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The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 85
ABSTRACT
Background/Purpose: Exercise induced lower leg pain (EILP) is a commonly diagnosed overuse injury in recreational runners
and in the military with an incidence of 27-33% of all lower leg pain presentations. This condition has proven difficult to treat
conservatively and patients commonly undergo surgical decompression of the compartment by fasciotomy. This case series inves-
tigates the clinical outcome of patients referred with exertional lower leg pain symptoms of the anterior compartment of the lower
leg following a gait re-training intervention program.
Case Description: 10 patients with exercise related running pain in the anterior compartment of the lower leg underwent a gait
re-training intervention over a six-week period. Coaching cues were utilized to increase hip flexion, increase cadence, to maintain-
ing an upright torso, and to achieve a midfoot strike pattern. At initial consult and six-week follow up, two-dimensional video
analysis was used to measure kinematic data. Patients self reported level of function and painfree running were recorded through-
out and at one-year post intervention.
Outcomes: Running distance, subjective lower limb function scores and patient’s pain improved significantly. The largest mean
improvements in function were observed in ‘running for 30 minutes or longer’ and reported ‘sports participation ability’ with increases
of 57.5% and 50%, respectively. 70% of patients were running painfree at follow-up. Kinematic changes affected at consultation were
maintained at follow-up including angle of dorsiflexion, angle of tibia at initial contact, hip flexion angle, and stride length. A mean
improvement of the EILP Questionnaire score of 40.3% and 49.2%, at six-week and one-year follow up, respectively.
Discussion: This case series describes a conservative treatment intervention for patients with biomechanical overload syndrome/
exertional compartment syndrome of the anterior lower leg. Three of the four coaching cues affected lasting changes in gait kine-
matics. Significant improvements were shown in painfree running times and function.
Level of Evidence: 4
Keywords: Chronic exertional compartment syndrome, biomechanical overload syndrome, overuse injury, gait analysis,
running
IJSPT
CASE SERIES
GAIT RE-TRAINING TO ALLEVIATE THE SYMPTOMS
OF ANTERIOR EXERTIONAL LOWER LEG PAIN:
A CASE SERIES
David T. Breen, PT1
John Foster, PT1
Eanna Falvey, MD, PhD1,2
Andrew Franklyn-Miller, MD, PhD1,2
1 Department of Sports Medicine, Sports Surgery Clinic, Santry
Demesne, Dublin Ireland
2 Centre for Health, Exercise and Sports Medicine, University
of Melbourne, Australia
The protocol for this study was approved by the Sports Surgery
Clinic Research Ethics Committee, Santry, Dublin 9, Ireland.
Financial Disclosure and Confl ict of Interest:
We affi rm that we have no fi nancial affi liation (including
research funding) or involvement with any commercial
organization that has a direct fi nancial interest in any matter
included in this manuscript, except as disclosed in an
attachment and cited in the manuscript. Any other confl ict of
interest (ie, personal associations or involvement as a
director, offi cer, or expert witness) is also disclosed in an
attachment.
CORRESPONDING AUTHOR
Mr. David Breen
Department of Sports Medicine
Sports Surgery Clinic
Santry Demesne
Dublin, Republic of Ireland
Tel: +353.1.5262030
Fax: +353.1.5262046
E-mail: mrdavidbreen@gmail.com
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 86
BACKGROUND / PURPOSE
Exertional lower leg pain is a commonly diagnosed
overuse injury in recreational runners and in the
military with an incidence of 27-33% of all lower leg
pain presentations.1-3 Typically, patients present with
incremental pain on exercise, which is described
as ‘tightness’, or ‘constricting pain’. Symptoms can
increase with up-hill running or by increasing run-
ning speed with a fixed cadence. Symptoms tend
to worsen to a point whereby continued running is
impossible. The pain and symptoms are alleviated
by rest and are occasionally accompanied by tempo-
rary paraesthesia or foot slapping, however typically
the individual is able to briefly recommence run-
ning prior to a recurrence of symptoms. Classically
the patient is pain free when not exercising.
