ArticlePDF Available

Gait re-training to alleviate the symptoms of anterior exertional lower leg pain: A case series

Authors:

Abstract and Figures

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 investigates 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. 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 maintaining 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 throughout and at one-year post intervention. 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. 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 kinematics. Significant improvements were shown in painfree running times and function. 4.
Content may be subject to copyright.
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.
REFERENCES
1. Cunningham A, Spears IR. A successful conservative
approach to managing lower leg pain in a university
sports injury clinic: A two patient case study. Br J
Sports Med. 2004;38(2):233-234.
2. Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot
running improves pain and disability associated with
chronic exertional compartment syndrome. Am J
Sports Med. 2012;40(5):1060-1067.
3. Franklyn-Miller A, Roberts A, Hulse D, Foster J.
Biomechanical overload syndrome: defi ning a new
diagnosis. Br J Sports Med. 2012; 0: 1-3.
4. Zhang Q, Styf J. Abnormally elevated intramuscular
pressure impairs muscle blood fl ow at rest after
exercise. Scandinavian journal of medicine & science in
sports. Aug 2004;14(4):215-220.
5. Edmundsson D, Toolanen G, Thornell LE, Stal P.
Evidence for low muscle capillary supply as a
pathogenic factor in chronic compartment
syndrome. Scand J Med Sci Sports. 2010;20(6):805-813.
6. Blackman PG. A review of chronic exertional
compartment syndrome in the lower leg. Med Sci
Sports Exerc. 2000;32(3 Suppl):S4-10.
7. Mizrahi J, Verbitsky O, Isakov E. Fatigue-related
loading imbalance on the shank in running: a
possible factor in stress fractures. Ann Biomed Eng.
2000;28(4):463-469.
8. Roberts A, Franklyn-Miller A. The validity of the
diagnostic criteria used in chronic exertional
compartment syndrome: a systematic review. Scand
J Med Sci Sports. 2012;22(5):585-595.
9. Roscoe D, Roberts A, D H. Intramuscular
Compartment Pressure Measurement in Chronic
Exertional Compartment Syndrome: New and
Improved Diagnostic Criteria . Am J Sports Med.
2014; 20(12): 1-7.
10. Cook S, Bruce G. Fasciotomy for chronic
compartment syndrome in the lower limb. ANZ J
Surg. 2002;72(10):720-723.
11. Brennan FHJr, Kane SF. Diagnosis, treatment
options, and rehabilitation of chronic lower leg
exertional compartment syndrome. Cur Sport Med
Rep. 2003;2(5):247-250.
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
The International Journal of Sports Physical Therapy | Volume 10, Number 1 | February 2015 | Page 93
treadmill running for measuring the three-
dimensional kinematics of the lumbo-pelvic-hip
complex. Clin Biomech. 2001;16(8):667-680.
25. Ugbolue UC, Papi E, Kaliarntas KT, Kerr A, Earl L,
Pomeroy VM, Rowe PJ. The evaluation of an
inexpensive, 2D, video based gait assessment system
for clinical use. Gait & posture. 2013;38(3):483-489.
26. Willy RW, Scholz JP, Davis IS. Mirror gait retraining
for the treatment of patellofemoral pain in female
runners. Clin Biomech. 2012;27(10):1045-1051.
27. Nauck T, Lohrer H, Padhiar N, King JB.
Development and validation of a questionnaire to
measure the severity of functional limitations and
reduction of sports ability in German-speaking
patients with exercise-induced leg pain. Br J Sports
Med. 2012; 49(2): 113-117..
28. Alkjaer T, Simonsen EB, Dyhre-Poulsen P.
Comparison of inverse dynamics calculated by two-
and three-dimensional models during walking. Gait
Posture. 2001;13(2):73-77.
29. Bencke J, Christiansen D, Jensen K, Okholm A,
Sonne-Holm S, Bandholm T. Measuring medial
longitudinal arch deformation during gait. A
reliability study. Gait Posture. 2012;35(3):400-404.
30. McGinley JL, Baker R, Wolfe R, Morris ME. The
reliability of three-dimensional kinematic gait
measurements: a systematic review. Gait Posture.
2009;29(3):360-369.
31. Reber L, Perry J, Pink M. Muscular control of the
ankle in running. Am J Sports Med. 1993;21(6):805-
810.
