... The increase in IMP associated with CECS may be due to changes in compartment compliance, compartment volume, or muscle activity.  It has been suggested that abnormally increased IMP in CECS directly correlates with fascia thickness and structural stiffness, which results in reduced compartment compliance. 8,9 Measurement of IMP is the currently accepted gold standard to confirm the diagnosis of CECS, and the 1-min post-exercise IMP is suggested as the best measure. ...
... 12 There have been questions over the value of IMP testing in the diagnosis of CECS. 6,13,14 Non-invasive methods for the diagnosis of CECS have been suggested, including magnetic resonance imaging (MRI) and near-infrared spectroscopy (NIRS). However, MRI may only be used as a screening test for CECS in the anterior compartment, and further, there is a need for an in-scanner exercise-based MRI, 15 which presently is not available. ...
... The value of IMP measurements has been questioned in earlier studies, 6,13,14 and there is no consensus as to how best to perform or evaluate the IMP measurements in suspected CECS patients. 31,32 Although non-invasive methods for the diagnosis of CECS, including MRI and NIRS, have been suggested, they may be applied as a screening test for CECS but have low sensitivity. ...
This study aimed to compare intramuscular pressure (IMP) in all four compartments of the lower leg between men and women in patients with suspected chronic exertional compartment syndrome (CECS), and to assess possible effects of gender in relation to covariation factors. A consecutive series of patients with exertional leg pain (n = 962, median age 27 years, 56.2% women) underwent IMP measurements between 2009 and 2019. The CECS diagnosis was confirmed (n = 491, 48% women) or ruled out (n = 471, 65% women) based on the patient’s history, clinical examination, and IMP measurements. IMP values of the compartments were compared between genders. A multiple linear regression analysis was performed for IMP in the anterior and lateral compartments, where the number of patients was large enough to investigate the possible impact of other factors such as height, age, and duration of pain. Among those with a confirmed CECS diagnosis, one‐minute post‐exercise IMP was significantly lower in women than in men for all four muscle compartments: anterior (median [range] mmHg 44 [24–120] vs. 50 [24–130]), lateral (35 [20–89] vs. 40 [26–106]), deep posterior (31 [25–36] vs. 34 [24–53]), and superficial posterior (32 [27–39] vs. 37 [22–54]). In the multiple regression analysis, gender differences remained significant in the anterior compartment but not the lateral compartment, where only height remained a significant predictor of IMP. Gender should be considered when using cut‐off values for IMP in diagnosing CECS, especially for the anterior compartment.
... Several strategies for the prevention and treatment of running injuries are applied by coaches and runners themselves; these include stretching, warming up, technical training, and changing the running technique (called retraining) to reduce the load on certain muscle groups and joints . Biomechanical studies have extensively examined running retraining strategies that include changes in the step cadence, stride length, distance between the heel and the center of mass at the initial foot contact with the ground, duration of flight phase, foot strike pattern, hip and knee movement, trunk position, step width, and impact load variables, among others; these studies also reported changes in the variables of kinematics, kinetics, and electromyography . ...
The effectiveness of lower-cost equipment used for running gait retraining is still unclear. The objective of this systematic review was to evaluate the effectiveness of lower-cost equipment used in running gait retraining in altering biomechanical outcomes that may be associated with injuries. The literature search included all documents from MEDLINE, Web of Science, CINAHL, SPORTDiscus, and Scopus. The studies were assessed for risk of bias using an evaluation tool for cross-sectional studies. After screening 2167 initial articles, full-text screening was performed in 42 studies, and 22 were included in the systematic review. Strong evidence suggested that metronomes, smartwatches, and digital cameras are effective in running gait retraining programs as tools for intervention and/or evaluation of results when altering step cadence and foot strike patterns. Strong evidence was found on the effectiveness of accelerometers in interventions with feedback to reduce the peak positive acceleration (PPA) of the lower leg and/or footwear while running. Finally, we found a lack of studies that exclusively used lower-cost equipment to perform the intervention/assessment of running retraining.
... This can explain the overall high level of tibialis anterior activation observed during this phase (Novacheck, 1998;Reber et al., 1993). These errors can have important implications for investigations of running-related injuries that are associated with tibialis anterior fatigue and overuse, such as chronic exertional compartment syndrome (Franklyn-Miller et al., 2014), medial tibial stress syndrome (Hamstra-Wright et al., 2015), and tibialis anterior muscle pain. Likewise, many other structure-specific load metrics can be considerably over-or underestimated by ignoring muscle inertia in inverse dynamics calculations, which in turn can lead to erroneous study conclusions. ...
