Compartment Syndrome Update

Chronic exertional compartment syndrome (CECS)—can be a completely sidelining injury. It’s a condition most commonly seen in the lower leg among athletes, especially endurance runners. Symptoms typically develop as a tolerable pain, but as the runner continues running the pain worsens until it becomes unbearable and the runner has to stop. The pain usually subsides with rest.

This happens because the fascia (the connective tissue surrounding muscles, nerves, arteries, and veins) loses its elasticity. The lower leg is divided into 4 compartments, each surrounded by fascia. When you exercise and contract your muscles, the fascia expand and increase in volume. So if the fascia isn’t pliable, the pressure within the compartment increases, resulting in pain. There is mixed research on the exact cause of pain, but is generally thought to be a result of nerve and/or arterial compression. How the fascial elasticity is lost is unclear, but there is a genetic predisposition. Other risk factors include using creatine supplements and androgenic steroids.

CECS commonly requires surgery, and most surgeries have very good success rates. Typically CECS affects the anterior or anteriolateral compartments, and these have success rates from 70-80% for surgery. However, more recently there has been research into conservative treatments, particularly running mechanics retraining since so many CECS cases involve runners.

One study showed that participants with CECS had a decreased forward trunk lean, longer step length, and increased plantarflexion at push off. The longer step length can cause forces from landing to have a greater impact on the anterior lower leg. The anterior tibialis muscle is required to do more work to control the foot landing if the step length is longer and there is more plantarflexion in push off. So, the general idea is that there is more force going to the front of the lower leg (anterior compartment) and more work required from the anterior tibialis muscle (muscle in the anterior compartment).

The goal of running mechanics retraining would then be to decrease the landing force going to the front of the lower leg and reduce the amount of work required by muscles in the anterior compartment. Forefoot striking, increasing cadence (steps per minute) and cueing hamstring focus instead of calf focus to initiate push off have all been used. In one study, runners were able to complete a 5k pain free as a result of these running mechanics combined with a consistent physical therapy treatment program

While bad running mechanics in and of themselves are not a cause of CECS, the evidence shows that they may perpetuate the symptoms. It is worth addressing, especially as some cases have avoided surgery as a result.

Dr Cathlin Fitzgerald, DPT, CSCS


Roberts A Roscoe D Hulse D Bennett AN Dixon S “Biomechanical differences between cases with suspected chronic exertional compartment syndrome and asymptomatic controls during running”. Gait & Posture. 2017; 58: 374-379. Rajasejaran S Hall MM “Nonoperative management of chronic exertional compartment syndrome: a systematic review”.

Current Sports Medicine Reports. 2016; 15(3): 191-198. Campano D Robaina JA Kusnezov N et al. “Surgical management for chronic exertional compartment syndrome of the leg: a systematic review of the literature”. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2016; 32(7): 1478-1486.

Brennan FH Kane SF “Diagnosis treatment options, and rehabilitation of chronic lower leg exertional compartment syndrome”. Current Medical Reports. 2003; 2:247-250.