Zhang et al describe the underlying pathophysiol-
ogy as transient muscle ischemia,4 where due to
increased intra-compartmental pressure the arterial
blood supply to muscle is reduced, causing ischemic
pain similar to acute compartment syndrome (a
surgical emergency) but termed chronic exertional
compartment syndrome (CECS) due to its progres-
sive sub acute nature. The underlying pathology
is suggested as fascial non-compliance or muscle
hypertrophy but to date no conclusive proof of tis-
sue necrosis or cell hypoxia has been demonstrated.5
CECS has been described in the anterior, peroneal
and deep posterior compartments6 of the lower leg
but the anterior is the most commonly affected.7
The diagnosis is typically confirmed with intra-com-
partmental pressure measurement but a systematic
review of diagnostic pressures revealed substantial
overlap of criteria and significant confounding vari-
ables of measurement technique, throwing doubt
on the diagnostic process,8 and recent work by Ros-
coe et al suggests that a major revision of diagnos-
tic criteria may be needed.9 Other diagnoses exist
including medial tibial stress syndrome, stress frac-
ture, popliteal artery and common peroneal nerve
entrapment, all of which may need to be excluded.
Historically, first line treatments10,11 such as myofas-
cial release, orthotic intervention, stretching, mas-
sage, and training load modification12 have been
tried in an attempt alleviate CECS. However, none
have proved successful in a return to similar levels
of activity. This was primarily due to an inability
to modify the intra-compartmental pressures with
short term intervention.13 To date, the only definitive
treatment is surgical decompression of the compart-
ment by fasciotomy, an operative technique used to
open the fascia covering the muscle compartment
thereby de-tensioning the purported constrictive
effect on muscles. However, a high proportion of
surgical interventions are unsuccessful.14 Published
outcome data on operative data is good in the short
term but studies are limited with regard to duration
of follow up, use of outcome measures, and demon-
strate wide variation in operative technique.14,15
Recent work on running technique and kinematic
and kinetic changes of gait by Davis and Heiders-
cheit may provide details relating to the underlying
mechanism behind the propagation of muscle over-
load. Reduction in the stride length, ground contact
time, vertical oscillation and lower extremity angle all
contribute to improved running economy,16 reduced
ground reaction force, and movement efficiency.17,18
During running gait, tibialis anterior (TA) and exten-
sor hallucis longus have a high state of preactivation19
prior to rear foot initial contact. TA activity decreases
rapidly with running induced metabolic fatigue.7,20
This led the authors of this case series to believe that,
based on clinical observations in a military popula-
tion, chronic exertional compartment syndrome is a
mechanical muscular overload rather than a patho-
logical process. The authors suggest it be considered
as a Biomechanical Overload Syndrome.3
Recent researchers have shown it is possible to
change muscle loading patterns by altering kine-
matics.21-23 Therefore, the authors designed a gait
re-training program to reduce the overload pattern.
The aim of this gait re-training was to reduce the
eccentric activity in TA, the proposed mechanism
of increased compartment pressure in anterior com-
partment syndrome, by promoting a slight forefoot
or midfoot ground contact pattern.7,24,25 This was
facilitated via the use of visual feedback. Visual feed-
back has been shown to improve patient compliance
and successful adoption of technique with lasting
benefit.26 This teaching tool was utilized within the
gait re-training to improve the training effect.
This case series is intended to examine the clinical
outcome of patients referred with exertional lower
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 87
leg pain symptoms of the anterior compartment of
the lower leg following a gait re-training interven-
tion program. A patient reported outcome tool and
overall running distance competence, along with
maintenance of kinematic changes were used to
help track these outcomes.
CASE DESCRIPTION: PATIENT HISTORY
AND SYSTEMS REVIEW
Ten adult subjects, nine males and one female (mean
+/- SD: 30.5 +/- 8.8 years, weight 80.8 +/- 11.4 kg,
height 182.6 +/- 6.7 cm, BMI 24.2 +/- 2.4 kg/m),
presenting with anterior exertional lower leg pain
were recruited for the trial. Subjects were included
after giving their informed consent to participate in
this study, which received ethical approval (Study
25-AFM-003).
CLINICAL IMPRESSION #1
Subjects were recruited based on a primary com-
plaint of exercise induced lower leg pain localized
to the anterior shank. Subjects presented with incre-
mental pain, which worsened to a crescendo such
that they were unable to continue running. Symp-
toms typically alleviated by rest following running
cessation.