Skeletal muscles have inertia that leads to inertial forces acting around joints. Although these inertial muscle forces contribute to joint kinetics, they are not typically accounted for in musculoskeletal models used for human movement biomechanics research. Ignoring inertial forces can lead to errors in joint kinetics, but how large these errors are in inverse dynamics calculations of common movements is yet unclear. We, therefore, examined the role of shank muscle inertia on ankle joint moments during the swing phase of running at different speeds. A custom musculoskeletal modelling and simulation platform was used to perform inverse dynamics with a model that either combined muscle mass in the total shank mass, or considered the gastrocnemius lateralis/medialis, soleus, and tibialis anterior muscles as separate masses from the shank. Ankle moments were considerably affected when muscles were modelled as separate masses, with a general shift towards reduced dorsiflexion and higher plantarflexion moments. Differences between both modelling conditions increased with running speed and ranged between 0.8-1.6 Nm (ankle moment profile root mean square error), 8-18% (peak dorsiflexion moment difference) and 24-42% (peak plantarflexion moment difference). Moreover, we observed a complex combination of inertial forces, especially those due to rotation and translation of the shank, in which the direction of inertial force changed during the swing phase. These results show that ignoring muscle inertia in musculoskeletal models can lead to under- or overestimations of structure-specific loads and thus erroneous study conclusions. Our results suggest that muscle inertial forces should be carefully considered when using musculoskeletal models.
... Since the tibialis anterior is the primary dorsiflexor of the ankle joint, changes in dorsiflexion moments can be reasonably assumed to affect tibialis anterior force requirements. Peak dorsiflexion moment reductions of up to 18% suggest that tibialis anterior force demands can be substantially overestimated when using CSM, which can have implications for investigations of running-related injuries that are associated with tibialis anterior fatigue and overuse, such as chronic exertional compartment syndrome (Franklyn-Miller et al., 2014). However, the muscle inertia effects demonstrated in this simple example are likely to be further magnified in other scenarios, especially those including high-velocity movements, joints crossed by biarticular muscles, and/or large muscle masses. ...
Skeletal muscles have substantial inertia that cause inertial forces working around joints. These inertial forces are not typically considered in musculoskeletal models used for sport biomechanics research, which can lead to considerable errors in estimated joint kinetics. How large these errors are in common sports movements is yet unclear. We therefore examined the role of shank muscle inertia on ankle joint moments during the swing phase of running at different speeds. Ankle moments were considerably affected when muscles were modelled as separate masses, with a general shift towards reduced dorsiflexion and higher plantarflexion moments. These results show that ignoring inertial muscle forces in musculoskeletal simulations can lead to under-or overestimations of structure-specific loads and possibly erroneous conclusions. We therefore encourage sport biomechanics researchers to consider the impact of muscle inertia on inverse dynamics calculations.
... 2 In 2014, the term "biomechanical overload syndrome" was introduced and later used for a syndrome that clinically mimics ant-CECS without pathologically elevated ICPs values. 2,3 ERLP has a manifest effect on young active duty service members in the armed forces. 4 In the Netherlands, ERLP is consistently in the top 3 of overuse injuries and constitutes a significant portion of the 25% attrition rate from musculoskeletal injuries during both basic and elite military training. ...
Objective: To explore the relationship between a single the intracompartmental pressure value in the anterior compartment of the leg one minute after provocative exercise and the outcome of a conservative treatment program in a cohort of military service members with chronic exercise-related leg pain.
Design: Retrospective cohort study.
Setting: Department of military sports medicine at a secondary care facility.
Participants: In the years 2015 through 2019, the conservative treatment program was completed by 231 service-members with chronic exercise related leg pain, of whom 108 patients with 200 affected legs met all inclusion criteria.
Interventions: All patients completed a comprehensive conservative treatment program, consisting of four to six individual gait retraining sessions during a period of 6-12 weeks. In addition, patients received uniform homework assignments, emphasizing acquisition of the new running technique.
Main Outcome Measure(s): The primary treatment outcome was return to active duty. The duration of treatment, occurrence of acute on chronic compartment syndrome, and patient reported outcome measure were considered secondary treatment outcomes. Potential risk factors for the primary treatment outcome were identified with a generalized logistic mixed model.
