As sports physiotherapists we treat all sorts of patients that want to do crazy things. You know… run, swim and ride all day and even climb mountains and cliffs. Many of these athletes are young and physically active, and they strive to push their body to its physical limits. A well recognised condition to affect this group of people is chronic exertional compartment syndrome (CECS). In fact, eighty-seven percent of patients with CECS participate in sports, and runners account for 69% of these cases (Detmer et al., 1985; Shah et al., 2004). Thus, sports physiotherapists, particularly those that deal with endurance sports, will assess and treat this condition with considerable frequency. Therefore, this article discusses new research on changing biomechanics to manage CECS.
So What Is Chronic Exertional Compartment Syndrome?
CECS is a condition of increased pressure in the fascial compartments (muscles and neurovascular structures bound by fascia and bone) related to exercise and leads to recurrent episodes of pain (Brewer & Gregory, 2012). Whilst several hypotheses exist to explain the development of tissue ischemia that occurs in the condition, it is primarily believed that increased intramuscular pressure compromises circulation, prohibits muscular function, and causes pain and disability in the lower leg (Blackman, 2000).
As most of us will know there are 4 distinct compartments located in the lower leg:
- Superficial posterior
- Deep posterior
Of these, the anterior compartment is the most commonly reported location of CECS. Subsequent to its frequency of presentation, the anterior compartment is also the most frequently studied in regard to intramuscular pressure (Edmundsson et al., 2007).
Athletes that present with CECS will complain of increasing lower leg pain upon physical exertion. Importantly, this must also be in conjunction with the absence of other physical signs and symptoms at rest (Brewer & Gregory, 2012; Blackman, 2000). As the athlete continues with the exertional activity, most frequently running, the intramuscular/intra-compartmental pressures continue to rise and may then result in reported symptoms of increasing pain, sensory abnormalities, and muscle weakness.
So What Treatments Should We Use?
We all know what a tricky condition chronic exertional compartment syndrome can be to treat. Unfortunately for the sports physiotherapist (or physical therapist) the research has suggested that a successful long-term nonoperative treatment option does not exist (Dieball et al., 2012). Research has suggested that treatments of anti-inflammatory medications, drugs, stretching, prolonged rest, ultrasound, electrical stimulation, orthotics, and massage have resulted in limited success (Tzortziou et al., 2006; Dieball et al., 2012).
This means that many athletes (a group who normally do not want to stop their aggravating ‘exertional activity’) often progress to surgical management in the form of fasciotomy. Fortunately, the majority of patients do well after surgery and do not report any further issues. However, approximately 3% to 17% of people who have undergone a fasciotomy experience less than favorable outcomes such as ankle pain, decreased sensation at the incision site, numbness at the lateral lower leg, hypersensitivity to touch, paresthesia in the legs, and recurrence of symptoms (Howard et al., 2000; Schepsis et al., 1993).
Well then… what should we do?
I don’t think anybody would be surprised to hear that assessing and correcting biomechanical faults is a core component of rehabilitation for chronic exertional compartment syndrome. In many athletes the success that can be achieved via identifying and managing biomechanical faults is nothing short of amazing. Subsequently, biomechanical assessment and treatment (particularly with respect to running) is a topic that has been discussed on this site previously, including:
- The Running Shoe
- Footwear Prescription (including Barefoot Running) Podcast
- Gait/Running Technique Training for Patellofemoral Pain
….and the list goes on…. so don’t be surprised if you read about it even more! When it comes to the relevance of biomechanics of running to the development of chronic exertional compartment syndrome research tells us that a hindfoot strike gait pattern leads to increase ground-reaction forces, stride length, and ground-contact time. See this great Powerpoint Presentation from Sports Podiatrist Emily Smith for more in depth information on this topic. Furthermore, it has been shown that running technique also influences the anterior compartment pressures of the leg, conceivably through decreased eccentric activation of the anterior musculature (Kirby et al., 1983; Tsintzas et al., 2009).