EXAMINATION
On initial presentation a full clinical history was
taken and an examination performed by a sports
medicine physician and physiotherapist. Any further
investigation required was performed including mag-
netic resonance imaging (MRI) to exclude stress frac-
ture and medial tibial stress syndrome. The subjects’
current running shoes were used during retraining
without orthotics, which were removed if prescribed.
CLINICAL IMPRESSION #2
Based upon the clinical reasoning of both the sports
medicine physician and physiotherapist, and sup-
ported by history and MRI examination to exclude
stress fracture or periostitis and any muscle pathol-
ogy, subjects were diagnosed with ‘anterior biome-
chanical overload syndrome’ (ABOS) and deemed
suitable for the study intervention. Subjects agreed
to undergo a six week gait re-training intervention
using kinematic measures pre- and post-intervention
combined with a self-report outcome measure of
functional ability, and the exercise induced leg pain
(EILP) questionnaire,27 to ascertain intervention suc-
cess. The EILP is a validated and reliable self-report
measure of exercise-induced leg pain symptoms.27 It
measures the perceived severity of symptoms that
impact function and sports ability.
INTERVENTION
On initial assessment subjects were asked to run
at a self-selected pace for 2.5 to 3 minutes on a
commercial treadmill at 0 degree incline (Nordic-
Track, Icon Health and Fitness™, Beaumont, Cali-
fornia). Treadmill speed was then self-selected by
the subject between 9 to 12 kph. When subjects
informed the tester they were comfortable run-
ning at their preferred pace a video recording was
taken. Video recording was taken prior to the onset
of symptoms to minimize any pain effect on run-
ning biomechanics.10km/hr for 60 seconds. A 10
second digital recording was taken using 2HD video
cameras (Panasonic HDC-SD80, Panasonic Corpo-
ration™, Japan) recording at a frame rate of 60fps
(resolution 1920 x 1080i) from sagittal and coro-
nal viewpoints obtained against a fixed reference
backdrop (MAR Systems™, England). Subjects were
instructed to maintain their running position in the
center of the treadmill belt during data recording.
Both cameras were fixed to wall mounts maintaining
a consistent field of view between subjects. Angular
and kinematic data from each recording was inter-
preted using a 2D motion analysis system connected
via HDMI cabling to a plasma screen (Contemplas™
TEMPLO V6.0 GmbH, Germany).
Sagittal plane two-dimensional (2D) analysis has
previously been assessed for validity and reliabil-
ity against the ‘gold standard’ of three-dimensional
(3D) analysis in previous studies of treadmill run-
ning.25,28-30 Moreover a pilot comparative analysis
(2D versus 3D) demonstrated comparable reliability
in measures across five consecutive foot contacts
while treadmill running (Appendix A). Initial foot
contact was matched synchronously for both 2D and
3D measurement. Stance phase kinematics, such as
foot inclination and tibial angle, were found to be
highly agreeable between both methods at identical
gait cycle time points. While there was some differ-
ences in absolute magnitudes (e.g., max hip flexion
[2D versus 3D] of 56.23° and 64.91°, respectively),
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 88
of coaching cues based on the therapist’s observa-
tion and feedback from the subject on whether they
thought the change was sustainable. Care was taken
to cue only minimal kinematic change to avoid early
fatigue in subjects. At this stage a ‘walk-run’ program
as a template for embedding these motor patterns was
given. This training program was performed three
times per week with a minimum of one days rest
between sessions (Appendix B). Only two additional
independent training sessions were performed on
weeks where the subject was reviewed by the sports
medicine team. A review of the subjects running gait
was typically carried out fortnightly, with kinematic
adjustments made as needed. Each subject had three
video coaching sessions in total. The EILP question-
naire was also repeated prior to retesting and at one-
year post intervention. In addition, a 15-point global
rating of change (GROC) was included at one-year
follow up to measure subjects perceived change and
overall improvement.33 The scale directed the sub-
ject to rate his or her change from ‘a very great deal
worse’ (-7) to ‘a very great deal better (+7).