32. Hunter I, Smith GA. Preferred and optimal stride
frequency, stiffness and economy: changes with
fatigue during a 1-h high-intensity run. Eur J App
Physiol. 2007;100(6):653-661.
33. Cavanagh PR, Williams KR. The effect of stride
length variation on oxygen uptake during distance
running. Med Sci Sports Exerc. 1982;14(1):30-35.
34. de Ruiter CJ, Verdijk PW, Werker W, Zuidema MJ, de
Haan A. Stride frequency in relation to oxygen
consumption in experienced and novice runners.
Eur J Sport Sci. 2013; 14(3): 251-258.
35. Crowell HP, Davis IS. Gait retraining to reduce lower
extremity loading in runners. Clin Biomech.
2011;26(1):78-83.
36. Krosshaug T, Nakamae A, Boden B, et al. Estimating
3D joint kinematics from video sequences of
running and cutting maneuvers-assessing the
accuracy of simple visual inspection. Gait Posture.
2007;26(3):378-385.
12. Gill CS, Halstead ME, Matava MJ. Chronic exertional
compartment syndrome of the leg in athletes:
evaluation and management. Phys Sportsmed.
2010;38(2):126-132.
13. Matsen FA, Winquist RA, Krugmire, RBJr. Diagnosis
and management of compartmental syndromes. J
Bone Joint Surg. 1980;62(2):286-291.
14. Slimmon D, Bennell K, Brukner P, Crossley K, Bell
SN. Long-term outcome of fasciotomy with partial
fasciectomy for chronic exertional compartment
syndrome of the lower leg. Am J Sports Med.
2002;30(4):581-588.
15. Schepsis AA, Fitzgerald M, Nicoletta R. Revision
surgery for exertional anterior compartment
syndrome of the lower leg: technique, fi ndings, and
results. Am J Sports Med. 2005;33(7):1040-1047.
16. Tweed JL, Barnes MR. Is eccentric muscle
contraction a signifi cant factor in the development
of chronic anterior compartment syndrome? A
review of the literature. Foot (Edinb). 2008;18(3):165-
170.
17. Kellis E, Liassou C. The effect of selective muscle
fatigue on sagittal lower limb kinematics and muscle
activity during level running. J Orthop Sports Phys
Ther. 2009;39(3):210-220.
18. Rodgers MM. Dynamic biomechanics of the normal
foot and ankle during walking and running. Phys
Ther. 1988;68(12):1822-1830.
19. Jerosch J, Castro WH, Halm H, Bork H. Infl uence of
the running shoe sole on the pressure in the anterior
tibial compartment. Acta orthopaedica Belgica.
1995;61(3):190-198.
20. Geyer H, Seyfarth A, Blickhan R. Spring-mass
running: simple approximate solution and
application to gait stability. J Theor Biol.
2005;232(3):315-328.
21. Chumanov ES, Wille CM, Michalski MP, Heiderscheit
BC. Changes in muscle activation patterns when
running step rate is increased. Gait Posture. Jun
2012;36(2):231-235.
22. Heiderscheit BC, Chumanov ES, Michalski MP, Wille
CM, Ryan MB. Effects of step rate manipulation on
joint mechanics during running. Med Sci Sports
Exerc. 2011;43(2):296-302.
23. Milner CE, Ferber R, Pollard CD, Hamill J, Davis IS.
Biomechanical factors associated with tibial stress
fracture in female runners. Med Sci Sports Exerc.
2006;38(2):323-328.
24. Schache AG, Blanch PD, Rath DA, Wrigley TV, Starr
R, Bennell KL. A comparison of overground and
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
... For example, variables such as stride length and cadence are often targeted by gaitretraining studies to reduce ERLLP. 10 If these metrics are decreased during treadmill running but not in an outdoor running environment, then they may not be factors that deserve focus during gait-retraining interventions. Therefore, it is necessary to quantify running-gait patterns among runners with ERLLP in outdoor running settings. ...
... After gait retraining, runners' total running distance, subjective function, and pain improved. 10 Hence, focusing in-field gait-retraining programs on decreasing contact time and reducing pain in runners with ERLLP appears to be warranted. Reducing ground contact time may decrease the ground reaction forces and, thus, decrease muscle overloading. ...
