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.

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.

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.

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.

Strong Calves for Fast Running

Runners basically require every muscle in their bodies to be strong in order to run well and with less risk of injury. Even knowing this we continue to pick and choose what body parts we feel are more important when fitting in exercise. What ends up happening is we run out of time during our weeks and squeeze in a few squats and lunges, and maybe a couple of core exercises and head on our way to run. One muscle group that is often ignored is the calves, which are composed of two different muscles—the gastrocnemius and soleus muscles. Runners are not the only ones who require these areas to function at their best, but everyone is in need of strong and flexible calves for basic daily activities.

The basic function of the calf muscles is to lift the heels up and shift the body weight onto the toes. This motion is required for pushing off during stepping, whether running or walking, as well as climbing stairs. The other important role of the calves is for circulation. These muscles are in charge of pumping blood and fluids out of the lower legs and up to the heart. They perform this function by compressing the veins around them when contracting, forcing blood upward and out of the area. When the calf muscles are relaxed, especially for prolonged periods of time such as when sitting at work, the veins in the muscles and the surrounding area fill up with blood and fluid causing swelling.

Calves for Runners

The calf muscles are in charge of that final push-off during running to propel our bodies upward and forward. They play a crucial role in our stride length and pace. Since this muscle group is smaller than the other main groups higher up in the legs, the quads, hamstrings, and glutes, they fatigue at a much quicker rate during runs. During long runs and races, our slowed pace may be greatly due to the calves tiring out. Even if the hip flexors are significantly strong to drive our knees high during a stride or our quads strong enough to extend our leading leg far forward to lengthen our stride, our pace gets affected if the calves are too weak and tired to push off efficiently.

Runners must rely on the feet and ankles in order to keep sufficient balance. Running, especially fast running is considered a single leg balance movement, therefore our stability is important in order to master faster paces. The calf muscles play a role in this stability as they provide the strength required to prevent swaying forward. If the calves are not strong enough for this role, the end result is increased stress to the Achilles tendon. The same goes for insufficient strength for the push-off—the Achilles will have to take the load. Achilles tendon issues such as tendinitis and strains can be a prolonged and limiting condition for runners, which may lead to tendon tears—an issue that will leave you out of running for several months to over a year.

Calf Strengthening

Runners should incorporate exercises for the calf muscles two to three days per week, along with proper stretching techniques after runs. Focusing on both the gastrocnemius and soleus groups and other supporting ankle muscles is key to keeping proper stability in the feet and ankles. Basic standing heel raises are the most common way to strengthen the calves, but since the gastrocnemius group has two heads—the lateral and medial heads, ideally one should also perform heel raises with their toes pointing outwards as well as inwards. To strengthen the soleus muscle group, heel raises should be performed with the knees bent, as in a squat if standing or simply sitting with a dumbbell or other weight over the thighs for added resistance.

To keep the calves flexible, stretching after runs is important. The easiest stretch is to place the balls of the feet on a step, keeping the heel on the ground and lean the body forward. Keeping the knee straight will mostly stretch the gastrocnemius muscles while performing with the knee bent hits the soleus more effectively. Foam rolling is also another great way to break up any adhesions in the muscle groups that are causing tightness. Significantly tight calves are what leads to Achilles tendon strains, therefore runners should emphasize flexibility exercises as much as possible.

Other effective exercises to keep the calves strong and ready for running are plyometrics. Jumping rope, box jumps, squat jumps and any other explosive movements are great additions to your exercise program that will strengthen the fast twitch muscle fibers of the calves and Achilles tendon. Strong fast-twitch fibers are required to perform an efficient push-off during running. Adding in one or two plyometric moves to your warm-up routine before easy runs or in between other exercises is an effective way to incorporate calf strengthening even if you are short on time. If you want to be a fast runner, you must keep in mind that stronger muscles are needed for faster paces.