Results: Return to active duty was possible for 74 (69%) patients, whereas 34 (31%) needed further treatment. The multivariable analysis showed that the absolute values of ICP in the anterior compartment were not associated with the treatment outcome (odds ratio 1.01, p=0.64). A lower SANE-score at intake was negatively associated with the potential to successfully return to active duty (odd ratio 0.95, p=0.01). No acute on chronic compartment syndromes were reported.
Conclusions: A single postexercise intracompartmental pressure value in the anterior compartments of the lower leg of military service members with chronic exercise-related leg pain was not associated with the outcome of a secondary care conservative treatment program and can be safely postponed.
... It is known that high recurrent loading of the ACL can lead to graft creeping and eventually failure . Furthermore, issues such as patellofemoral pain syndrome are typically the cumulation of chronic overload  and common after ACLR. It is recommended to monitor the cumulative loading of respective tasks, which can be done through documenting the exercise sets, reps and weight lifted/foot contacts alongside the task intensity. ...
Nach einer Rekonstruktion des vorderen Kreuzbands wollen verletzte Sportler so schnell wie möglich wieder zurück auf den Platz. Die Autoren erklären, welche Rolle das Sprungtraining dabei spielt und was man beachten muss.
Dieser Artikel beschäftigt sich mit den biomechanischen Eigenschaften der Arterien und dem Einfluss des perivaskulären Gewebes auf die Durchblutung. Es wird erläutert, wie die Arterien in ihrer Umgebung stabilisiert sind, wie sie sich gegenüber der Umgebung bewegen und wie sich das perivaskuläre Gewebe und die Arterien gegenseitig beeinflussen. Anschließend wird, abgeleitet aus der embryologischen Entwicklung, eine Referenzposition für die unteren Extremitäten vorgeschlagen. Am Ende des Artikels werden am Beispiel der unteren Extremität osteopathische Techniken gezeigt, welche die biomechanische Integration der Beinarterien als Ziel haben.
Chronic leg pain is a common problem found in running athletes that can pose challenges for both patient and providers. Metabolic, osseous, soft tissue, and neurovascular etiologies have been implicated. Though common, the presentation of these pathologies can at times be vague and overlapping with reported intermixed symptoms of pain, weakness, numbness, or tingling. This can lead to clinical difficulty in arriving at the proper diagnosis and suggesting the optimal treatment of these conditions. In this chapter, causes of chronic leg pain in running athletes will be reviewed including its clinical presentation, diagnostic evaluation, as well as targeted treatment options with the goal of offering providers a thorough understanding of these pathologies to aid in their practice.KeywordsRunningAthleteLeg painStress fractureChronic painExertional compartment syndromeNerve entrapment|Tibial stress syndrome
The development of computer vision technology has enabled the use of Markerless (ML) movement tracking for biomechanical analysis. Recent research has reported the reliability of ML in motion analysis but has not yet further explored the clinical potential and limitations. The purpose of this study was to investigate the effects of speed on the comparison of estimated lower extremity joint moments and powers between ML and marker-based (MB) technologies during treadmill running. Kinematic data of both MB/ML and ground reaction force data were collected from 16 recreational young adults running on an instrumented treadmill for 120 s at three speeds: 2.24 m/s, 2.91 m/s, and 3.58 m/s. Three-dimensional moments and powers of the hip, knee, and ankle were calculated. Compared to the MB, ML estimated greater increased hip and knee joint kinetics with faster speeds during the swing. Additionally, increased greater ankle joint moments with increased speeds estimated by ML were observed during early swing. In contrast, greater ankle joint power occurred during the initial stance. Despite the promising application of ML technology in clinical settings, systematic ML overestimation requires extra attention. These observations may indicate that inconsistent segment pose estimations (mainly the center of mass estimated by ML being farther away from the relevant distal joint center) might lead to systematic differences in joint moments and powers estimated by MB versus ML.
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.
Chronic exertional compartment syndrome (CECS) is occasionally observed in the forearm flexor muscles of motocross racers. Long-term results of fasciectomy and fasciotomy for this syndrome are scarce.
To study the long-term effects of 2 surgical techniques for forearm flexor CECS.
Case series; Level of evidence, 4.
A database of patients with forearm CECS who underwent surgery was analyzed. Long-term pain reduction (visual analog scale [VAS], 0-100) and efficacy were evaluated using a questionnaire.
Data of 24 motocross racers were available for analysis. Intracompartmental pressures during rest, during provocation, and after 1 and 5 minutes of provocation were 15 ± 4, 78 ± 24, 29 ± 10, and 25 ± 7 mm Hg, respectively. Painful sensations in the forearm were reduced from 53 to 7 (median VAS; P < .001). Both fasciectomy (n = 14) and fasciotomy (n = 10) were equally effective. More than 95% (23/24) of the patients were satisfied with the postoperative result after 5 ± 2 years' follow-up.
