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Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome

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Anterior compartment pressures of the leg as well as kinematic and kinetic measures are significantly influenced by running technique. It is unknown whether adopting a forefoot strike technique will decrease the pain and disability associated with chronic exertional compartment syndrome (CECS) in hindfoot strike runners. For people who have CECS, adopting a forefoot strike running technique will lead to decreased pain and disability associated with this condition. Case series; Level of evidence, 4. Ten patients with CECS indicated for surgical release were prospectively enrolled. Resting and postrunning compartment pressures, kinematic and kinetic measurements, and self-report questionnaires were taken for all patients at baseline and after 6 weeks of a forefoot strike running intervention. Run distance and reported pain levels were recorded. A 15-point global rating of change (GROC) scale was used to measure perceived change after the intervention. After 6 weeks of forefoot run training, mean postrun anterior compartment pressures significantly decreased from 78.4 ± 32.0 mm Hg to 38.4 ± 11.5 mm Hg. Vertical ground-reaction force and impulse values were significantly reduced. Running distance significantly increased from 1.4 ± 0.6 km before intervention to 4.8 ± 0.5 km 6 weeks after intervention, while reported pain while running significantly decreased. The Single Assessment Numeric Evaluation (SANE) significantly increased from 49.9 ± 21.4 to 90.4 ± 10.3, and the Lower Leg Outcome Survey (LLOS) significantly increased from 67.3 ± 13.7 to 91.5 ± 8.5. The GROC scores at 6 weeks after intervention were between 5 and 7 for all patients. One year after the intervention, the SANE and LLOS scores were greater than reported during the 6-week follow-up. Two-mile run times were also significantly faster than preintervention values. No patient required surgery. In 10 consecutive patients with CECS, a 6-week forefoot strike running intervention led to decreased postrunning lower leg intracompartmental pressures. Pain and disability typically associated with CECS were greatly reduced for up to 1 year after intervention. Surgical intervention was avoided for all patients.
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Forefoot Running Improves Pain and
Disability Associated With Chronic
Exertional Compartment Syndrome
MAJ Angela R. Diebal,
*
y
PT, DSc, Robert Gregory,
z
PhD, COL Curtis Alitz,
y
MD, and
COL J. Parry Gerber,
y
PT, PhD
Investigation performed at Keller Army Community Hospital, West Point, New York
Background: Anterior compartment pressures of the leg as well as kinematic and kinetic measures are significantly influenced by
running technique. It is unknown whether adopting a forefoot strike technique will decrease the pain and disability associated with
chronic exertional compartment syndrome (CECS) in hindfoot strike runners.
Hypothesis: For people who have CECS, adopting a forefoot strike running technique will lead to decreased pain and disability
associated with this condition.
Study Design: Case series; Level of evidence, 4.
Methods: Ten patients with CECS indicated for surgical release were prospectively enrolled. Resting and postrunning compart-
ment pressures, kinematic and kinetic measurements, and self-report questionnaires were taken for all patients at baseline and
after 6 weeks of a forefoot strike running intervention. Run distance and reported pain levels were recorded. A 15-point global
rating of change (GROC) scale was used to measure perceived change after the intervention.
Results: After 6 weeks of forefoot run training, mean postrun anterior compartment pressures significantly decreased from 78.4 6
32.0 mm Hg to 38.4 611.5 mm Hg. Vertical ground-reaction force and impulse values were significantly reduced. Running dis-
tance significantly increased from 1.4 60.6 km before intervention to 4.8 60.5 km 6 weeks after intervention, while reported pain
while running significantly decreased. The Single Assessment Numeric Evaluation (SANE) significantly increased from 49.9 621.4
to 90.4 610.3, and the Lower Leg Outcome Survey (LLOS) significantly increased from 67.3 613.7 to 91.5 68.5. The GROC
scores at 6 weeks after intervention were between 5 and 7 for all patients. One year after the intervention, the SANE and
LLOS scores were greater than reported during the 6-week follow-up. Two-mile run times were also significantly faster than pre-
intervention values. No patient required surgery.
Conclusion: In 10 consecutive patients with CECS, a 6-week forefoot strike running intervention led to decreased postrunning
lower leg intracompartmental pressures. Pain and disability typically associated with CECS were greatly reduced for up to 1
year after intervention. Surgical intervention was avoided for all patients.
Keywords: chronic exertional compartment syndrome; anterior compartment syndrome; forefoot running; leg pain
Despite nearly 100 years since Dr Edward Wilson wrote
one of the first clinical encounters pertaining to chronic
exertional compartment syndrome (CECS) of the lower
leg during his return trip from the South Pole,
26
the true
cause of CECS remains elusive. Chronic exertional com-
partment syndrome is a well-recognized condition that
chiefly affects young, physically active people. While several
hypotheses exist that explain the development of tissue
ischemia present with CECS, the primary accepted belief
is that exercise increases intramuscular pressure, which
in turn compromises circulation, prohibits muscular func-
tion, and causes pain and disability in the lower leg.
