Awkward Tightness in the Legs? It May Be Compartment Syndrome

The most common area of the body in which runners complain of pain is the lower leg. Of course when you think about the mechanics of running, the lower leg receives the majority of the impact since it carries the most weight throughout the running cycle. This is why conditions such as knee pain, and more commonly plantar fasciitis are frequent. One of the more misdiagnosed conditions seen in recreational runners and elite athletes is chronic exertional compartment syndrome (CECS). During exercise blood flow increases and muscles expand. The pain from CECS is felt when the lower leg areas become swollen during exercise, if the fascia, which is basically a sheath that wraps around the muscles, does not expand with the muscles.

Symptoms

The type of pain usually felt with CECS is aching or burning in a specific area of the lower leg that begins at a certain time after beginning activity. Most commonly, the pain occurs in both legs and either in the posterior compartment (calves) or anterior compartment (shins). Along with pain, numbness or tingling, as well as tightness can be felt that worsens as you continue the exercise. These symptoms usually subside within 10 to 20 minutes after stopping the activity.

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Differential Diagnosis

The reason this condition is misdiagnosed is because it resembles other more common conditions such as shin splints and tibial stress fractures. Shin splints are caused by overuse of the muscles connected to the shin bone, causing small tears which result in the muscle being “pulled” off the bone. The pain from shin splints is felt along most of the shin bone, whereas a tibial stress fracture is felt at a localized point in the bone. Both of these conditions, along with CECS, result in pain in similar areas and are usually caused by either improper biomechanics or overuse from adding mileage or intensity too soon during training.

If you are experiencing pain during exertion, especially if it begins within the first 10 to 20 minutes of a run and relieves within 10 to 20 minutes after stopping, get evaluated by a professional. If along with the pain is a sensation of significant tightness in the lower legs, CECS is most likely expected. An MRI will help rule out specific muscular issues. There are newer, more advanced MRI exams that can assess how much fluid accumulation there is in the compartments of the lower leg during activity, which has been found to be accurate in diagnosing CECS. It may limit the need to use the more invasive approach of diagnosing which is compartment pressure testing where needles are inserted into the muscles to evaluate the amount of pressure present.

Treatment

The goal of treating CECS is to relieve the pressure in the affected compartment during exertion. Unfortunately, the first step in treatment is avoiding aggravating activities, such as running. Doctors may prescribe NSAIDs and an icing regimen to help decrease the inflammation. During this rest time from activity, it is effective to include techniques to keep the muscles and fascia flexible such as massage and stretching. Once the symptoms are more controlled, it is important to ease back into running VERY gradually to be able to monitor returning symptoms. As you do this, strengthening all lower leg muscles, including the feet, should be incorporated.

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Calf stretching should include performing with the knee straight, to stretch the outer muscles, and bent to stretch the deep soleus muscle.

The simplest way to keep the anterior dorsiflexors (along the shin) loose, is to use the foam roller or other deep tissue massager.

The first exercise most athletes include for the lower leg are basic heel raises. As mentioned above, the calves also include a deeper muscle called the Soleus, that often lacks sufficient strength. You can target these muscles by performing the heel raise exercise with a bent knee, or sitting adding weight to your lap.

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Weakness in the ankle and foot may also contribute to lower leg issues. To target these ankle and foot stabilizers, using a resistance band is effective. Other exercises include single leg standing on a stable and unstable surface such as a foam mat or balance disc.

Unfortunately, in the majority of the more severe cases, a surgical procedure, called a fasciotomy, is required. Basically the fascia itself is cut open to relieve the tension in order to allow normal blood flow and muscle expansion to cause less pressure during activity. The recovery time after this procedure is quite short and allows athletes to return to their sport within 6 to 12 weeks. Post-surgical rehabilitation requires the same treatment as the conservative approach mentioned above.

Prevention & Maintenance

Biomechanics, or running form, is commonly blamed for lower leg dysfunction, such as CECS. Research has been done on evaluating foot strike patterns in runners and how these patterns may cause mechanical issues in joints from the lower leg to the hip and spine. When one uses the heel strike for landing during running, the anterior compartment muscles, the dorsiflexors, must act eccentrically to control the foot from slapping onto the ground with every step. This causes overuse and inflammation in the area. Many studies have evaluated the outcome of changing this foot strike pattern to a mid-foot or forefoot landing, and have concluded that this may help control and even resolve CECS. This is a change that should be done gradually, such as beginning with 5 minutes of forefoot strike in a single run and adding 5 minutes every few runs.

Another prevention option is running with shoes and/or orthotics that limit pronation of the foot. Overpronating requires even more work for the dorsiflexor muscles and causes increased tightness to the entire lower leg compartment muscles.

The exercises mentioned above should be incorporated to help prevent CECS and other lower leg dysfunction, as many times weakness and inflexibility are the cause. If you have been diagnosed with CECS or are experiencing symptoms, make sure to back off of the aggravating activities and always ease back into it during recovery. Seek medical advice if symptoms do not resolve or become severe. Remember, the quicker you take care of your pain, the quicker you will be back to doing what you love.


Sources

Tucker, Alicia K, Chronic Exertional Compartment Syndrome of the Leg, Current Reviews in Musculoskeletal Medicine, April 2, 2020.