... Increased hip flexion during running may promote a midfoot or forefoot strike and has been used as an effective gait-retraining cue to reduce pain associated with running. 10 Additionally, increasing the step rate above a preferred rate has been shown to increase hip-flexor muscle loading during the swing phase, resulting in less peak force during the loading response. 32 Thus, adding hip-flexor strengthening exercises for runners with ERLLP may be appropriate. ...
Article
Full-text available
Context Exercise-related lower leg pain (ERLLP) is common in runners. Objective To compare biomechanical (kinematic, kinetic, and spatiotemporal) measures obtained from wearable sensors as well as lower extremity alignment, range of motion, and strength during running between runners with and those without ERLLP. Design Case-control study. Setting Field and laboratory. Patients or Other Participants Of 32 young adults who had been running regularly (>10 mi [16 km] per week) for ≥3 months, 16 had ERLLP for ≥2 weeks and 16 were healthy control participants. Main Outcome Measure(s) Both field and laboratory measures were collected at the initial visit. The laboratory measures consisted of alignment (arch height index, foot posture index, navicular drop, tibial torsion, Q-angle, and hip anteversion), range of motion (great toe, ankle, knee, and hip), and strength. Participants then completed a 1.67-mi (2.69-km) run along a predetermined route to calibrate the RunScribe devices. The RunScribe wearable sensors collected kinematic (pronation excursion and maximum pronation velocity), kinetic (impact g and braking g), and spatiotemporal (stride length, step length, contact time, stride pace, and flight ratio) measures. Participants then wore the sensors during at least 3 training runs in the next week. Results The ERLLP group had a slower stride pace than the healthy group, which was accounted for as a covariate in subsequent analyses. The ERLLP group had a longer contact time during the stance phase of running (mean difference [MD] = 18.00 ± 8.27 milliseconds) and decreased stride length (MD = −0.11 ± 0.05 m) than the control group. For the clinical measures, the ERLLP group demonstrated increased range of motion for great-toe flexion (MD = 13.9 ± 4.6°) and ankle eversion (MD = 6.3 ± 2.7°) and decreased strength for ankle inversion (MD = −0.49 ± 0.23 N/kg), ankle eversion (MD = −0.57 ± 0.27 N/kg), and hip flexion (MD = −0.99 ± 0.39 N/kg). Conclusions The ERLLP group exhibited a longer contact time and decreased stride length during running as well as strength deficits at the ankle and hip. Gait retraining and lower extremity strengthening may be warranted as clinical interventions in runners with ERLLP.
... Earlier it was thought no form of conservative treatment was helpful for ant-CECS, but now several articles show positive and promising results for gait retraining programs, especially in the military. [8][9][10]29,30 Diebal et al 8 were the first to report positive effects of gait retraining for ant-CECS; all 10 participants (100%) were able to return to base for active duty, without surgery. In our current study, 74 of 108 service members (69%) were able to return to active duty. ...
... This discrepancy is probably best explained by differences in patient selection because the current study included all referred military service members with ERLP and Diebal included only young, male, very fit cadets from officer training. In a group of 10 civilian runners with anterior exertional lower leg pain, Breen et al 29 reported that 70% were able to run 30 minutes without pain 1 year after a 6-week gait retraining program. In the 2 previous studies and current data, no conversion from chronic to acute compartment syndrome was reported. ...
Article
Full-text available
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.
... Altering gait mechanics to emphasize mid-foot strike or forefoot running has shown excellent results; between 57% and 100% of patients were able to return to activity without surgical intervention following a minimum six-week intervention. [24][25][26] Patients reported improvement in pain and function relative to the duration of the intervention. 25 They retained the technical changes to their running technique at six-week follow-up. ...
... 25 They retained the technical changes to their running technique at six-week follow-up. 24 This method of management, however, may be impractical for certain athletes and certain military personnel. ...
