The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 312
Introduction: Chronic exertional compartment syndrome (CECS) is a condition that occurs almost exclu-
sively with running whereby exercise increases intramuscular pressure compromising circulation, prohibit-
ing muscular function, and causing pain in the lower leg. Currently, a lack of evidence exists for the effective
conservative management of CECS. Altering running mechanics by adopting forefoot running as opposed to
heel striking may assist in the treatment of CECS, specifically with anterior compartment symptoms.
Case Description: The purpose of this case series is to describe the outcomes for subjects with CECS through
a systematic conservative treatment model focused on forefoot running. Subject one was a 21 y/o female
with a 4 year history of CECS and subject two was a 21 y/o male, 7 months status-post two-compartment
right leg fasciotomy with a return of symptoms and a new onset of symptoms on the contralateral side.
Outcome: Both subjects modified their running technique over a period of six weeks. Kinematic and
kinetic analysis revealed increased step rate while step length, impulse, and peak vertical ground reaction
forces decreased. In addition, leg intracompartmental pressures decreased from pre-training to post-
training. Within 6 weeks of intervention subjects increased their running distance and speed absent of
symptoms of CECS. Follow-up questionnaires were completed by the subjects at 7 months following inter-
vention; subject one reported running distances up to 12.87 km pain-free and subject two reported running
6.44 km pain-free consistently 3 times a week.
Discussion: This case series describes a potentially beneficial conservative management approach to CECS in
the form of forefoot running instruction. Further research in this area is warranted to further explore the bene-
fits of adopting a forefoot running technique for CECS as well as other musculoskeletal overuse complaints.
Key Words: anterior compartment syndrome, fasciotomy, forefoot running, shin splints.
1 Keller Army Community Hospital, West Point, NY, USA
2 Assistant Professor, Biomechanics, United States Military
Academy, West Point, NY, USA
3 Orthopedic Surgeon, Keller Army Community Hospital, West
Point, NY, USA
4 Baylor University, Waco, TX, USA
IRB approval was granted for the study protocol by Keller
Army Community Hospital on 5 OCT 2010
This research was conducted at the United States Military
Academy, West Point, NY. At the time of the research, MAJ Diebal
was completing a post professional sports medicine physical
therapy residency under the mentorship of Dr. Gerber as well as
EFFECTS OF FOREFOOT RUNNING ON CHRONIC
EXERTIONAL COMPARTMENT SYNDROME:
A CASE SERIES
MAJ Angela R. Diebal, PT, DPT1
Dr. Robert Gregory, PhD2
COL Curtis Alitz, MD3
LTC J. Parry Gerber, PT, PhD1,4
completing her DScPT in Physical Therapy from Baylor
University, Waco TX. The opinions or assertions contained herein
are the private views of the authors and are not to be construed as
offi cial or as refl ecting the views of the US Army, the Department
of Defense, or the United States Government.
MAJ Angela Diebal
Keller Army Community Hospital
West Point, NY 10996
The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 313
Since the 1970’s the popularity of aerobic exercise has
increased tremendously.1 Running has long been a
primary popular choice of aerobic exercise for many
people and boasts several positive health benefits. It
can be performed virtually anywhere without any
special equipment, can complement most physical
training programs, and can improve aerobic endur-
ance with three 30 minute training sessions per
week.2 As the number of individuals participating in
leisurely jogging and running activities has increased,
the incidence of injuries has also increased.3,4
In an effort to prevent, treat, and reduce running
injuries, a current trend in rehabilitation has cen-
tered on modifying running technique. Several run-
ning techniques that have recently gained popularity
are Chi Running, Barefoot Running, Evolution Run-
ning, and the Pose Method.5-7 These running styles
are similar in the sense that they aim to eliminate
the initial heel strike at ground contact by promot-
ing a forefoot strike upon impact. While much more
research is needed to determine if adopting such a
running style can help prevent injuries, several
authors have demonstrated that a significant reduc-
tion of ground reaction forces can occur if the heel
strike is eliminated at initial impact.8-10 Research has
not been thoroughly conducted to determine what
musculoskeletal conditions would respond favorably
or not so favorably to changing running styles. Theo-
retically, adopting a forefoot running style would be
best suited for those conditions that could benefit
from reduced ground reaction forces while running
(i.e., stress reactions/fractures, anterior knee pain,
back pain, etc.). This case series presents prelimi-
nary data which suggests that chronic exertional
compartment syndrome (CECS) is one musculoskel-
etal condition that may respond positively to adopt-
ing an alternate running style.