5,54
There are 4 distinct compartments located in the lower
leg: the anterior, lateral, superficial posterior, and deep
posterior. Of these, the anterior compartment is the most
commonly reported location of CECS and is the most fre-
quently studied in regard to intramuscular pressure.
18,32
The classic symptom of CECS is a complaint of increasing
lower leg pain upon physical exertion in conjunction with
the absence of other physical signs and symptoms at
rest.
5
As the problematic exertional activity (typically run-
ning) continues, compartment pressures incrementally
increase, which presumably causes increasing lower leg
pain, sensory abnormalities, and muscle weakness, even-
tually resulting in a premature cessation of the activity.
§
*
Address correspondence to MAJ Angela R. Diebal, PT, DPT, Keller
Army Community Hospital, West Point, NY 10996 (e-mail:
angie.diebal@us.army.mil).
y
Keller Army Community Hospital, West Point, New York.
z
United States Military Academy, West Point, New York.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546512439182
Ó2012 The Author(s)
§
References 3, 18, 19, 23-25, 41, 48, 52, 55, 56.
1
AJSM PreView, published on March 16, 2012 as doi:10.1177/0363546512439182
Upon termination of the activity, the compartment pres-
sures decrease, pain subsides, and the functional examina-
tion quickly returns to ‘‘normal’’.
19,25
Eighty-seven percent of patients with CECS partici-
pate in sports, and runners account for 69% of these
cases.
12,50
Despite the prevalence of CECS in athletic pop-
ulations, a successful long-term nonoperative treatment
option does not exist.
12,29,36,45,47,49,58
Anti-inflammatory
drugs, stretching, prolonged rest, ultrasound, electrical
stimulation, orthotics, and massage have resulted in lim-
ited success in treating CECS.
23,29,48,55
Becausenoneof
these nonoperative approaches have yielded consistently
positive outcomes, a patient with CECS who does not
choose to modify his or her activity level may elect to
undergo surgical management in the form of a fasciot-
omy.
29,48
While the majority of patients do well after sur-
gery, 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, hypersen-
sitivity to touch, paresthesia in the legs, and recurrence of
symptoms.
12,29,45,49
In addition, another consequence is
the significant hiatus from athletic activity to allow
for tissue healing and the gradual return to activity
thereafter. An effective nonoperative management
approach could eliminate these potential postsurgical
complications.
One nonoperative approach for CECS that has not
thoroughly been investigated is the alteration of running
technique. It is well known that running technique can
significantly influence the kinematic and kinetic meas-
ures used to quantify gait biomechanics.
2,6,10,11,21,35
A
forefoot strike, as opposed to a hindfoot strike, gait pat-
tern leads to decreased ground-reaction forces, stride
length, and ground-contact time.
51,54
Running technique
also influences the anterior compartment pressures of
the leg.
32,53
Specifically, the anterior compartment pres-
sures are decreased when a forefoot contact pattern is uti-
lized when running.
32
Eccentric activity of the tibialis
anterior, which is the primary muscle contained within
the anterior compartment, is also decreased with a fore-
foot strike gait pattern.
51,54
Theoretically, incorporating
the use of a systematic running instructional model
(which focuses on landing on the forefoot as opposed to
the heel) as part of a nonoperative treatment strategy
may buffer the elevation of compartment pressures with
running. If successful, this approach could allow those
suffering from CECS the ability to increase run duration
and intensity without symptoms and greatly reduce the
need for fasciotomy for this condition. The purpose of
this study was to evaluate the effectiveness of a forefoot
running technique intervention on reducing the symp-
toms associated with CECS. It was hypothesized that
this alteration in running technique would result in
decreased anterior compartment pressures, decreased
pain levels, and increased run duration, thereby reducing
the need for surgical intervention for those diagnosed
with CECS.
MATERIALS AND METHODS
Patients
On the basis of history and physical examination, all
patients diagnosed with CECS by an orthopaedic surgeon
and indicated for surgical intervention (fasciotomy) were
prospectively enrolled in the study. Common criteria to
assist with the diagnosis of CECS include symptom onset
within the first 10 to 30 minutes of exercise and symptom
resolution or degradation within several minutes after
exercise cessation.
