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 ( and ). Post-exercise compartment pressures were lower by as much as 30% in some cases ( & ). 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.