CECS is defined as a condition that causes lower leg
pain and disability during exercise in the presence of
increased intramuscular pressure in a closed fibro-
osseous space.3,11,12 This condition is most prevalent in
young adult athletes and occurs with increased fre-
quency among members of the military.11,13,14 The
exact cause of CECS remains unclear but it is specu-
lated that the pressure increase is due to arterial
spasm, capillary obstruction, arteriovenous collapse,
venous outflow obstruction, muscle hypertrophy, fas-
cial inflexibility, or a release of protein bound
ions.4,11,12,15 The high pressure may cause vascular
occlusion and decreased tissue perfusion which may
lead to ischemic pain that often occurs bilaterally.16-19
The anterior compartment is the most common loca-
tion for CECS to occur, with runners accounting for
69% of all cases.14,19 The anterior compartment is bor-
dered by the tibia, fibula, interosseous membrane, and
the anterior intermuscular septum. It consists of the
tibialis anterior muscle and anterior tibial artery,
extensor digitorum longus, extensor hallucis longus,
fibularis tertius muscles, the anterior tibial artery, and
the deep fibular nerve. Diagnosis of this condition is
difficult due to the lack of clinical signs and symp-
toms. History and physical examination alone are
often considered inadequate for the diagnosis of
CECS.20 Intracompartmental pressure measurements
confirm the diagnosis of CECS and help differentiate it
from other conditions causing exercise induced pain.21
Pedowitz et al developed intramuscular pressure
thresholds using a slit catheter to further assist in the
diagnosis of CECS.18 For those suffering from CECS,
running activities present a significant problem. As
the compartment pressure increases, a person may
develop lower leg pain, sensory abnormalities, and
muscle weakness which eventually results in a pre-
mature cessation of the activity.4,11-13,20,22-27 Upon cessa-
tion of the activity the compartment pressure decreases,
pain subsides, and the functional examination returns
to “normal”, typically within ten minutes.11,12 Recom-
mended non-surgical management for CECS includes
anti-inflammatory drugs, stretching, prolonged rest,
decreasing or avoiding the problematic activity, orthot-
ics, and massage.16,20,23,25 None of these conservative
approaches have yielded consistently positive long
term results; however, no randomized controlled stud-
ies exist in the literature to truly investigate conserva-
tive management techniques.28 If those with CECS do
not desire to modify their activity level, the only effec-
tive treatment for this condition is surgical manage-
ment in the form of a fasciotomy.16,25 While the majority
of patients do well following surgery, approximately
3-17% of individuals undergoing fasciotomy experi-
ence less than favorable outcomes such as ankle pain,
reoccurrence of symptoms, decreased sensation at the
incision site, numbness at the lateral leg, hypersensi-
tivity to touch, and paresthesias in the legs.16,19,29,30
The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 314
One conservative management approach that has not
been investigated, but theoretically could assist those
with anterior CECS, is altering running technique.
Kirby et al found that anterior compartment pressures
were significantly influenced by running style, report-
ing anterior compartment pressures were increased
when a heel striking gait pattern was utilized.15 It has
also been well documented that forefoot striking as
opposed to heel striking causes a decrease in ground
reaction forces, stride length, and ground contact time
and an increase in step rate.8-10,31-42 To the authors’
knowledge, the modification of running technique as
an intervention for CECS has not previously been
investigated. Incorporating the use of a systematic
instructional model, which focuses on landing on the
forefoot as opposed to the heel, may assist in control-
ling the elevation of compartment pressures with run-
ning. If successful, this could allow those suffering
from CECS the ability to run longer without symptoms
and possibly reduce the need for fasciotomy.