Article
Full-text available
Objective: The objective of this review is to evaluate the effectiveness of surgical management versus non-surgical management on pain, range of motion, intracompartmental pressure values, patient satisfaction, recurrence of symptoms, return to activity, function, strength, and sensation in patients diagnosed with chronic exertional compartment syndrome of the anterior compartment of the leg. Introduction: Chronic exertional compartment syndrome is the most prevalent cause of exercise-induced leg pain in athletes. Current evidence suggests that the best methods for management include activity modification or cessation, injection of botulinum toxin into the affected compartment, or surgical intervention. Due to the limited number and quality of studies available, the evidence needs to be synthesized to pool findings from current research and to identify gaps in the literature. Inclusion criteria: This review will consider studies that include people with chronic exertional compartment syndrome of the anterior compartment of the leg diagnosed through a combination of elevated intracompartmental pressure values and patient history. Studies that include patient-reported outcome measures will be included. Methods: MEDLINE, SPORTDiscus, Physiotherapy Evidence Database, MasterFILE Premier, CINAHL Complete, ProQuest Health and Medical Complete, Scopus, and Science Direct will be searched from 1956 to date. Gray literature databases will also be searched. Two reviewers will independently retrieve and screen full-text studies, critically appraise included studies, and extract data. Meta-analyses will be performed where possible. Systematic review registration number: PROSPERO CRD42020189661.
... 29,30 It is defined as "the implementation of any cue or strategy to alter an individual's running technique." 28 Gait retraining by transitioning a runner from a rearfoot strike (RFS) to a non-rearfoot strike (NRFS) pattern is effective in treating running related chronic exertional compartment syndrome(CECS) 28,31,32 and patellofemoral pain syndrome (PFPS). 29 Clinicians often facilitate alterations in foot strike pattern (FSP) through verbal explanation 33 or video 7,34 which make this intervention cost effective and clinically feasible. ...
Article
Introduction: Running-related musculoskeletal injury (RRI) among U.S. military service members continues to negatively impact force readiness. There is a paucity of evidence supporting the use of RRI interventions, such as gait retraining, in military populations. Gait retraining has demonstrated effectiveness in altering running biomechanics and reducing running load. The purpose of this pilot study was to investigate the clinical effect of a gait retraining intervention on a military cadet population recovering from a lower-extremity RRI. Materials and methods: The study design is a pilot study. Before study initiation, institutional approval was granted by the Keller Army Community Hospital Office of Human Research Protections. Nine rearfoot strike (RFS) runners recovering from a lower-extremity RRI at the U.S. Military Academy were prospectively enrolled and completed a gait retraining intervention. Participants followed-up with their assigned medical provider 6 times over 10 weeks for a clinical evaluation and running gait retraining. Gait retraining was provided utilizing verbal, visual, and audio feedback to facilitate a change in running foot strike pattern from RFS to non-rearfoot strike (NRFS) and increase preferred running step rate. At pre-intervention and post-intervention running ground reaction forces (GRF) [average vertical loading rate (AVLR), peak vertical GRF], kinematic (foot strike pattern) and temporospatial (step rate, contact time) data were collected. Participants self-reported their level of function via the Single Assessment Numeric Evaluation, Patient-Specific Functional Scale, and total weekly running minutes. Paired samples t-tests and Wilcoxon signed rank tests were used to compare pre- and post-intervention measures of interest. Values of P < .05 were considered statistically significant. Results: Nine patients completed the 10-week intervention (age, 20.3 ± 2.2 years; height, 170.7 ± 13.8 cm; mass, 71.7 ± 14.9 kg; duration of injury symptoms, 192.4 ± 345.5 days; running speed, 2.8 ± 0.38 m/s). All nine runners (100%) transitioned from RFS to NRFS. Left AVLR significantly decreased from 60.3 ± 17.0 bodyweight per second (BW/s) before intervention to 25.9 ± 9.1 BW/s after intervention (P = 0.008; effect size (d) = 2.5). Right AVLR significantly decreased from 60.5 ± 15.7 BW/s to 32.3 ± 12.5 BW/s (P < .001; d = 2.0). Similarly, step rate increased from 169.9 ± 10.0 steps per minute (steps/min) before intervention to 180.5 ± 6.5 steps/min following intervention (P = .005; d = 1.3). Single Assessment Numeric Evaluation scores improved significantly from 75 ± 23 to 100 ± 8 (P = .008; d = 1.5) and Patient-Specific Functional Scale values significantly improved from 6 ± 2.3 to 9.5 ± 1.6 (P = .007; d = 1.8) after intervention. Peak vertical GRF (left, P = .127, d = 0.42; right, P = .052, d = 0.53), contact time (left, P = 0.127, d = 0.42; right, P = 0.052, d = 0.53), and total weekly continuous running minutes (P = 0.095, d = 0.80) remained unchanged at post-intervention. All 9 patients remained injury free upon a 6-month medical record review. Conclusions: In 9 military service members with a RRI, a 10-week NRFS gait retraining intervention was effective in improving running mechanics and measures of function. Patients remained injury-free 6 months following enrollment. The outcomes of this pilot study suggest that individuals recovering from certain lower-extremity RRIs may benefit from transitioning to an NRFS running pattern.
