Posted by: Joe Nuss on Apr 30, 2012
By Brian Schiff
Lower leg pain is a common issue that most runners will face at some point during their training runs. Predictable causes of pain include general muscle soreness, calf strains, shin splints, and even stress fractures. However, some runners will experience a less common and more debilitating condition known as compartment syndrome that significantly reduces running capacity or prohibits running altogether.
This type of problem is often referred to as chronic exertional compartment syndrome (CECS). This atypical syndrome is an exercise-induced neuromuscular condition that causes pain, swelling, and at times disability in the affected muscles of the legs or arms. It is more common in athletes who are involved in repetitive activities such as running, fast walking, biking, and swimming. According to the Mayo Clinic, it is seen more in athletes under age 40, and overuse/overtraining may increase the risk for developing CECS.
So how does this condition really differ from shin splints or stress reactions?
Shin splints - Inflammation of the soft tissue (usually mid-lower leg) attaching to the tibia due to overuse, overtraining and increasing mileage too quickly. Overpronation and genu vlagum (knock knees) may contribute to increased risk for pain inside of the tibia. There may be local tenderness and pain on each side of the shinbone. This condition usually improves with rest, modified training, stretching, arch supports (if needed), and physical therapy.
Stress fracture - The most common site for a tibial stress fracture in runners is the junction between the middle and distal (lower) third of the tibia. Pain usually increases with running and is better with rest. There is typically pin point and significant tenderness along the tibia. This injury may require prolonged rest, immobilization, or in some cases even surgery. This diagnosis can usually be made with X-rays, but if it is an acute stress fracture it may not show up for three to four weeks following the onset of symptoms. A bone scan or MRI may be needed to confirm the injury.
Chronic Exertional Compartment Syndrome - Exercise or even repetitive muscle contraction causes the tissue pressure within a compartment in the lower leg to increase to an abnormally high level. These compartments are encased by a thick layer of connective tissue called fascia. Because the fascia cannot stretch, the tissues in the compartment aren’t able to expand sufficiently under the increased pressure. If blood flow is insufficient, oxygen flow is inadequate and damage to muscles and nerves in the compartment may occur.
CECS is typically diagnosed by your physician through a complete medical history, imaging tests, and testing of the compartmental pressures themselves using needles. Conservative treatment may include medication, massage therapy, stretching, rest, and physical therapy.
Research published in the 2012 American Journal of Sports Medicine related to a West Point study looking at anterior compartment pressure and running form may hold some promise for sufferers hoping to avoid surgery. In 10 consecutive patients with CECS who were surgical candidates, a six-week forefoot strike running intervention led to decreased post-running lower leg intracompartmental pressures. Pain and disability typically associated with CECS were greatly reduced for up to one year after intervention. Surgical intervention was avoided for all patients.
In cases where compartment syndrome does not respond to conservative treatment, athletes who want to continue training may have to undergo a fasciotomy (cutting open the facia) or a fasciectomy (removal of some of the fascial tissue). Either way, these procedures work to decompress the compartment and free it from the restrictive fascia. If you are suffering from chronic and significant lower leg pain, be sure to seek medical attention to correctly identify and treat the source of your pain.
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Brian Schiff, PT, CSCS, is a sports physical therapist and supervisor at the Athletic Performance Center in Raleigh. The APC in Raleigh and Cary currently offer a RunSmart Assessment available in group and individual formats. For more information, visit www.apcraleigh.com or www.apccary.com.