The purpose of this case series is to describe the out-
comes for two subjects with anterior CECS through
the implementation of a systematic conservative
treatment model focused on forefoot running.
Both participants were given a verbal explanation of
the study protocol and provided written informed
consent prior to testing. Approval was granted by
the Institutional Review Board at Keller Army Com-
Case 1: A 21-year old female (154.9 cm, 52.6 kg) pre-
sented to physical therapy with a four year history of
bilateral anterior and lateral lower leg pain that occurred
while running. The patient reported leg symptoms
while running that began predictably before 0.8 km
resulting in pain and tightness, which progressively
worsened to include numbness and pressure with pain
throughout the exercise. She reported the ability to tol-
erate the leg pain for several kilometers if running on
flat surfaces at a slower pace; however, she could toler-
ate less than 1 km if she ran up hills. She reported that
upon cessation of running her symptoms would com-
pletely resolve within 5 to 10 minutes.
The initial physical examination at rest was unremark-
able (i.e., full ankle and knee range of motion (ROM)
and strength, no tenderness or compartment tightness
to palpation, and full functional ability to squat and
hop without symptoms). A running evaluation was
conducted by real time observation using a commer-
cial grade treadmill (LifeFitness, 97Ti, Franklin Park,
IL). The patient ran at a self-selected pace of 11 km per
hour, demonstrating a heel striking and over-striding
gait pattern. The patient reported an onset of pain in
the anterior and lateral aspect of both lower legs after
running 3 minutes, at which time an audible and visual
foot slap was observed for both lower extremities. After
0.8 km (5 minutes, 10 seconds), the patient reported a
6/10 pain on the left leg (2/10 on the right leg) and
requested to end the session. A physical examination
immediately following revealed an appreciable firm-
ness and tenderness to palpation in both anterior com-
partments, and decreased dorsiflexion strength
bilaterally (4+/5). Based on history and physical exam-
ination, a preliminary diagnosis of leg pain consistent
with CECS was made.
The subject returned the following day for the col-
lection of kinematic and kinetic running data. An
instrumented treadmill was utilized (Kistler- Gaitway,
Zurich, Switzerland) to assess variables illustrating
running technique such as; step length, step rate,
vertical ground reaction force (GRF), and impulse,
(Table 1). Impulse is defined as the product of the
Table 1. Kinematic and Kinetic Variables for Subject Number 1.
The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 315
magnitude of a force and its time of application. It is
specifically the area under a vertical ground reac-
tion force-time curve. In a third visit, pre- and post-
exercise intracompartmental pressures of the
anterior compartments were measured by an ortho-
pedic surgeon (refer to Tables 6 and 7 for values)
using a Stryker Intracompartmental Pressure Moni-
tor (Side Port Needle, Kalamazoo, MI).20,43,44 Position-
ing of the knee, leg, and foot was standardized for all
measurements. Post-exercise pressure measure-
ments were taken at 1 minute following exercise
cessation. Due to the elevation in post exercise inter-
compartmental pressure, the diagnosis of CECS was
made by the orthopedic surgeon.
Physical therapy intervention was initiated that focused
on modifying the patient’s running technique. The
patient was instructed in a forefoot running technique
on both land and treadmill, with the aim of eliminating
the initial heel strike and consequently reducing
ground reaction forces.7,45 Training included increasing
her running step rate to 3 steps per second and using
her hamstrings to pull her foot from the ground versus
push her foot from the ground using the gastocneu-
mius.9 A digital metronome (Seiko, DM50S, Singapore)
was also utilized to increase step cadence to 180 steps
per minute. Focused training drills and exercises con-
sisted of weight shifting, falling forward, foot tapping,
high hopping, and running with a specialized belt (EZ
Run Belt, Posetech.com) as described by Romanov
(Figures 1-5).7,46 The subject also practiced running
barefoot with verbal cueing to “run quietly” to elimi-
nate the tendency to heel strike upon ground contact.