4,5,14,45,57
To be included in this study,
patients had to be military members required to pass the
biannual Army Physical Fitness Test, which includes
a timed 2-mile run test. They had to report a minimum
of a 6-month history of recurrent anterior and/or lateral
leg pain and tightness in one or both legs that worsened
with running. Pain had to occur within the first 30 minutes
of running and lead to cessation of desired exercise. In
addition, all symptoms had to completely resolve within
15 minutes upon cessation of running. The physical exam-
ination finding had to be ‘‘normal’’ at rest (ie, 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). Exclusion cri-
teria included previous fasciotomy or other lower extremity
surgery, any medical condition that could cause lower
extremity swelling, creatine supplementation in the past
2 months, any injury that would affect running tolerance
besides CECS, any respiratory issue that could effect run-
ning tolerance, and current use of nonsteroidal anti-
inflammatory drugs (NSAIDs). Exclusion criteria also
included an abnormal finding on any imaging modality
(ie, radiographs or magnetic resonance imaging); however,
there were no requirements to order imaging studies for
screening purposes.
Each participant was given a verbal explanation of the
study protocol and provided written informed consent
before testing. Approval was granted by the Institutional
Review Board at Keller Army Community Hospital.
Preintervention Measurements
Shortly after the clinical diagnosis of CECS and enrollment
in the study, baseline measurements were taken for each
patient by the same practitioner, which included height,
weight, and blood pressure. Baseline kinematic and kinetic
measurements as well as anterior compartment pressures
were obtained. Self-report questionnaires including the
Lower Leg Outcome Survey (LLOS) and the Single Assess-
ment Numeric Evaluation (SANE) for the leg were also
completed. Because no validated subjective outcome meas-
ures were available to specifically assess orthopaedic con-
ditions of the leg, a team of physical therapists, athletic
trainers, and orthopaedic surgeons created the LLOS to
evaluate leg conditions such as CECS and tibial stress
injuries (Appendix A, available in the online version of
this article at http://ajs.sagepub.com/supplemental/). This
2Diebal et al The American Journal of Sports Medicine
12-item survey is patterned after a validated knee outcome
survey and uses several questions from that instrument.
30
Raw scores are tallied and reported as percentages (100%
signifying full function without limitation).
Compartment Pressures and Running Performance. To
objectify and confirm the clinical diagnosis of CECS, pre-
exercise and postexercise intracompartmental pressures
of the anterior compartments were measured by the
same orthopaedic surgeon using a side-port needle (Intra-
Compartmental Pressure Monitor, Stryker, Kalamazoo,
Michigan). This device has been shown to demonstrate
acceptable levels of accuracy and precision.
7,37
During
intracompartmental measurements, the patient was posi-
tioned in a long seated position (knee fully extended,
with both the knee and ankle completely relaxed). Because
the entry point for the anterior compartment is located
anterolaterally to the midtibia and over the anterior tibia-
lis muscle belly, measurements of the leg were taken to
find the location of the midtibia on each patient; the needle
was then inserted 3 cm lateral to the midtibial crest. The
pressure monitor was zeroed at a 90°angle, and the skin
was penetrated at a 45°angle through the fascia until
a ‘‘pop’’ was felt, which represented entry into the fascia.
The compartment pressures were obtained after the injec-
tion of 0.3 to 0.5 mL of saline into the compartment to allow
equilibration with the interstitial fluids.
Postexercise measurements were collected after a run at
a self-selected speed using a treadmill (Life Fitness 97Ti,
Franklin Park, Illinois). All patients ran until they
reported a pain level of 7 of 10 on a verbal rating scale. Rat-
ings of perceived exertion and pain levels were also col-
lected immediately after the run using the Borg rating of
perceived exertion (RPE) scale
8
and visual analog scale
for pain, respectively. Postexercise anterior compartment
pressure measurements were taken within 1 minute after
run cessation. Average running speed and total run dis-
tance were documented after completion of the treadmill
running test.
Kinematic and Kinetic Measurements. Kinematic (step
length, step rate, and support time) and kinetic (vertical
ground-reaction force, impulse, and weight acceptance
rate) data were collected utilizing an instrumented tread-
mill (Kistler Gaitway, Winterthur, Switzerland) within 2
days after the pressure measurements. Patients ran at
the same self-selected speed that was established during
baseline testing. Ground-reaction force (GRF) data were
sampled at 250 Hz and filtered using a zero-lag, fourth-
order low-pass Butterworth filter with a cutoff frequency
of 10 Hz. Kinematic and kinetic data were collected for
50 strides before running termination occurred (after
symptoms reached 7/10 on a verbal rating scale).
Self-Report Questionnaires. Self-report questionnaires
included the LLOS and the SANE. The LLOS specifically
evaluates conditions of the leg such as CECS and tibial
stress injuries (Appendix A, available online). The SANE
is a global question that asked patients in this study the
following: ‘‘On a scale from 0-100, how would you rate
your lower leg with 100 being normal?’’