Background Chronic exertional compartment syndrome (CECS) is a muscular overuse injury, usually affecting runners, athletes, or military personnel. The present study aims to provide a systematic overview of the surgical and conservative treatment options and their effectiveness in lower limb CECS. Method A systematic literature search following the PRISMA guidelines was conducted. The quality of the evidence was measured using an adapted version of the Critical Appraisal Skills Programme (CASP). Results 44 studies were included. 37 of them deal with surgical fasciotomy or fasciectomy, six used conservative management in form of gait-retraining and physical therapy and one study evaluated the effect of BoNT-injections in the affected compartments. Fifteen studies reported satisfaction rates above 70% in patients treated with fasciotomy. Conservative management showed good, but slightly lower results than surgical treatment. Conclusion Fasciotomy is an effective treatment in most patients suffering from CECS of the lower leg. Results of conservative treatment by gait-retraining and of treatment with BoNT-injections are promising. Specifically, gait-retraining may be considered as treatment of choice in military personnel, as in this population fasciotomy appears to be less effective than in athletes. Meanwhile, in an athlete population, where fasciotomy remains the standard treatment for CECS, gait-retraining should at least be envisioned in patients with post-surgical symptom recurrence.
Chapter
Chronic exertional compartment syndrome is an exercise-induced condition causing pain that ceases at rest and most frequently affects young, active individuals. The pathophysiology is multifactorial and associated with abnormally high intracompartmental pressures in the lower leg, resulting in various signs and symptoms. Compartment pressure testing is necessary to confirm diagnosis, although there is discrepancy about which methods and values are most accurate for proper diagnosis. Chronic exertional compartment syndrome can be managed nonoperatively or surgically via open, minimal incision, or endoscopy-assisted fasciotomy.
Chapter
Unterschenkelbeschwerden betreffen oftmals Läufer und wurden in der Vergangenheit meist unter dem Begriff „Shin Splint“ summiert. Dieses Kapitel gibt einen Überblick über häufige Ursachen von Unterschenkelbeschwerden und deren differenzialdiagnostischen Abgrenzung voneinander. Darüber hinaus werden evidenzbasierte Therapieprinzipien, ausgehend von der zugrunde liegenden Pathologie, vorgestellt.
Conference Paper
Full-text available
Due to the limited learning time allotted in most foot strike pattern modification studies, the reliability of pattern alterations may be jeopardized. The purpose of the current study was to investigate the reliability and validity of requested acute alteration of foot strike patterns performed by participants in a laboratory environment. Participants employed a high degree of consistency within foot strike pattern conditions and across the steps within a condition (average within subjects 95% confidence interval = 0.5°-4°). On a group level, participants accurately performed all foot strike conditions with the exception of the midfoot strike pattern. Thus, even with the alteration of foot strike pattern, a generally reliable and valid foot strike angle performance is evidenced.
Chapter
This chapter focuses on presentations that are generally nontraumatic in nature and often have a higher prevalence in a military environment due to the nature of a service person’s role. Carrying extra weight in a Bergen while marching at a set pace over a long distance can lead to the development of pain or injury in the lower limb. Exercise-induced leg pain (EILP) is an umbrella term used to encompass conditions such as tendinopathy, chronic exertional compartment syndrome (CECS), popliteal artery entrapment syndrome (PAES), and medial tibial stress syndrome (MTSS). Other conditions, such as superficial peroneal nerve entrapment syndrome (SPNES), can also occur due to overuse and subsequent compression, but it more typically follows an episode of trauma. While these conditions are separate clinical entities in their own right, there is often an overlap in how they present, which places strong emphasis on a thorough history taking and a detailed objective assessment. In the military environment, these conditions are generally managed with multidisciplinary input from general practice, orthopedics, sport and exercise medicine, rehabilitation, radiology, pain management, and psychology in order to return the service person to active duty as quickly as possible.