The running kinematics were quantified from digital
video recordings obtained during testing. Running
cycle phases of interest and angular data assessed at
each event are outlined in Table 1. Kinematic vari-
ables were measured for five consecutive strides on
both sides, pre- and post- retraining intervention.
Stride length was measured from the point of initial
contact to the point of toe off. The midstance phase
was defined as the last point at which the heel stays
in contact with the ground before lifting; given no
subjects were forefoot runners.
Initial contact was identified from the rearview coro-
nal imaging, which proved more accurate than sag-
ittal views due to rearfoot supination, which occurs
before contact. Thereafter, sagittal imaging was used
to measure kinematic data. Foot inclination angle was
measured from the sole of the shoe to treadmill. Tib-
these would not be unexpected due to the difference
in how 2D and 3D measures are obtained.28
Following initial 2D analysis, gait re-training began
immediately in session one in the form of verbalized
cues to alter kinematics at the foot, ankle, knee, hip,
and torso. Gait re-training sessions were 60 minutes
in duration with each subject receiving a maximum
of three sessions over a six-week period. Sessions
consisted of running drills and walk-run interval
training with the aid of video feedback to facilitate
kinematic change. The use of video feedback was
progressively withdrawn over the three sessions..
Cues were individualized to each subject in order
to reduce ankle dorsiflexion at the landing position.
Various cues were used to achieve this goal. Typi-
cal coaching cues involved landing with a mid-foot
strike pattern, slightly increasing hip flexion, pro-
moting an earlier foot lift- off and running with a
more upright torso position. Previous clinical expe-
rience in delivering coaching cues suggests that
slightly increasing hip flexion was sometimes more
effective in reducing ankle dorsiflexion angle at foot-
strike rather than instructing subjects to land with a
mid-foot strike, although to date there is no research
to support this. The authors chose to cue an earlier
and slightly higher foot lift-off as it was hoped this
would have the double effect of increasing step-rate,
which has been shown to reduce ankle dorsiflexion
at foot-strike as well as promote increased hip flex-
ion.18 A more upright body position was promoted
if necessary as the authors previous experience in
delivering coaching cues had suggested this was
often complimentary to achieving greater hip flex-
ion with resultant reduction in ankle dorsiflexion at
foot strike.
Between one and three individualized coaching cues
were used until the therapist felt that desired changes
were achieved. This allowed for individualization
Table 1. Kinematic gait cycle variables for both sides at each phase; with pre-, post- and p-values for each.
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 89
ial angle was measured from malleolus center to mid
shaft tibia at tibial tuberosity level, against the ver-
tical. Lumbar flexion angle was measured from the
L5 level to the thoraco-lumbar junction, against the
vertical in order to represent change in body position.
At midstance, ankle dorsiflexion was measured from
mid shaft tibia at tibial tuberosity level through mal-
leolus center against the horizontal at shoe sole
level. The point of maximum hip flexion was iden-
tified and hip angle measured through mid thigh
at femoral condyle level to lumbo-sacral junction,
against lumbar flexion angle.
Data analysis and statistics
Statistical analysis was carried out on all data sets for
each variable. Paired t-tests showed significant changes
in all but two sets of kinematic variables (p < 0.05),
lumbar flexion (p = 0.102) and cadence (p = 0.354).
A Wilcoxon matched pairs test (p < 0.05) was used to
analyze the paired datasets. Using the EILP question-
naire, the percentage improvement for each subject
was identified and average improvement ascertained.
A scatterplot graph (Figure 1) was produced to repre-
sent the pre and post intervention differences in time
to first onset of pain and time to pain limit/threshold.
OUTCOME
At six week follow up there was a mean improvement
of the EILP Questionnaire score of 40.3%. At the one-
year follow up, with 9 out of the 10 subjects respond-
ing, there was a mean improvement of 49.2% from
baseline measures. Eight patients were running
pain free over 30 minutes and the other two patients
significantly increased their running distance before
symptom onset. Running symptoms reported at one
year after intervention reported 7 of the 10 subjects
running entirely painfree with one subject symptom
free for at least 80 minutes. One subject was not run-
ning due to a foot injury and one was subject did not
respond. GROC scores at one-year follow up were an
average of 4.9 or ‘quite a bit better’.
