle dorsiflexion), eliminating the heel strike upon ground contact by replacing it with a forefoot strike may reduce the eccentric muscle activity of the anterior leg compartment musculature and therefore mitigate the increase of anterior compartment pressures and symptoms of CECS during running.21,47,48 As previously noted, Kirby et al reported that anterior compartment pressures were increased when a heel striking gait pattern was utilized as opposed to a neutral or forefoot running gait.15 Therefore, a forefoot running technique may favorably reduce the variables that contribute to the onset of CECS symptoms and reduce the necessity for surgical management for this condition.
The cases presented in this paper are interesting for several reasons. In case one, the patient quickly adapted the new forefoot running technique. Compared to pre-intervention measures her impulse, ground reaction forces, and step length decreased by approximately 5%, 7%, and 9% respectively. Step rate increased by approximately 9%. It is possible that altering these aspects of running mechanics favorably affected her during her rehabilitation as she was able to return to running without pain or limitation in 6 weeks.
Case two differs from case one in that he previously had a fasciotomy on his right leg, in which his CECS symptoms returned approximately 2 months after surgery when he resumed running. As his running distance progressed, his left leg became more symptomatic than the right, and his bilateral leg symptoms were consistent with CECS. Adjusting running technique and learning to pull the foot from the ground was challenging for this subject. No specific functional deficits were identified as contributors to this challenge. However, it is the authors' experience that some individuals have a more difficult time than others while attempting to perform a forefoot running technique. A great deal of attention to detail and video feedback was necessary for this patient. Ultimately, he avoided fasciotomy on his left leg and a revision fasciotomy on his right leg, and his running distance has continued to increase.
Ultimately, no cause and effect relationship can be inferred by the results of case report research. Interpretation of the current findings presents challenges related to the fact that pressure measurements post-intervention performed at rest and 1 minute following running could be considered elevated according to previous researchers.18 For example, over 20 years ago, Pedowitz et al published that resting values higher than 15 mmHg and post exercise values over 30 mmHg were indicative of CECS with the caveat that elevated pressures without symptoms of CECS would not be considered a positive test.49 Resting pressure values in these 2 subjects ranged from 20 mmHg to 32 mmHg while post running pressures ranged from 36 mmHg to 63 mmHg. Direct comparison to previously reported values should be cautioned, as conflicting values have been reported by several studies, with reports of normal intracompartmental pressures varying by up to 500%.50,51 It has also been documented that pressure varies with the depth of the catheter placement, which is difficult to control.52 These variables could explain the fact that resting pressures at 6 weeks were elevated compared to the resting pressures at baseline. We are unable to make direct comparisons of our pressure data to findings reported by Pedowitz et al due to the fact that their study used a slit catheter to establish CECS pressure criteria, and the current report describes pressures obtained via a side-port needle catheter. Despite elevated pressure readings, the subjects were asymptomatic. Therefor, they no longer met the diagnostic criteria for CECS; elevated pressures in the presence of other clinical findings.
Caution and careful instruction may be required to avoid undesired complications when one attempts to alter his or her current running style. Common complications include achilles tendonopathy, plantar fascia pain, gastrocnemius soreness, blisters, iliotibial band syndrome, and anterior knee pain.45 Running errors while attempting to transition to a forefoot running gait pattern typically contribute to these musculoskeletal complaints and can be greatly reduced by careful supervision and correction during training. Similar to most new exercise programs, proper form and gradual progression in time and intensity must be emphasized. Additionally, patients presenting with leg pain should be evaluated by a credentialed medical provider.
While no generalizations or intervention recommendations can be made from this case series, it does illuminate the need for further research in this area. For those patients with CECS, adopting a forefoot running style may lead to an increased tolerance for running and therefore potentially decrease the need for surgical management of this condition. The authors are currently conducting a clinical trial with a larger sample size to further explore the effectiveness of forefoot running on those diagnosed with CECS.