Feedback was provided using video recorded from a
Figure 1. Weight Shifting—In this drill the patient focuses on shifting the pressure from the heels onto the forefeet to improve
perception of how minute adjustments can dramatically change body weight during support.
Figure 2. Falling Forward—In this drill the patient focuses
on falling forward while maintaining the funning pose in
front of a wall. Start close to the wall and move farther from
the wall as comfort level increases.
The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 316
commercial camera (Flip Video, Cisco, California) and
placed on a personal laptop computer (MacBook Pro,
Apple) to help demonstrate and correct running errors.
This instruction was conducted 3 times a week for
approximately 1 hour each and took place over the
course of 6 weeks. The instruction initially consisted
of the training drills listed in Figures 1-5 and then
progressed to forefoot running intervals for distances
of .25 km with a two minute walking period between
intervals. Running endurance was gradually progressed
as proper running form was maintained for longer dis-
tances between walking bouts. Instruction during the
last 3 weeks of training mainly focused on improving
running speed and endurance while maintaining
proper form during running duration.
At 6 weeks post-intervention, the physical examina-
tion, including intracompartmental pressures, and
the kinematic and kinetic treadmill measurements
were repeated. The physical examination was unre-
markable before and after running. The patient ran
5 km (26 minutes, 18 seconds) on the treadmill with-
out any pain complaints; treadmill testing concluded
at a predetermined distance of 5 km. The force plate
treadmill measurements and the pre- and post-intra-
compartmental pressures of the anterior compart-
ments are presented in Table 1 and Figure 6. She also
completed a global rating of change (GROC) score at
that time, rating herself as a 6 (a great deal better).
Figure 3. Foot Tapping—In this drill the patient pulls the
foot from the ground using the hamstrings and allows the
foot to fall back to the ground using gravity. The patient
does not actively lower the foot.
Figure 4. High Hopping—Start in the running pose,
and work on hopping, progressing to the point where the
heels touch the buttocks. Attempt to maintain quadriceps
relaxation throughout this drill.
Figure 5. The EZ Run Belt (Joe Sparks, Perrysburg, OH).
This is a training tool to assist learning and self correction of
running gait. It assists by pulling the foot from the ground
and helps prevent over striding.
The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 317
A follow-up questionnaire was completed at 7 months,
at which time the subject reported the ability to run
12.87 km (including) hills without an increase of leg
symptoms and she reported that she was training to
run a marathon.
Case 2: A 21-year old male (172.7 cm, 97.4 kg) pre-
sented to physical therapy with complaints of bilat-
eral anterior and lateral lower leg pain while running
seven months status post two-compartment (ante-
rior and lateral) right leg fasciotomies (to correct
CECS). He stated that his pre-surgical symptoms
returned on the right leg within two months follow-
ing surgery and now has a new onset of pain and
tightness in the left leg. The patient reported that his
left leg was now worse than the right, and his overall
pain caused him to stop running after approximately
5 minutes. He verbalized concern that he may need
a surgery on the left leg. He reported complete
reduction of symptoms within 5 minutes of rest.
Similar to the first case, the physical examination was
unremarkable at rest. However, this patient had
noticeably hypertrophied lower legs (calf muscula-
ture). A running evaluation, utilizing visual analysis,
was conducted on a commercial treadmill at a self-
selected speed of 10.5 km/hr, during which he dem-
onstrated a heel striking gait pattern. After running
for 2 minutes, 30 seconds, he reported pain and tight-
ness in the right anterior and lateral lower leg. After
0.81 km (5 minutes, 14 seconds), the subject noted
the onset of pain and tightness on the left side. After
1.56 km (9 minutes, 11 seconds), a foot slap was
observed on the left side at which time he requested
to stop the activity. Physical exam immediately fol-
lowing revealed an appreciable firmness and tender-
ness to palpation in both anterior compartments. He
complained of pain in the legs with resisted dorsiflex-
ion (5/5 strength) and with full passive plantar flex-
ion. Kinematic and kinetic data was gathered along
with pre- and post-exercise intracompartmental pres-
sures of the anterior compartments (Table 2 and Fig-
ure 7). The patient was diagnosed with CECS by an
orthopedic surgeon and the intervention of modify-
ing his running technique was initiated.