Persistent changes were observed in foot inclination
angle, tibial angle, and maximum hip flexion angle
(Table 1). Foot inclination angle at initial contact on
the right and left foot changed from an average dor-
siflexion angle of 18.32 and 18.26, respectively, to
plantar flexion angle of 1.89 (p = 0.001) and 3.43 (p
= 0.001), respectively. This represents a technical
change from heel strike foot position to slight fore-
foot/midfoot strike position.
Similarly, mean tibial angle at initial contact changed
on the right and left lower leg from 11.72 and 11.98,
respectively, to 2.89 (p = 0.001) and 2.48 (p = 0.001),
respectively This represents a reduction in tibial angu-
lation to an almost vertical tibia on initial contact.
Maximum hip flexion angle averages on the right
and left changed from 35.99 and 35.10, respectively,
to 45.74 (p = 0.003) and 45.17 (p = 0.002), respec-
tively. Small but statistically significant changes were
observed in right and left ankle dorsiflexion at mid-
stance changing from 63.18 and 63.27, respectively,
to 64.92 (p = 0.03) and 65.1 (p = 0.04), respectively.
A significant reduction in stride length was observed
of 67.58cm to 46.8cm (p = 0.001) on the right, and
69.59cm to 50.36cm (p = 0.001) on the left. There
was no significant change in lumbar flexion at initial
contact (p = 0.102).
Mean differences in EILP questionnaire scores of
function are outlined in Table 2. Significant changes
(p < 0.05) in EILP questionnaire scores (Table 2) were
seen in all four running activities and perceived abil-
ity scores. An average increase in function of 40.3%
was observed for EILP scores, pre versus post inter-
vention. Importantly, the largest changes in function
were observed for ‘Running after 30 minutes or lon-
ger’ and ‘Ability to participate in your desired sport as
long as you like’, 57.5% (p = 0.005) increase and 50%
(p = 0.007) increase in scores, respectively.
Figure 1. re-training versus post-training time to pain onset
(fi rst onset of exertional lower limb pain) and pain limit (time
taken to pain limit/threshold), where x-axis ‘PF’ = ‘pain free’
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 90
Figure 1 illustrates the change in subjective report
of time taken (minutes) to pain onset and pain limit
during each subjects run. All but three subjects
achieved pain-free (PF) status for exertional lower
leg pain, with all subjects showing improvements.
DISCUSSION
The authors hypothesized that by altering key ele-
ments of running kinematics in patients with exer-
tional anterior lower leg pain, with no demonstrable
stress response in bone, that the symptoms would
be alleviated by a more vertical tibial strike angle,
reduced stride length, increased running cadence
and a more vertical torso angle. In this cohort, all
subjects showed an improvement in their pain free
running tolerance and 70% of subjects were running
entirely symptom free post-treatment. Subjects also
reported improvements in their outcome scores and
demonstrated lasting kinematic changes in running
gait following running re-education training. The
only interventions used were coaching cues and
intermittent visual feedback over a six-week period.
Subjects demonstrated statistically significant improve-
ments in exercise induced leg pain score (EILP), and
changes in foot inclination angle, mean tibial angle, hip
flexion, ankle dorsiflexion and stride length following
running re-education training. The results were main-
tained at follow-up six weeks later. The EILP inventory
is highly specific to running function and athletic per-
formance comparing favorably to other lower leg func-
tion tools previously used in the monitoring of exercise
induced CECS 15, 22.
To date there has been limited evidence of the effec-
tiveness of conservative management of chronic exer-
tional anterior compartment syndrome. Diebal et al
used forefoot running to reduce the symptoms in a
case series of 10 patients with associated reduction in
intracompartmental pressures.2 However, despite sig-
nificant improvements in their running performance,
none were symptom free and pain remained the limit-
ing factor. Results from the cohort in the current study
demonstrate all but three subjects running entirely
pain-free. Coaching cues utilized in the current study
were individualized in an attempt to alter the kine-
matic variables selected. Coaching aims were to
reduce ankle dorsiflexion at the landing position using
a combination of coaching cues including increased
hip flexion, early foot lift-off, and a more upright torso.