Surgical fasciotomy and fasciectomy of the forearm flexor compartment are equally successful in motocross racers suffering from forearm CECS.
The available data on the innervation of the thoracolumbar fascia (TLF) are inconsistent and partly contradictory. Therefore, the role of the fascia as a potential source of pain in the low back is difficult to assess. In the present study, a quantitative evaluation of calcitonin gene-related peptide (CGRP) and substance P (SP)-containing free nerve endings was performed in the rat TLF. A preliminary non-quantitative evaluation was also performed in specimens of the human TLF. The data show that the TLF is a densely innervated tissue with marked differences in the distribution of the nerve endings over the fascial layers. In the rat, we distinguished three layers: (1) Outer layer (transversely oriented collagen fibers adjacent to the subcutaneous tissue), (2) middle layer (massive collagen fiber bundles oriented obliquely to the animal's long axis), and (3) inner layer (loose connective tissue covering the paraspinal muscles). The subcutaneous tissue and the outer layer showed a particularly dense innervation with sensory fibers. SP-positive free nerve endings-which are assumed to be nociceptive-were exclusively found in these layers. Because of its dense sensory innervation, including presumably nociceptive fibers, the TLF may play an important role in low back pain.
In this paper the authors present a case history along with results of case series and a literature review to demonstrate the complexity of this condition.
The main aim is to increase the awareness among clinicians and the scientist to research in the area of chronic exertional compartment syndrome (CECS).
CECS usually refers to myoneural ischaemia due to a reversible increase in tissue pressure within a myofascial compartment.
CECS of the leg is well documented in the literature since it was first described by Mavor in 1956.
CECS of the foot remains underdiagnosed and has been reported in the literature only on an anecdotal basis. Wood Jones proposed that there were four compartments in the foot but Manoli and Weber suggest that there are nine separate muscle compartments.
Clinical signs and symptoms of CECS of the foot remain diverse and lack the consistency of its counter part in the leg. The range of signs and symptoms include swelling, tension, cramps, tightness, paraesthesia, numbness, cyanosis and soft tissue indurations. As a result number of diagnosis is first considered and includes plantar fasciitis, tibialis posterior tendonitis, tarsal tunnel syndrome and medial Lisfranc injury.
CECS of the foot remains a diagnosis of exclusion.
The most effective treatment is a superficial fasciotomy.
Striding bipedalism is a key derived behaviour of hominids that possibly originated soon after the divergence of the chimpanzee and human lineages. Although bipedal gaits include walking and running, running is generally considered to have played no major role in human evolution because humans, like apes, are poor sprinters compared to most quadrupeds. Here we assess how well humans perform at sustained long-distance running, and review the physiological and anatomical bases of endurance running capabilities in humans and other mammals. Judged by several criteria, humans perform remarkably well at endurance running, thanks to a diverse array of features, many of which leave traces in the skeleton. The fossil evidence of these features suggests that endurance running is a derived capability of the genus Homo, originating about 2 million years ago, and may have been instrumental in the evolution of the human body form.
Using a survey questionnaire design, we investigated the incidence, site, and nature of jogging injuries among all participants of a popular 16 km race. The response rate was 83.6%. Of 4,358 male joggers, 45.8% had sustained jogging injuries during the 1 year study period, 14.2% had required medical care, and 2.3% had missed work because of jogging injuries. Occur rence of jogging injuries was independently associated with higher weekly mileage (P < 0.001), history of previous running injuries (P < 0.001), and competitive training motivation (P = 0.03). Higher mileage was also associated with more frequent medical consultations due entirely to jogging-related injuries. In 33 to 44 year olds (N = 1,757), the number of years of running was inversely related to incidence of injuries (P = 0.02). Injuries were not significantly related to race running speed, training surface, characteristics of running shoes, or relative weight. Achillodynia and calf muscle symptoms were the two most common overuse injuries and occurred significantly more often among older run ners with increased weekly mileage. We conclude that jogging injuries are frequent, that the number of firmly established etiologic factors is low, and that, in recom mending jogging, moderation should be the watchword.
The purpose of this study is to evaluate the effects of increased compartment pressure on anterior tibial arteriovenous flow patterns and to determine whether mechanical and biochemical properties of fascia are responsible for compartment pressure abnormalities.