The running instruction and training mirrored that
provided during case one, emphasizing a forefoot
running pattern, increasing the step rate to 3 steps
per second, and use of the hamstrings to pull his foot
from the ground while running.7
After 6 weeks, the physical examination, intracom-
partmental pressures, and instrumented treadmill
measurements were repeated. The physical exami-
nation was unremarkable before and after running.
The patient ran 4.02 km (21 minutes, 8 seconds) on
the treadmill without complaints of leg pain; however,
Table 2. Kinematic and Kinetic Variables for Subject Number 1.
Figure 6. Intracompartmental pressures of the anterior
compartment for subject 1. Pre-intervention running
pressures were measured after running 0.8 km while
post-intervention running pressures were measured after
running 5 km.
The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 318
the test was discontinued due to complaints of left
foot arch pain. A subsequent physical exam of his
foot and ankle was unremarkable. The kinematic
and kinetic measurements and the pre- and post-
intracompartmental pressures of the anterior com-
partments are provided in Table 2 and Figure 7. He
also completed a GROC score at that time and rated
himself as a 7 (a great deal better). After 2.5 months
he reported he was able to run 6.43 km without pain.
On a follow-up questionnaire at 7 months he reported
running distances of 6.43 km pain-free 3 times a
This case series presents two subjects with CECS
whereby altering running mechanics to a forefoot
striking technique was the primary intervention. The
subjects had favorable results which allowed them to
return to pain-free running activity without surgical
intervention. The change in running technique was
demonstrated by increased step rate and decreased
impulse, GRF, and step length (Tables 1 and 2). Post-
exercise compartment pressures were lower by as
much as 30% in some cases (Figures 6 & 7). In addi-
tion, these two subjects, who could not run over 1 km
without severe symptoms prior to the intervention,
could now run 4 and 5 km with minimal difficulty.
Successful rehabilitation for CECS has historically
been challenging. Physical therapists typically per-
form patient examinations looking for impairments
that can be addressed through therapeutic exercise,
various modalities, or manual therapies. CECS is a
unique condition whereby it is commonly very diffi-
cult to find impairments related to a patient’s symp-
toms. Although research is certainly limited, this is
potentially one reason why attempts at non-surgical
management with anti-inflammatory drugs, stretch-
ing, prolonged rest, decreasing or avoiding the prob-
lematic activity, orthotics, and massage have largely
proved unsuccessful. In these two cases, the selected
intervention was not based on any specific impair-
ment observed or measured during the physical
examination. Rather, it was based on observing a
heel striking gait pattern with running and the the-
ory that decreasing anterior compartment muscle
activity could potentially be beneficial for this
There are several possible reasons to explain how the
forefoot running training technique may assist those
with CECS. Gershuni et al and Tsintzas et al found a
significant increase in the anterior compartment
pressures of healthy individuals in the full ankle dor-
siflexion and full knee extension positions.47,48 The
position of full knee extension coupled with full ankle
dorsiflexion is consistent with the typical heel strike
technique used by runners at initial contact. In addi-
tion to a potentially more favorable foot position at
initial ground contact (less ankle dorsiflexion), elimi-
nating the heel strike upon ground contact by replac-
ing it with a forefoot strike may reduce the eccentric
muscle activity of the anterior leg compartment mus-
culature and therefore mitigate the increase of ante-
rior compartment pressures and symptoms of CECS
during running.21,47,48 As previously noted, Kirby et al
reported that anterior compartment pressures were
increased when a heel striking gait pattern was uti-
lized as opposed to a neutral or forefoot running gait.15
Therefore, a forefoot running technique may favor-
ably reduce the variables that contribute to the onset
of CECS symptoms and reduce the necessity for sur-
gical management for this condition.