Intervention
The intervention in this study was instruction and training
to adopt a forefoot strike running technique. The aim was to
eliminate the initial hindfoot strike, which would presum-
ably reduce the eccentric activity of the anterior compart-
ment musculature of the leg. Additional emphasis included
increasing the running step rate to 3 steps per second and
using the hamstrings muscle group to pull the foot from
the ground versus push the foot off the ground using the gas-
trocnemius and soleus muscles (Figures 1 and 2).
44
Specific
training drills and exercises designed to teach forefoot strik-
ing consisted of weight shifting, falling forward, foot tapping,
high hopping, and running with the EZ run belt (Pose Tech
Corp, Miami, Florida) and are described previously.
14,42,43
The patients also practiced running barefoot and were pro-
vided with verbal cueing to ‘‘run quietly’’ to eliminate the
tendency to heel strike upon ground contact. A digital metro-
nome was utilized to stabilize step cadence at 180 steps per
minute. A video camera was used to record individual run-
ning form to allow the physical therapist to demonstrate
forefoot technique running errors (ie, overstriding, heel
striking). Exercise instruction was conducted 3 times per
week for approximately 45 minutes each session and took
place over the course of 6 weeks. A typical training session
during the first 3 weeks consisted of approximately 15 to
20 minutes of the specific training drills followed by forefoot
running practice intervals for distances of 0.25 km with a 2-
minute walking period between intervals. The verbal cueing,
digital metronome, and video camera were used during the
running practice time. During the last 3 weeks of training,
the focus was on gradually progressing running speed and
endurance as patients were able to maintain proper running
form for longer distances between walking bouts. The online
video demonstrates the transition of one patient from a hind-
foot striking gait pattern to a forefoot striking pattern.
Postintervention Measurements
Six-Week Follow-up. At 6 weeks after the intervention,
the physical examination, intracompartmental pressures,
kinematic and kinetic measurements using the instrumented
treadmill, and self-report questionnaires were repeated; the
protocol was identical to that used to obtain the baseline
measurements. The primary purpose of collecting kinematic
and kinetic data was to substantiate that a treatment effect
occurred or that running form had indeed changed compared
with baseline from implementing the forefoot running inter-
vention. For the treadmill running test and postexercise
pressure measurements, patients ran until they reported
a pain level of 7 of 10. If a pain level of 7 of 10 was not
reached during the posttest, the running test was terminated
at 5 km or if the patient requested to stop.
In addition to the repeated measures, a 15-point global
rating of change (GROC) scale was included at the comple-
tion of the study to measure the patients’ perceived change
and overall improvement.
31
The scale allowed the patient
to rate his or her change from ‘‘a very great deal worse’’
Vol. XX, No. X, XXXX Forefoot Running Improves Pain and Disability Associated With CECS 3
to ‘‘a very great deal better.’’ The minimal clinically impor-
tant difference for the GROC scale is a 3-point change from
baseline.
31
One-Year Follow-up. At a minimum of 1 year after the
intervention, participants were contacted to complete an
activity questionnaire, the LLOS, and the SANE. In addi-
tion, the military requires a biannual physical fitness
test that includes a timed 2-mile run. The performance
on this test before entering the study and 1 year after
intervention was gathered from institutional records.
Statistical Analysis
Descriptive statistics for variables and measures of cen-
tral tendency for continuous variables were calculated to
summarize the data. Because this study did not use a ran-
dom sampling technique and the sample size was small,
nonparametric tests were utilized for statistical analysis.
To evaluate the primary outcome variables (intracom-
partmental pressures, running time and distance, and
pain) and the biomechanical variables (step length, step
rate,verticalGRF,impulse,andrateofloading),aWil-
coxon signed–rank test was used to analyze differences
between baseline and at 6 weeks postintervention. A Wil-
coxon signed–rank test was also used to evaluate the sec-
ondary outcome variables (LLOS and SANE) between
baseline and at 6 weeks and at 1 year (after intervention)
as well as the 2-mile run time between baseline and at 1
year after intervention. The level of significance was set
at P\.05. All statistical analyses were performed using
SPSS statistics software (Version 11.5, SPSS Inc,
Chicago, Illinois).
RESULTS
Ten consecutive patients (8 male, 2 female) accepted
enrollment into the study. Baseline patient characteristics
are included in Table 1. All patients reported a history of
CECS symptoms for a minimum of 10 months. All patients
participated in self-selected athletic activities as required
by the United States Military Academy, which included
sports such as football, basketball, crew, equestrian, and
grappling. Patients reported that participation in these
sports did not increase CECS symptoms; however, one
patient elected to participate in grappling instead of soccer
because of leg pain experienced during soccer. All patients
were required to run 2 miles for their biannual physical fit-
ness test. Training for and attempting to pass this event
during testing was reportedly the primary symptom-
producing activity. Patients reported not being able to com-
plete the 2-mile run test because of pain or reported being
able to complete the run only through immense pain in
order to pass the event.