Article
Full-text available
Background Currently, there is no generally agreed measure available to quantify a subject's perceived severity of exercise-induced leg pain symptoms. The aim of this study was to develop and validate a questionnaire that measures the severity of symptoms that impact on function and sports ability in patients with exercise-induced leg pain. Methods The exercise-induced leg pain questionnaire for German-speaking patients (EILP-G) was developed in five steps: (1) initial item generation, (2) item reduction, (3) pretesting, (4) expert meeting and (5) validation. The resulting EILP-G was tested for reliability, validity and internal consistency in 20 patients with exercise-induced leg pain, 20 asymptomatic track and field athletes serving as a population at risk and 33 asymptomatic sport students. Results The patient group scored the EILP-G questionnaire significantly lower than both control groups (each p<0.001). Test–retest demonstrates an excellent reliability in all tested groups (Intraclass Correlation Coefficient, ICC=0.861–0.987). Concurrent validity of the EILP-G questionnaire showed a substantial agreement when correlated with the chronic exertional compartment syndrome classification system of Schepsis (r=−0.743; p<0.001). Internal consistency for the EILP-G questionnaire was 0.924. Conclusions EILP-G questionnaire is a valid and reliable self-administered and disease-related outcome tool to measure the severity of symptoms that impact on function and sports ability in patients with exercise-induced leg pain. It can be recommended as a robust tool for measuring the subjectively perceived severity in German-speaking patients with exercise-induced leg pain.
Article
Full-text available
Background: Abnormal hip mechanics are often implicated in female runners with patellofemoral pain. We sought to evaluate a simple gait retraining technique, using a full-length mirror, in female runners with patellofemoral pain and abnormal hip mechanics. Transfer of the new motor skill to the untrained tasks of single leg squat and step descent was also evaluated. Methods: Ten female runners with patellofemoral pain completed 8 sessions of mirror and verbal feedback on their lower extremity alignment during treadmill running. During the last 4 sessions, mirror and verbal feedback were progressively removed. Hip mechanics were assessed during running gait, a single leg squat and a step descent, both pre- and post-retraining. Subjects returned to their normal running routines and analyses were repeated at 1-month and 3-month post-retraining. Data were analyzed via repeated measures analysis of variance. Findings: Subjects reduced peaks of hip adduction, contralateral pelvic drop, and hip abduction moment during running (P<0.05, effect size=0.69-2.91). Skill transfer to single leg squatting and step descent was noted (P<0.05, effect size=0.91-1.35). At 1 and 3 months post retraining, most mechanics were maintained in the absence of continued feedback. Subjects reported improvements in pain and function (P<0.05, effect size=3.81-7.61) and maintained through 3 months post retraining. Interpretation: Mirror gait retraining was effective in improving mechanics and measures of pain and function. Skill transfer to the untrained tasks of squatting and step descent indicated that a higher level of motor learning had occurred. Extended follow-up is needed to determine the long term efficacy of this treatment.
Article
Full-text available
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.
Article
Full-text available
Running with a step rate 5-10% greater than one's preferred can substantially reduce lower extremity joint moments and powers, and has been suggested as a possible strategy to aid in running injury management. The purpose of this study was to examine how neuromuscular activity changes with an increase in step rate during running. Forty-five injury-free, recreational runners participated in this study. Three-dimensional motion, ground reaction forces, and electromyography (EMG) of 8 muscles (rectus femoris, vastus lateralis, medial gastrocnemius, tibialis anterior, medial and lateral hamstrings, and gluteus medius and maximus) were recorded as each subject ran at their preferred speed for three different step rate conditions: preferred, +5% and +10% of preferred. Outcome measures included mean normalized EMG activity for each muscle at specific periods during the gait cycle. Muscle activities were found to predominantly increase during late swing, with no significant change in activities during the loading response. This increased muscle activity in anticipation of foot-ground contact likely alters the landing posture of the limb and the subsequent negative work performed by the joints during stance phase. Further, the increased activity observed in the gluteus maximus and medius suggests running with a greater step rate may have therapeutic benefits to those with anterior knee pain.