Table 2. Mean improvement in function fo the EILP questionnaire pre-gait re-training versus
post gait re-training.
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 91
strike but the authors hypothesized a higher knee
position in late swing allows the subject more time
to align the tibia and foot to achieve the desired ver-
tical tibia and midfoot strike pattern. While vertical
ground reaction force may increase as a result of a
more direct downward foot drive, evidence is lacking
to make a direct connection between impact forces
and many running injuries,32 and in this population
no evidence of stress fracture was present.
Torso Position
A more upright torso position was sometimes advo-
cated as a complementary cue to achieve greater hip
flexion. However, this was only encouraged if increas-
ing hip flexion was a necessary cue. In this case
series, the authors’ were unable to effect lasting kine-
matic change in lumbar flexion during the six week
intervention but this did not appear to limit an aver-
age increase in hip flexion at late swing of 10°. The
method of measurement using 2D kinematics may be
too inaccurate to record small differences in lumbar
flexion angulation. It may be that lumbar flexion angle
was not a good measure of torso positioning and mid-
thoracic angulation using electro-goniometers would
have been a better method for recording this variable.
As the rate of perceived exertion is initially higher
with a step rate increase of 10%22 the authors’ used
a graduated walk/run program while the new run-
ning technique was being learned to limit fatigue.
Although not recorded it was found that subjects
reported initially increased rating of perceived exer-
tion (RPE), which reduced after four weeks of train-
ing. Many studies report that running economy (RE)
in experienced runners is best at self-selected step
rate.32,33 However inexperienced runners have been
shown to have better RE at step rates 9% higher than
preferred.34 It seems likely that adoption of a new
technique and step-rate causes initial increase in RPE
and reduction in RE. Improvements in both these val-
ues may be possible with training adaption but fur-
ther research is needed to confirm this observation.
The ability to make both short and long term kinematic
changes in running technique is often challenged. In
practice, the authors identified changes occurring very
rapidly but few studies have looked at the retention
of changes made. It has been shown that after only
two weeks of retraining, retention is possible26 and
This is the first study in which joint angle kinemat-
ics are recorded throughout the gait cycle as a mea-
sure of gait re-training for exercise induced leg pain.
Previous research in this area, make reference only to
affected kinematic change in stride length, cadence,
and ground contact time.2,15
Mid-Foot Strike position
The focus for the cohort group was on adopting a mid-
foot strike in order to reduce TA activity as this has been
shown to be highest in late swing through to the foot flat
position.19 All subjects were able to achieve this within
six weeks. It has been shown that TA activity increased
primarily in late swing for the purpose of altering the
landing posture of the limb in preparation for subse-
quent joint moments and energy absorption.21,31
Excessive tibialis anterior (TA) eccentric activity has
been proposed as a major contributor to the mecha-
nism of increased compartment pressure in anterior
compartment syndrome.7,31,32 Eccentric muscle activ-
ity is strenuous and results in more rapid muscle
fatigue ad by products of breakdown, and possible
edema. It may be possible to reduce the eccentric
activity in TA by promoting earlier ground contact of
the forefoot 32 or adopting a midfoot strike. This also
results in a more vertical tibia at foot contact, reduc-
ing the preload of the anterior compartment
Step rate
An increase in step rate has been shown to reduce
tibialis anterior activity. Emphasis was placed on an
earlier and higher foot lift-off to achieve this increase
while maintaining the same running speed. It had
been observed that simply instructing subjects to
increase step-rate often resulted in a fast shuffle-like
gait pattern. As this was considered undesirable, the
former cue was used. This was reflected by a signifi-
cant reduction in stride length of 20cm (p = 0.001)
measured post gait re-training. Step rate is inversely
proportional to step length and a 10% increase in
step frequency has been shown to significantly
decrease foot inclination angle.22
Hip Flexion
All subjects maintained increased hip flexion in this
study after intervention. Hip flexion angle has not
been addressed in the literature in relation to foot
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 92
the use of gait re-training as the primary treatment
of choice. This case series demonstrated the effec-
tive use of visual and verbalized coaching cues to
alter running technique and reduce the symptoms of
anterior biomechanical overload syndrome. The use
of such cues improved the ability of the subjects to
adopt a modified gait pattern. These changes in gait
were adopted and retained over a six-week period.