The initial physical examination at rest was unremark-
able in all cases (ie, full ankle, knee, and hip ROM and
strength, no tenderness or compartment tightness to pal-
pation, and full functional ability to squat and hop without
symptoms). No excessive wear pattern was evident for any
of the running shoes, and one patient in the study wore
custom orthotics (several years’ history of use).
During the initial running examination, all patients
demonstrated a hindfoot striking gait pattern. All patients
Figure 1. A hindfoot striking runner at ground contact (A)
and toe off (B). Notice the extended knee and dorsiflexed
ankle at ground contact (muscular activity is increased in
the tibialis anterior). The ankle is plantarflexed, and the runner
is pushing off from the ground, which increases the activity of
the gastrocnemius/soleus muscles. Reprinted with permis-
sion from the Pose Tech Corporation.
Figure 2. A forefoot striking runner at ground contact (A) and
toe off (B). The ankle is in a more neutral position at ground
contact, therefore decreasing the activity of the tibialis ante-
rior. At toe off, the foot is pulled from the ground by the ham-
string muscles, and no push off occurs. Reprinted with
permission from the Pose Tech Corporation.
TABLE 1
Patient Characteristics (n = 10)
a
Characteristic
Age, y 20.2 61.5
Weight, kg 88.5 615.9
Height, cm 176.6 65.1
Body mass index, kg/m
2
28.2 64.3
Baseline systolic blood pressure, mm Hg 121 617.8
Baseline diastolic blood pressure, mm Hg 75 611.6
a
All values are means 6standard deviations.
4Diebal et al The American Journal of Sports Medicine
reported the onset of leg pain within the first 5 minutes of
running, which progressively worsened while running.
Physical examination findings immediately upon running
cessation in all cases included increased pain with passive
ankle plantar flexion, increased pain with resisted dorsiflex-
ion, and increased tightness and tenderness to palpation in
the anterior compartment of the leg. Other findings that
occurred infrequently (fewer than 3 cases for each) included
paresthesia, weakness with resisted dorsiflexion, pain with
passive inversion or eversion, and pain with resisted plan-
tar flexion, inversion, or eversion. Symptoms resolved in
all cases within 15 minutes of running cessation.
Of the 10 patients enrolled, 8 had bilateral symptoms,
while 2 had unilateral symptoms. For those patients with
bilateral symptoms, there were no significant differences
in compartment pressures between the right and left legs
at baseline resting (P= .78), baseline after running (P=
.81), postintervention resting (P= .49), or postintervention
after running (P= .71). For the statistical analysis of com-
partment pressures, the mean value was taken for the
patients with bilateral leg symptoms.
Intracompartmental Pressures
There was a significant difference (P= .001) in intracom-
partment pressures between preintervention resting (40.4
611.4 mm Hg) and preintervention after running (78.4
632.0 mm Hg). There was no significant difference (P=
.33) in intracompartment pressures between 6 weeks after
intervention resting (35.9 611.7 mm Hg) and 6 weeks
after intervention postrunning (38.4 611.5 mm Hg). There
was a significant difference (P= .002) between preinter-
vention after running (78.4 632.0 mm Hg) and 6 weeks
postintervention after running (38.4 611.5 mm Hg) (Fig-
ure 3). The increase in postrunning intracompartmental
pressure compared with resting pressure 6 weeks after
intervention (3.7 66.9 mm Hg) was significantly less (P
= .002) than the increase in postrunning pressure preinter-
vention (38.0 624.7 mm Hg).
Running Performance
Running distance increased significantly (P\.001) from
preintervention (1.4 60.6 km) to 6 weeks after interven-
tion (4.8 60.5 km) (Figure 4). Reported pain on the visual
analog scale while running significantly decreased (P\
.001) from preintervention (71.3 67.9 mm) to 6 weeks
after intervention (2.7 65.1 mm) (Figure 4). The Borg
RPE also increased significantly (P\.001) from baseline
(13 61.9) to 6 weeks after intervention (16.7 61.6). No
patient had to withdraw from the study because of compli-
cations or an inability to tolerate the running technique
over the duration of the 6-week instructional period. The
GROC scores at 6 weeks after the intervention were
between 5 and 7 (quite a bit better to a very great deal bet-
ter) for all patients.