Gallo, Robert A., Michael Plakke, and Matthew L. Silvis, Common Leg Injuries of Long-Distance Runners: Anatomical and Biomechanical Approach, Sports Health, April 2, 2020.

Gibson, Alexander, Chronic Exertional Compartment Syndrome and Forefoot Striking: A Case Study, International Journal of Athletic Therapy & Training, April 2, 2020.

Balance Training: A Key to Injury-Free Running

Most runners are primarily focused on improving their endurance and speed during their training cycles. Strength and flexibility are usually a secondary focus, especially if the runner has had a history of an injury and has been educated on the importance of these components. Balance training, on the other hand, seems to be of less importance to runners. In general, balance declines as we get older—by up to 75% by the time we are 75 years old. This is why older people are prone to falls, which is currently the leading cause of injury and death in the geriatric population. Balance is fundamentally the skill of keeping the body aligned and upright by reacting to changes in our center of mass at all times. Taking this definition into consideration, it seems balance should also be a primary focus during training, since after all, running is basically a one-legged balancing act.

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Balance is (Almost) Everything

Most people will think of running as an activity involving a push-off phase, forward propulsion, and a landing. These are all most definitely parts of the running cycle, but about 50% of running is an action of falling forward. Thankfully, we developed the ability at an early age to stabilize ourselves against falling while running. This natural reaction gets harder to control as we run longer and faster, since the muscles in charge of this action get fatigued. And if running straight with no disruptions gets harder to control when we are tired, then the task of maintaining our balance is that much more difficult when having to make a sharp turn, stepping over uneven surface, or having to make a sudden stop to avoid a collision with a person or object. Improving our body’s balance directly will not only improve running form and posture, but it will also decrease injury risk and pain.

How to Train Balance

Balance is controlled by proprioceptors in our muscles and joints, which are basically tiny sensory nerves that can anticipate changes in our body’s center of mass. When we step on a pebble that causes a loss of balance, the proprioceptors fire this sensation to our muscles, so that they can react as quickly as possible to stabilize our joints and avoid a fall. For the case of running, the main proprioceptors to focus on when working on balance training are the ones located in the feet, ankles, and hips. It is always best to start working from the ground up as the feet and ankles are the first to sense any position changes from running on uneven surface, for example.

Exercise (and Run) Barefoot

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One theory of why Kenyans are one of the fastest and most efficient runners is because they grew up walking and running barefoot on uneven terrain, therefore constantly strengthening their proprioceptors and intrinsic foot muscles that control balance. This enables these runners to devote the majority of their energy to forward propulsion while running. Unlike the Kenyans, most of us have grown up running in some good-looking shoes with excellent support and cushioning. On top of that, we opt for road running when training for a marathon. This means we leave our proprioceptors pretty quiet during our entire run. The only time those nerve receptors are active is when there is a sudden change in our position that we are not prepared for.

Strengthen Balance Muscles

A part of every runner’s strengthening program should include core, hip, ankle, and foot exercises. Most of us occasionally incorporate upper leg strengthening, which is important, but often forget to directly strengthen the joints and muscles below. The foot and ankle joint are probably one of the most important body parts for runners, as they carry the entire weight of the body at all times. The feet absorb the initial impact of striking the ground, which makes them extremely vulnerable to injury.

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Easy exercises to work the ankle stabilizers can be done with resistance bands, strengthening the four main movements of the joint. For the intrinsic muscles of the feet, towel curls are an effective strengthening exercise. Place a small towel on the floor and try to pick it up with your toes for 10 to 15 repetitions at a time.

Simple exercises for strengthening the hip stabilizers can also be done with resistance bands such as clamshells, bridges, standing legs lifts, and lateral squat walks. All of these moves can be done without the bands, along with bodyweight squats, step-ups, lunges, and heel raises. Isolating one leg at a time is also useful, especially if you have experienced a one-sided injury or low back pain in the past. Incorporating a handful of these moves before or after runs is the easiest way to make sure to get them in.

Uneven Surface Training

One of the most effective ways to challenge your balance muscles and proprioceptors further is to perform lower and upper body exercises standing on a wobble board, balance disc, foam mat, or other unstable surface. This will help work the ankle and hip stabilizers, intrinsic foot muscles, and the entire core all at once. As mentioned above, most runners training for marathons limit their runs to the road. Trail running is a beneficial way to strengthen the proprioceptors as you constantly challenge the joints and muscles with the varying terrain.

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Keep in mind the reasoning for emphasizing balance training along with your regular marathon preparation. Good balance will help relax the body more while running, leading to better posture and less tension when fatigued. This means less energy wasted and more to use for the push-off phase and increasing speed. Keeping these specific muscle groups and proprioceptors strong will ultimately make you a better runner by allowing your legs to effortlessly move faster, while lowering your chances of injury and pain.


Sources

Scott Mullen, MD, Jon Cotton, MD, Megan Bechtold, DPT, and E. Bruce Toby, MD, Barefoot Running: The Effects of an 8-Week Barefoot Training Program, Journal, Nov 4, 2019.

Anna Brachman, Anna Kamieniarz, Justyna Michalska, Michał Pawłowski, Kajetan J. Słomka, and Grzegorz Juras, Balance Training Programs in Athletes – a Systematic Review, Journal, Nov 4, 2019.