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maintained up to six months later.35 Further work is
required to demonstrate optimal training techniques
and time frames but it is apparent that once kinematic
changes are learned, subjects are able to retain these
changes in the absence of continued feedback.
This case series has a number of limitations. No bio-
medical markers were placed on patients to act as
reference points and this has been shown to intro-
duce possible error in the reporting of kinematic
angles.36 Error was minimized by comparing five
steps on each leg and taking the mean value and
using fixed angle cameras and backdrops, however
it is recognized either using reference markers or
3D analysis, despite being available to the authors,
would have been more accurate but too time con-
suming and costly for the clinical population.
The effect of being tested/observed influences the
performance of motor tasks so the authors cannot be
sure that running technique observed in lab condi-
tions mimics technique performed outside in varying
conditions. Treadmill running is capable of being used
to obtain a representation of the typical human run-
ning action24 but the problem of being observed may
be overcome in future with wearable inertial sensors
currently being developed. In this way we hope to
improve compliance, feedback and recording of kine-
matic change and also in longer-term compliance.
Further studies are required to identify whether kine-
matic variables are maintained and the extent of fol-
low up required and whether other exertional lower
leg conditions can be successfully treated using the
biomechanical overload principles on a larger scale.
CONCLUSIONS
This case series provides further evidence that ante-
rior exertional lower leg pain symptoms can be allevi-
ated by kinematic changes in running gait. Follow-up
assessment with 2D kinematics at the six-week stage
confirmed that 100% of patients had retained their
new running form with significant reduction of symp-
toms as measured using the EILP Questionnaire.
The changes in gait kinematics and resultant improve-
ment in self-reported scores of function and pain
free running distance supports the authors’ conten-
tion that this clinical condition represents a biome-
chanical overload without irreversible pathological
pressure change. As such the authors’ recommend
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The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 94
APPENDIX 1A Comparison measures (in degrees) between two-dimensional (2D) and three-dimensional (3D) kinematic
analysis of gait cycle variables for both sides at each phase pre intervention and post intervention; Initial contact: foot
inclination (Foot Inclin), tibial angle (Tib angle), Back fl exion angle (Back fl x); Midstance: ankle dorsi-fl exion angle (Ankle
DF); Maximum hip fl exion: hip fl exion angle (Hip fl x)
APPENDIX B
NOIX
E
LFPIHXAMECNATSDIMTCA
T
NOC
LA
ITIN
I
ES
AH
P
T
IA
G
VARIABLE Foot Inclin (°) Tib angle (°) Back flx (°) Ankle DF (°) Hip flx (°)
POST RRED R L R L R L R L R L
2D -7.2 -7.04 -3.3 0.5 5.2 5.18 25.58 27.52 53.4 59.06
3D -9.52 -8.74 0.14 1.96 5.28 5.42 17.48 18.9 62.68 67.14
2D Mean -7.12 -1.4 5.19 26.55 56.23
3D Mean -9.13 1.05 5.35 18.19 64.91
RUNNING RE-EDUCATION NAME_____________
WALK/RUN PROGRAM DATE_____________
GOAL: 30 minutes continuous running in 4-6 weeks
Your therapist will help advise you at what level to start.
Level WALK
TIME
(mins)
RUN
TIME
(mins)
TOTAL
TIME
(mins)
TOTAL
RUN
TIME
Runs at
this level
11 1 20 10 1-2
2 1 2 21 14 1-2
31 3 20 15 1-2
4 1 3 24 18 1-2
51 4 25 20 1-2
6 1 5 24 20 1-2
71 5 30 25 1-2
8 1 6 28 24 1-2
91 8 27 24 1-2
10 1 10 33 30 1-2
11 1 11 36 33 1-2
12 1 14 30 28 1-2
- 30 30 30 1-2
APPENDIX A
Note: Walking pace should be sufficient to ease any symptoms. If discomfort rises to 4 out of 10 on a pain scale,
go back to previous level Perform on alternate days. Eg Monday, Wednesday, Friday Progress to next level if
pain does not rise above 3 out of 10 within 24 hours