Reported running distance at 1 year after intervention
revealed that 8 of the 10 patients were running a minimum
of 5 km 2 to 3 times per week. Regarding the 2 patients who
were not running 5 km, one reported recently tearing his
anterior cruciate ligament while playing soccer, and the
other had sprained her ankle. Neither of these 2 patients
reported running limitations before their recent injuries.
Two patients reported that they completed half-marathons
since their 6-week follow-up. Compared with the 2-mile
run time on the Army Physical Fitness Test before begin-
ning the study, patients completed the 2-mile run signifi-
cantly faster 1 year after intervention (P\.01). All
patients recorded a faster 2-mile run time, while 5 of 10
patients ran at least 30 seconds faster. All of the patients
reported being able to return to sports participation without
limitation, and no patient required a fasciotomy.
Kinematics and Kinetics
Both kinematic and kinetic changes were noted after the 6-
week instructional program. As compared with the
100
120
80
60
Resting Running
mmHg
*
20
40
0
PRE-INTERVENTION 6 WEEKS POST-INTERVENTION
Figure 3. Preintervention and postintervention compartment
pressure measurements at rest and after running. *Statistical
difference between preintervention and 6 weeks postinter-
vention (P\.01). Error bars denote standard deviation.
100
6
70
80
90
5
*
40
50
60
3
4
Km
VAS
10
20
30
1
2
*
-10
0
06WEEKSPOST-INTERVENTION
PRE-INTERVENTION
Run Distance Km VAS
Figure 4. Visual analog scale and running tolerance changes
from preintervention to postintervention. *Statistical differ-
ence between preintervention and 6 weeks postintervention
(P\.001). Error bars denote standard deviation.
Vol. XX, No. X, XXXX Forefoot Running Improves Pain and Disability Associated With CECS 5
preintervention values, step length and contact time sig-
nificantly decreased (P\.05), while step rate significantly
increased (P\.05) 6 weeks after intervention (Table 2). In
addition, peak vertical GRF, impulse, and weight accep-
tance rate all significantly decreased (P\.05) from prein-
tervention to postintervention (Table 2).
Self-Report Questionnaires
The SANE was significantly greater (P\.001) from before
intervention (49.9 621.4) to both 6 weeks after interven-
tion (90.4 610.3) and 1 year after intervention (93.8 6
11.0). Likewise, the LLOS was significantly greater (P\
.001) from before intervention (67.3 613.7) to both 6 weeks
after intervention (91.5 68.5) and 1 year after interven-
tion (94.2 68.2) (Figure 5). With the exception of the 2
patients who sustained unrelated injuries, all other
patients reported 98 or better on the SANE and 92 or bet-
ter on the LLOS at 1 year after intervention.
DISCUSSION
After a 6-week intervention focused on forefoot strike run-
ning instruction, postrunning intracompartmental pres-
sures of the leg were significantly reduced in 10 patients
diagnosed with CECS. In addition, running distance
increased over 300%, while reported pain decreased dra-
matically. The SANE and LLOS self-report questionnaires
were both significantly improved (Figure 5). All patients
after the 6-week intervention reported quite a bit better
(15) to a very great deal better (17) on GROC scores.
One year after the intervention, the SANE and LLOS
self-report questionnaires were overall greater than
reported during the 6-week follow-up. Two-mile run times
were also significantly faster compared with preinterven-
tion values. Perhaps most importantly, surgical interven-
tion was avoided for all patients.
The results of this study provide preliminary evidence
that this nonoperative treatment approach of forefoot
strike running instruction for those who have CECS can
yield positive outcomes. A potential rationale for the reduc-
tion in pain and intracompartmental pressures and the
resulting increase in running tolerance is the difference
in foot and knee position at ground contact during a forefoot
running style compared to a hindfoot running style. Kirby
and McDermott
32
found that anterior compartment pres-
sures were significantly influenced by running style,
reporting that anterior compartment pressures were
increased when a hindfoot striking gait pattern was uti-
lized. Gershuni et al
27
found a significant increase in the
anterior compartment pressures of healthy patients in
the full ankle dorsiflexion and full knee extension posi-
tions. Full knee extension coupled with full ankle dorsiflex-
ion is the exact position of a hindfoot striking runner at
ground contact. This may explain the finding of increased
anterior compartment pressures when using a hindfoot
landing running style.
32
In addition to a more favorable
foot position (less ankle dorsiflexion) at initial ground con-
tact, eliminating the heel strike upon ground contact by
replacing it with a forefoot strike may reduce the eccentric
activity of the anterior leg compartment muscles and
therefore curtail the increase of anterior compartment
pressures and symptoms of CECS with running.
27,53,54
Further research using motion analysis and muscle elec-
tromyography is necessary to substantiate this hypothesis.