Thus, it is possible that training and adopting a forefoot running technique may be effective in reducing the symptoms of athletes with CECS who hind-foot strike… to the research!
New Research on Forefoot Running for Chronic Exertional Compartment Syndrome
Diebal et al (2012) took 10 patients (members of the Armed Forces) diagnosed with CECS and suffering a minimum of a 6-month history recurrent anterior and/or lateral leg pain and tightness in one or both legs that worsened with running. These patients were awaiting surgical intervention (fasciotomy) and were prospectively enrolled into the study. The intervention took place over 6 weeks with 3 x 45 minute sessions per week, which I feel is achievable and generalisable to a competitive athlete population. The aim of the intervention was for the patients to adopt a forefoot strike running technique and included specific training drills and exercises, verbal feedback, visual feedback including running technique analysis (see the article here for more details).
What Outcomes Were Assessed?
The authors assessed quite a few variables:
- Compartment Pressures (pre and post exercise)
- Running Performance
- Kinematic Measurements: including step length, step rate, and support time
- Kinetic Measurements: vertical ground-reaction force, impulse, and weight acceptance rate
- Subjective Self-Report Questionnaires
The Impact of Forefoot Running on Chronic Exertional Compartment Syndrome
Well, this intervention has showed some very positive early results. Interestingly (to same but maybe not to others) all of the 10 subjects included in the study displayed a hind-foot strike running technique, and 8 had bilateral symptoms. Following the 6 week intervention program the results showed an improvement in:
- Compartment Pressures: there was a significant difference between pre-intervention after running (78.4 +/- 32.0 mm Hg) and 6 weeks
post-intervention after running (38.4 +/- 11.5 mm Hg). Suggesting that the intervention reduced the previous intra-compartmental pressure rise associated with activity.
- Running Performance: running distance increased significantly from pre-intervention (1.4 6 0.6 km) to 6 weeks after intervention (4.8 6 0.5 km). At the 6 week mark 9 out of 10 subjects were able to run 5 km with reported verbal rating scale pain levels of less than or equal to 1 out of 10. At the 1 year follow-up 8 of the 10 patients were running a minimum of 5 km 2 to 3 times per week, and the 2 others had current musculoskeletal injuries.
- Kinematic Measurements: consistent with a change to a forefoot strike running technique step length and contact time significantly decreased while step rate significantly increased at 6 weeks.
- Kinetic Measurements: as anticipated peak vertical GRF, impulse, and weight acceptance rate all significantly decreased.
- Subjective Self–Report Questionnaires: there was a significant improvement in the subjective self-report questionnaires, and the improvement was maintained at 1 year follow-up.
- All of the 10 subjects included in the study avoided undergoing surgical intervention.
But it’s not all good news..
Limitations of The Research
As the more astute of you may have already identified there are many limitations to this study, including:
- Small sample size (n=10)
- No control group
- Short term follow-up of all variables (it would be great to see if all biomechanical adaptations were maintained long term!)
Take Home Message
The easy to read message is that teaching and training a forefoot strike running technique was effective at reducing pain and improving running performance in 10 subjects with chronic exertional compartment syndrome. Whilst a large randomised clinical trial is warranted (and the authors suggest they are planning one), this article provides preliminary evidence for the long known (to many sports physiotherapists) clinical effectiveness of biomechanical interventions for CECS.
What Are Your Thoughts?
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Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. 2000;32:s4-s10.
Brewer RB, Gregory AJM. Chronic lower leg pain in athletes: A guide for the differential diagnosis, evaluation, and treatment. Sports Health: A Multidisciplinary Approach 2012;4(2):121
Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med. 1985;13:162-170′
Diebal AR, Gregory R, Alitz C and Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med 2012 40(5): 1060
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Tsintzas D, Ghosh S, Maffulli N, King JB, Padhiar N. The effect of ankle position on intracompartmental pressures of the leg. Acta Orthop Traumatol Turc. 2009;43(1):42-48.
Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin J Sport Med. 2006;16(3):209-213