Chronic Exertional Compartment Syndrome – Is there an alternative to surgery?

Diebal et al, 2012. Forefoot Running Improves Pain and Disability associated with Chronic Exertional Compartment Syndrome. The American Journal of Sports Medicine Vol 40 No 5, 2012

Chronic Exertional Compartment Syndrome (CECS) is a condition chiefly affecting young and active individuals whereby an increase in activity or exercises, primarily running, increases the intramuscular pressure, which in turn compromises circulation, prohibits muscle function and causes pain and disability of the lower leg.  The anterior compartment is the most affected. You may or may not be aware that the compartment pressures of the lower leg are significantly influenced by running, as well as a change in running technique. This study was designed to see if patients with the diagnosis of CECS, and recommended by an orthopaedic surgeon to have a fasciotomy, can reduce their pain and disability by adopting a forefoot strike (FFS) running technique rather than a rear foot strike (RFS) pattern. Measurements were taken pre intervention and then again at 6 weeks.

The criteria for the diagnosis of CECS:

  • Symptom onset within the first 10 to 30 minutess of running
  • Resolution or reduction of symptoms within 7 minutes

The criteria to be included:

  • Members of the military
  • 6 month history of recurrent anterior or lateral leg pain
  • Symptom onset in first 30 minutes, leading to cessation of running
  • Symptoms had to completely resolve within 15 minutes
  • At rest, full range of motion and strength of the knee and ankle, no TOP or compartment tightness to palpation, full functional ability to squat and hop without symptoms


  • Previous fasciotomy (surgical procedure to release fascia around muscles at front of shin) or other lower limb surgery
  • Any medical conditions that could cause  lower extremity pain
  • Any creatine monohydrate (a common supplement for muscle building and weight gain) supplements last 2 months
  • Any injury that would affect running tolerance
  • Respiratory conditions that could affect running tolerance
  • Current use of NSAIDs

Measurements taken pre and post intervention:

  • Intra compartment pressure
  • Running Performance: VAS, distance, Borg RPE
  • Kinematics: step length, step rate, support time
  • Kinetics: GRF, impulse ,weight acceptance rate
  • Self reported questionnaires


  • Intracompartmental pressure postrunning was significantly reduced in all 10 patients
  • Running distance increased by over 300%
  • Pain significantly decreased
  • Self reported questionnaires significantly improved

At a 1 year follow up:

  • Self reported questionnaires were even better than at the 6 week follow up
  • Two mile run times were significantly faster
  • No surgical intervention for all patients


The criteria to be included and excluded for this study I thought were standardised, and very relevant for this study. The only assessments that could have been used are joint range of motion and strength of the hip, making sure they are adequate and consistent amongst the group. All patients were rear foot strikers (RFS).  The pre- and post-running compartment pressures, during the inclusion process, were taken by the same orthopaedic surgeon for all of the patients (use and skill of side port needle).

The intervention, which was the teaching of forefoot striking, was very detailed and comprehensive for the subjects. Exercises instructions were conducted 3 times per week for 45 minutes over a 6 week period. Emphasis was on:

  • Reducing hind foot striking reducing eccentric tibialise anterior (muscle at the front of the shin) activity
  • Increasing the step (cadence) rate for 3 steps per second (i.e. 180 steps per minute)
  • Reducing push from gastroc/soleus complex, and emphasising pull from the hamstrings

Specific training drills designed to teach forefoot striking such as lean forwards, foot tapping, weight shift, ‘ticking’ not thumping, metronome at 180 steps per minute, video analysis and verbal cueing was all used. There was a significant improvement in all 10 patients.


  • Only 10 subjects were used in this study, a rather small group for a generalisation
  • During the inclusion process there were no exact measurements of ROM and strength weren’t taken. Thus what is considered ‘normal’ to be included in this study?
  • They were all from the military; one would assume they are fairly strong and active individuals with adequate muscle strength proximally around the pelvis and through the lower limbs

Discussion and Conclusions

After reviewing the results of this study it is plausible to attempt adopting a forefoot running style to improve the pain and disability of patients who suffer from CECS, as well as their running performance. Although only 10 patients were used, which is definitely the main flaw with this study, I thought with a significant improvement in all patients this was very supportive of the evidence for forefoot running over hind foot strikers. The best outcome for this study is that no patients at 6 weeks, or even the 1 yr follow up required surgery or had deterioration in their symptoms. This could imply that the skills and knowledge of physiotherapy techniques, running analysis, and the ability to teach forefoot running is retained by the individual being taught.   The session length and attention to detail combined with the population of military means the results cannot be generalised – what it implies is that there may be a treatment alternative to surgery that was previously not well supported for patients who are suffering from Chronic Exertional Compartment  Syndrome.  It is worth exploring in clinic and is relatively easy to apply the techniques described in the study.

As clinicians it is our duty to be skilled at analysing running technique and identifying hind foot strikers. With this skill, we should then be able to teach our patients how to forefoot strike using video analysis, verbal cueing, metronomes, and a range of running drills. These running drills, as with this study, include foot tapping, forward lean and weight shifting, reducing push off with the gastroc/soleus and increasing hamstring pull, skipping, and conscious efforts from the patient listening, and ‘feeling’, the way they are running and be able to adjust it.

These are my thoughts.

Thanks for reading and feel free to comment.



Aaron Thomas BSc (Physiotherapy)

Musculoskeletal and Sports Physiotherapist



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