The importance of intracompartmental pressure measure-
ments to confirm the diagnosis of CECS or to make surgical
determinations is debatable. While Pedowitz et al
40
pub-
lished ‘‘normal’’ intracompartmental pressure values, only
35% of surgeons use this criteria to diagnose people with
CECS.
55
Pressure measurements vary in some cases up to
500% potentially because of operator experience, catheter
type, volume of instilled fluid, and the depth of catheter
placement.
5,33,59
Obviously, measurement reliability is
enhanced by using a single experienced tester and following
standardized procedures as employed in this study (intra-
class correlation coefficient, .86). Regardless of whether
TABLE 2
Kinematic and Kinetic Data
a
Preintervention Postintervention
Kinematics
Step length, m 1.18 60.08 1.12 60.10
b
Step rate, steps/s 2.71 60.11 2.86 60.17
b
Support time, s 0.30 60.03 0.28 60.02
b
Kinetics
Peak vGRF, BW 2.40 60.18 2.34 60.22
b
Impulse, BWs 0.38 60.02 0.36 60.02
b
Weight acceptance rate, BW/s 29.66 65.54 26.43 65.71
b
a
vGRF, vertical ground-reaction force; BW, body weight.
b
Denotes significant difference compared to preintervention
values at P\.05 for all measures.
Figure 5. Single Assessment Numeric Evaluation (SANE)
and Lower Leg Outcome Survey (LLOS) score changes
from preintervention to 6 weeks and 1 year postintervention.
*Statistical difference between preintervention and 6 weeks
and 1 year postintervention (P\.001). Error bars denote
standard deviation.
6Diebal et al The American Journal of Sports Medicine
a clinician uses pressure measurements, a positive pressure
test result alone is not sufficient to make a diagnosis of
CECS and should never replace a meticulous history and
comprehensive physical examination.
5,46
As an interesting
addendum, the results of this study suggest that there may
be limited benefit in measuring pressures bilaterally for
those who have bilateral symptoms of CECS. It appears
that measuring intracompartmental pressure on one leg
may be sufficient as there were no significant pressure differ-
ences between legs in these people at rest or after running.
Future research should be conducted to examine whether
pressure differences exist in the legs of those who have uni-
lateral symptoms.
Performance outcomes were impressive in this study.
With the exception of one patient, all were able to run
5 km after 6 weeks of the forefoot strike running interven-
tion with reported verbal rating scale pain levels of 1of
10; the single patient who was unable to complete the prede-
termined running distance (ran 3.4 km) stopped because of
a pre-existing patellofemoral problem. Not only did run dis-
tance increase and pain levels decrease, but also the RPE
values during exercise increased. Patients were able to
run harder, as demonstrated by their RPE values, without
an increase in their compartment symptoms. The Borg
RPE scale has been shown to be a good indicator of physical
stress during aerobic training.
22
Lagally et al
34
found that
a correlation exists between a person’s RPE and his or her
heart rate, blood lactate levels, percentage of VO
2
max,
and respiration rate. Given that run distance, pain levels,
and RPE values all demonstrated positive outcomes, it is
not surprising that the GROC score improved substantially
as well. While it may be unclear how a forefoot strike run-
ning style resulted in these notable changes, this study is
the first to provide evidence of a viable nonoperative treat-
ment option for CECS. Certainly, future research is needed
to support the findings of this investigation.
Future research may also be performed to examine the
effects of forefoot running on other musculoskeletal condi-
tions. Similar to our findings, many studies have demon-
strated reductions in impulse, GRF, and stride length as
well as an increase in step rate when adopting a forefoot
versus a hindfoot strike running technique.
||
It is possible
that implementing a similar forefoot running intervention
could improve other lower extremity stress injuries such as
stress fractures or medial tibial stress syndrome. The ideal
length of intervention needed to change a person’s running
style is also unknown. We are not aware of any clinical tri-
als pertaining to this topic. Based on experience and opin-
ion, Arendse et al
2
reported that 7.5 hours of training over
5 consecutive days was required to learn forefoot landing,
while Dallam et al
10
reported a 1-hour session for 12 weeks
was necessary. We chose 6 weeks based on a pilot work of 2
previous cases.
14
Anecdotally, it appeared that the major-
ity of patients in this study had changed running style rea-
sonably well by 3 to 4 weeks. However, running style
research is in its infancy, and thus, further research is
required to address these areas.
One limitation in this study is the small sample size
without having a control group with which to compare treat-
ment effects. A large randomized clinical trial is needed to
confirm these findings, and planning is underway. How-
ever, anecdotal experience at our institution suggests that
the majority of these patients would have elected to undergo
fasciotomy for symptomatic relief with running. The fact
that 10 consecutive patients dramatically improved in run-
ning performance and all avoided fasciotomy is noteworthy.