Twenty patients with chronic anterior compartment syndrome (CACS) and 20 age-matched control subjects had compartment pressure measurements and analysis of tibial arterial and venous flow before and after fasciectomy. Fascia specimens were evaluated for thickness, stress failure, structural stiffness, and total collagen content and prevalence of collagen cross-linkage.
Pressures were significantly elevated in patients with CACS versus control subjects (23.8 mm Hg vs 6 mm Hg). No significant difference in tibial arterial flow could be detected in either group (43 cm/sec mean vs 41.9 cm/sec mean). Venous drainage was severely impaired in patients with CACS but not in control subjects. CACS fascia was thicker and stiffer than control fascia specimens (0.35 mm +/- 0.12 mm, 109 +/- 65 MN/mm; versus 0.22 mm +/- 0.06 mm; 60.3 +/- 22 MN/mm). Fasciectomy normalized postoperative compartment pressures and improved venous drainage. Collagen content per unit mass was similar for both CACS and control fascia specimens, although collagen cross-linking was significantly lower in the CACS fascia than in the controls.
Tibial venous drainage is impaired, but arterial flow is not in patients with CACS. Fascia thickness and structural stiffness can account for increased pressure in CACS compartments. Collagen content and cross-linkage are unrelated to fascia stiffness or thickness. Postoperative improvement in vascular hemodynamics and reduction in compartment pressure is caused by increased capacitance in the compartment after fasciectomy.
This retrospective study tests if runners who habitually forefoot strike have different rates of injury than runners who habitually rearfoot strike.
We measured the strike characteristics of middle- and long-distance runners from a collegiate cross-country team and quantified their history of injury, including the incidence and rate of specific injuries, the severity of each injury, and the rate of mild, moderate, and severe injuries per mile run.
Of the 52 runners studied, 36 (69%) primarily used a rearfoot strike and 16 (31%) primarily used a forefoot strike. Approximately 74% of runners experienced a moderate or severe injury each year, but those who habitually rearfoot strike had approximately twice the rate of repetitive stress injuries than individuals who habitually forefoot strike. Traumatic injury rates were not significantly different between the two groups. A generalized linear model showed that strike type, sex, race distance, and average miles per week each correlate significantly (P < 0.01) with repetitive injury rates.
Competitive cross-country runners on a college team incur high injury rates, but runners who habitually rearfoot strike have significantly higher rates of repetitive stress injury than those who mostly forefoot strike. This study does not test the causal bases for this general difference. One hypothesis, which requires further research, is that the absence of a marked impact peak in the ground reaction force during a forefoot strike compared with a rearfoot strike may contribute to lower rates of injuries in habitual forefoot strikers.
Chronic exertional compartment syndrome (CECS) of the lower limb is part of a group of overuse lower limb injuries with common presenting features. It is commonly diagnosed by the measurement of raised intramuscular pressures in the lower limb. The pathophysiology of the condition is poorly understood, and the criteria used to make the diagnosis are based on small sample sizes of symptomatic patients. We carried out a systematic review to compare intramuscular pressures in the anterior compartment of healthy subjects with commonly used criteria for CECS. Thirty-eight studies were included. With the exception of relaxation pressure, the current criteria for diagnosing CECS, considered to be the gold standard, overlap the range found in normal healthy subjects. Several studies reported mean pressures that would prompt a positive diagnosis for CECS, despite none of the subjects reporting any symptoms. The intramuscular pressure at all time points has also shown to vary in relation to a number of other factors other than the presence of CECS. Taken together, these data have major implications on the ability to use these published criteria for diagnosis and question the underlying pathophysiology. Clinicians are recommended to use protocol-specific upper confidence limits to guide the diagnosis following a failed conservative management.
To examine the construct and concurrent validity of a new occupational military outcome measure (the Functional Activity Assessment [FAA]).
A validation study.
British Defence rehabilitation facilities.
A total of 141 service personnel who attended a musculoskeletal injury assessment clinic.
The association among the Short Form 36 (SF-36), Physical Workload Questionnaire, and the FAA was examined. Agreement and correlation with an actual medical category also was examined.
FAA, SF-36 and Physical Workload Questionnaire scores.
The FAA was significantly correlated with heavy physical workload and all SF-36 subscale and component scores, in line with predictions. The regression model retained 3 variables that accounted for 49% of the variation in FAA, most of which was accounted for by the role-physical subscale score of the SF-36. The FAA was well correlated with actual medical category.
The FAA is a valid measure of physical health in relation to physical workload.