The cases presented in this paper are interesting for
several reasons. In case one, the patient quickly
adapted the new forefoot running technique. Com-
pared to pre-intervention measures her impulse,
ground reaction forces, and step length decreased by
approximately 5%, 7%, and 9% respectively. Step rate
Figure 7. Intracompartmental pressures of the anterior
compartment for subject 2. Pre-intervention running
pressures were measured after running 1.56 km while
post-intervention running pressures were measured after
running 4.02 km.
The International Journal of Sports Physical Therapy | Volume 6, Number 4 | December 2011 | Page 319
increased by approximately 9%. It is possible that
altering these aspects of running mechanics favor-
ably affected her during her rehabilitation as she was
able to return to running without pain or limitation in
Case two differs from case one in that he previously
had a fasciotomy on his right leg, in which his CECS
symptoms returned approximately 2 months after
surgery when he resumed running. As his running
distance progressed, his left leg became more symp-
tomatic than the right, and his bilateral leg symp-
toms were consistent with CECS. Adjusting running
technique and learning to pull the foot from the
ground was challenging for this subject. No specific
functional deficits were identified as contributors to
this challenge. However, it is the authors’ experience
that some individuals have a more difficult time
than others while attempting to perform a forefoot
running technique. A great deal of attention to detail
and video feedback was necessary for this patient.
Ultimately, he avoided fasciotomy on his left leg and
a revision fasciotomy on his right leg, and his run-
ning distance has continued to increase.
Ultimately, no cause and effect relationship can be
inferred by the results of case report research. Inter-
pretation of the current findings presents challenges
related to the fact that pressure measurements post-
intervention performed at rest and 1 minute follow-
ing running could be considered elevated according
to previous researchers.18 For example, over 20 years
ago, Pedowitz et al published that resting values
higher than 15 mmHg and post exercise values over
30 mmHg were indicative of CECS with the caveat
that elevated pressures without symptoms of CECS
would not be considered a positive test.49 Resting
pressure values in these 2 subjects ranged from 20
mmHg to 32 mmHg while post running pressures
ranged from 36 mmHg to 63 mmHg. Direct compari-
son to previously reported values should be cau-
tioned, as conflicting values have been reported by
several studies, with reports of normal intracompart-
mental pressures varying by up to 500%.50,51 It has
also been documented that pressure varies with the
depth of the catheter placement, which is difficult to
control.52 These variables could explain the fact that
resting pressures at 6 weeks were elevated compared
to the resting pressures at baseline. We are unable to
make direct comparisons of our pressure data to find-
ings reported by Pedowitz et al due to the fact that
their study used a slit catheter to establish CECS pres-
sure criteria, and the current report describes pres-
sures obtained via a side-port needle catheter. Despite
elevated pressure readings, the subjects were asymp-
tomatic. Therefor, they no longer met the diagnostic
criteria for CECS; elevated pressures in the presence
of other clinical findings.
Caution and careful instruction may be required to
avoid undesired complications when one attempts
to alter his or her current running style. Common
complications include achilles tendonopathy, plan-
tar fascia pain, gastrocnemius soreness, blisters, ilio-
tibial band syndrome, and anterior knee pain.45
Running errors while attempting to transition to a
forefoot running gait pattern typically contribute to
these musculoskeletal complaints and can be greatly
reduced by careful supervision and correction dur-
ing training. Similar to most new exercise programs,
proper form and gradual progression in time and
intensity must be emphasized. Additionally, patients
presenting with leg pain should be evaluated by a
credentialed medical provider.
While no generalizations or intervention recommen-
dations can be made from this case series, it does
illuminate the need for further research in this area.
For those patients with CECS, adopting a forefoot run-
ning style may lead to an increased tolerance for run-
ning and therefore potentially decrease the need for
surgical management of this condition. The authors
are currently conducting a clinical trial with a larger
sample size to further explore the effectiveness of
forefoot running on those diagnosed with CECS.
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