Another potential limitation is that we did not utilize
motion analysis to definitively demonstrate that patients
were truly employing a forefoot strike at ground contact
while running. Direct visualization of patients and indirect
evidence of decreased impulse and GRF, however, are consis-
tent with the elimination of the hindfoot strike pattern and
the adaptation of a forefoot striking technique.
1,13,15-17,35,39,44
CONCLUSION
In 10 patients with diagnosed CECS, a 6-week forefoot
running intervention performed 3 times per week for 45
minutes led to decreased postrunning lower leg intracom-
partmental pressures. The pain and disability typically
associated with CECS were greatly decreased. All patients
demonstrated large improvements on self-report question-
naires including GROC scores following the 6-week inter-
vention. One year after the intervention, running speed
and distance as well as self-report questionnaires were
greater than reported during the 6-week follow-up, and
surgical intervention was avoided for all cases.
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8Diebal et al The American Journal of Sports Medicine
... Various feedback interventions have been utilized in the kinesiology literature to improve running form such as verbal cueing (e.g., Diebal et al., 2011Diebal et al., , 2012Messier & Cirillo, 1989), auditory cueing (e.g., Diebal et al., 2011Diebal et al., , 2012, biofeedback (e.g., Davis & Futrell, 2016), mirror training (e.g., Agresta & Brown, 2015;Michaud, 2016;Miller et al., 2020), real-time visual feedback (e.g., Clansey et al., 2014;Crowell et al., 2010), and video feedback (e.g., Diebal et al., 2011Diebal et al., , 2012Messier & Cirillo, 1989;Miller et al., 2020). For the four studies that used video feedback, it was never presented as a sole intervention for any of them, thus conclusions about the effects of video feedback on running form cannot be determined from these results. ...
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... Therefore, to treat and prevent many of the injuries, clinicians and runners have turned to many different strategies, including gait retraining. Gait retraining, or modifying an individual's running mechanics, has the potential to treat several running-related injuries, including patellofemoral pain (6, 17,38,43,56) and anterior compartment syndrome (22). Gait retraining can include manipulating step rate, reducing tibial acceleration, reducing hip adduction or altering foot strike pattern. ...
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Background: Suboptimal lower limb and trunk positionings is known to influence exercise-related leg pain (ERLP). It is unknown whether simple 2D video analysis is useful for recording and interpreting running variables in a primary care practice. Research question: Is 2D video analysis a reliable instrument to assess running variables in patients with ERLP in a primary care practice? Methods: Participants undergoing an evaluation for ERLP in two primary care practices were studied. In this reliability study, analysis of running variables was performed by 4 blinded raters on one-stride videos captured with non-high speed cameras (30 fps). Intraclass correlation coefficients (two-way random; ICC 2,1) were calculated to determine the inter-rater reliability. The intra-rater reliability was presented by ICC type two-way mixed (3,1). Footstrike pattern was analyzed by calculating the Fleiss' kappa for inter-rater agreement and Cohen's kappa for intra-rater agreement. Sample size calculation indicated that 16 participants would be required for answering the research question. Results: Data of all 16 participants (9 males, age 31 ± 10 yr) were of sufficient quality for analysis. The 2D video analysis demonstrated excellent inter-rater reliability with an overall ICC value of 0.999 (95 % CI = 0.998-0.999). The ICC value of the eversion was 0.384 (95 % CI = 0.148-0.66) and after correction of the systematic error, 0.817 (95 % CI = 0.664-0.922). The agreement on footstrike was substantial with a Fleiss kappa of 0.737. The overall intra-rater reliability was excellent with an ICC value of 0.997 (95 % CI = 0.996-0.997). The intra-rater agreement of the footstrike was excellent with a Cohen's kappa of 0.868. Significance: 2D video analysis provides a highly reliable, relative inexpensive, feasible and suitable measuring instrument for determining running variables in patients ERLP in a primary care setting. This simple technique may identify possible running variables associated with different types of ERLP and may serve as an instrument for tailor-made gait retraining programs.
... The approaches to retrain running gait may differ, but common threads of an effective conservative program seem to include an initial period of barefoot running practice, taking shorter and quicker strides with auditory assistance from a metronome, and focusing on running smoothly and quietly. 9,14,16 CLINICAL BOTTOM LINE Increasing evidence indicates that gait retraining is an effective, nonsurgical intervention for those who have CECS. Although previous researchers have demonstrated positive results in mostly young males with CECS symptoms of a relatively short duration, running gait retraining produced positive results in a 34-year-old female who had CECS symptoms for approximately 20 years. ...
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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.
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