Article
Patients with chronic exertional compartment syndrome (CECS) have pain during exercise that subsides with rest. Diagnosis is usually confirmed by intramuscular compartment pressure (IMCP) measurement. Controversy exists regarding the accuracy of existing diagnostic criteria. (1) To compare dynamic IMCP measurement and anthropometric factors between patients with CECS and asymptomatic controls and (2) to establish the diagnostic utility of dynamic IMCP measurement. Cohort study (diagnosis); Level of evidence, 2. A total of 40 men aged 21 to 40 years were included in the study: 20 with symptoms of CECS of the anterior compartment and 20 asymptomatic controls. Diagnoses other than CECS were excluded with rigorous inclusion criteria and magnetic resonance imaging. The IMCP was measured continuously before, during, and after participants exercised on a treadmill, wearing identical footwear and carrying a 15-kg load. Pain experienced by study subjects increased incrementally as the study progressed (P < .001). Pain levels experienced by the case group during each phase of the exercise were significantly different (P = .021). Subjects had higher IMCP immediately upon standing at rest compared with controls (23.8 mm Hg [controls] vs 35.5 mm Hg [subjects]; P = .006). This relationship persisted throughout the exercise protocol, with the greatest difference corresponding to the period of maximal tolerable pain (68.7 mm Hg [controls] vs 114 mm Hg [subjects]; P < .001). Sensitivity and specificity were consistently higher than the existing criteria with improved diagnostic value (sensitivity = 63%, specificity = 95%; likelihood ratio = 12.5 [95% CI, 3.2-49]). Anterior compartment IMCP is elevated immediately upon standing at rest in subjects with CECS. In patients with symptoms consistent with CECS, diagnostic utility of IMCP measurement is improved when measured continuously during exercise. A cutoff of 105 mm Hg in phase 2 provides better diagnostic accuracy than do the Pedowitz criteria of 30 mm Hg and 20 mm Hg at 1 and 5 minutes after exercise, respectively. © 2014 The Author(s).
Article
Abstract We hypothesised that experienced runners would select a stride frequency closer to the optimum (minimal energy costs) than would novice runners. In addition, we expected that optimal stride frequency could simply be determined by monitoring heart rate without measuring oxygen consumption ([Formula: see text]O2). Ten healthy males (mean±s: 24±2 year) with no running training experience and 10 trained runners of similar age ran at constant treadmill speed corresponding to 80% of individual ventilatory threshold. For two days, they ran at seven different stride frequencies (self-selected stride frequency±18%) imposed by a metronome. Optimal stride frequency was based on the minimum of a second-order polynomial equation fitted through steady state [Formula: see text]O2 at each stride frequency. Running cost (mean±s) at optimal stride frequency was higher (P < 0.05) in novice (236±31 ml O2·kg(-1.)km(-1)) than trained (189±13 ml O2·kg(-1.)km(-1)) runners. Self-selected stride frequency (mean±s; strides(.)min(-1)) for novice (77.8±2.8) and trained runners (84.4±5.3) were lower (P < 0.05) than optimal stride frequency (respectively, 84.9±5.0 and 87.1±4.8). The difference between self-selected and optimal stride frequency was smaller (P < 0.05) for trained runners. In both the groups optimal stride frequency established with heart rate was not different (P > 0.3) from optimal stride frequency based on [Formula: see text]O2. In each group and despite limited variation between participants, optimal stride frequencies derived from [Formula: see text]O2 and heart rate were related (r > 0.7; P < 0.05). In conclusion, trained runners chose a stride frequency closer to the optimum for energy expenditure than novices. Heart rate could be used to establish optimal stride frequency.
Article
Clinical evaluation of medial longitudinal arch deformation (MLAD) during walking gait is often estimated from static measures of e.g. navicular drop (ND) measured during quiet standing. The aim of the present study was to test the reliability of a new three-dimensional method of measuring the MLAD during gait and to compare this method with a static measure and a 2D dynamic method. Fifty-two feet (26 healthy male participants) were tested twice 4-9 days apart in a biomechanical gait analysis laboratory using a 3D three-marker foot model, a 2D video-based model for the measurement of MLAD during gait, and ND for measurements of MLAD during quiet standing. The 3D method showed the highest test-retest reliability among the measurements of MLAD. Furthermore, the ND showed only moderate correlation with both measurements of MLAD during gait. The new 3D method was found to be highly reliable and showed that ND obtained during quiet standing could not predict the MLAD during gait. The 3D method, or alternatively the 2D method, may be used in clinical settings as reliable methods for easy estimation of the foot longitudinal stability.