Sources

Samuel R. Hamner, Ajay Seth, and Scott L. Delp, Muscle Contributions to Propulsion and Support During Running, Journal, Jul 22, 2018

Injury Prevention 101

We all know that runners have a higher risk of injury than non-runners, just as do athletes of any other sport. Obviously this is true, as simply being more active means you are on your feet more often with a greater availability to trip over an object and fall, step on uneven surface and roll an ankle, or just overuse weak body parts. In my opinion this risk is better than being inactive and risking developing heart disease, diabetes, and other health issues that come from lack of exercise. Besides being cautious to avoid tripping and bumping into something, runners, and all other endurance athletes, should follow other steps to decrease their injury risk on a daily basis.

SLEEP & Rest

The first and most important method to help prevent injury is to make sure you are getting enough sleep. You may feel like your 4 or 5 hours of sleep every night is just fine to keep you going, but sleep does much more than help us get through our day. Most, if not all, of the muscle damage repair and growth occurs during sleep. Human growth hormone is released during certain stages of sleep that increase blood flow to our muscles so that they can repair from our workouts. Another stage of sleep, REM, is responsible for relaxing our muscles and reducing symptoms of chronic pain. Runners should aim for at least 7 hours of sleep each night, but research shows 9 or more hours gives the most benefit to competitive athletes.

Strength Training

A well-rounded exercise plan is always best when it comes to lowering your risk of overuse injuries. You’ve probably read that triathletes, even those who participate in Iron Man competitions, have a lower risk of injury than marathoners. That’s because triathletes train with a balanced mix of running, cycling, and swimming. As a distance runner, if all you are doing is running, then you are inching your way closer and closer to an injury every day. The best formula for runners is to incorporate a mix of running, weight lifting, and other cross training cardio exercises. Lack of time may be the reason most runners skip strength training, but you can highly benefit from a quick 20 to 30 minute session a few days per week. This should be a priority if your goal is to improve your performance and not get injured.

Pack on the Miles GRADUALLY

One of the quickest ways to get injured as a runner is to increase weekly mileage by a substantial amount—even if you’re feeling great. The rule of thumb is to never increase by more than 10% each week. This may even be too much for some runners. A safe method is to increase by a handful of miles each week for 3 to 4 weeks and then have one week as “recovery” where you drop your mileage by 20% to let your body rest. After this recovery week, you can safely start back from where you left off.

Rotate Your Shoes

Since the feet carry your entire body weight during all activities, it is beneficial to give this part of the body a break. One way to do this is to switch your shoes throughout the week. Most brands make running shoes for different types of workouts. Save your well-cushioned shoes for long runs and recovery runs, and your lighter pairs for speed and track sessions. The style of each shoe is different which means your foot muscles will work differently in each pair. Everything that happens down in the feet has an effect on the rest of the body—so shoe rotation lets different muscles all over the body work and rest all at different times. 

Focus on Good Form

The constant pounding on the ground from running has an impact on the entire body. The ideal running form is one that lessens this impact and keeps all parts in sync and balanced. It is beneficial to add strides once or twice a week to focus on this. Run 5 sets of 20 to 30 seconds at a hard pace where you practice holding an upright posture with relaxed shoulders, taking quick steps, landing on the mid-foot, and a having a slightly forward lean—all aspects of proper form. Once you master good running mechanics, you will lower your risk of overusing any part of your body.

Stretch & Foam Roll

Just like weak muscles are prone to overuse injuries, tight muscles are more prone to tearing—which is an injury that can put you out for months! Runners can get tight all over, but hamstrings and calves/Achilles are the common areas that get torn. My advice is to make it a habit to stretch after EVERY SINGLE RUN for 10 minutes. A few sets of 20 second holds for the glutes, hamstrings, quads, and calves is enough. Foam rolling can be more tedious but is useful to tackle much deeper muscular tightness. It may also help improve range of motion that is limited by chronic muscle inflammation.

These steps may seem like a large load added onto your regular running routine, but they are necessary if you want to run for years without worrying about easily getting injured. These components will also help you become a more efficient and faster runner over time, so it’s a win-win if you ask me!

Sources

How Sleep Adds Muscle. The National Sleep Foundation. www.sleep.org. Nov 15, 2019.

Running After a Race: The Reverse Taper

After several months of dedicated training, race day finally arrives and it is time to showcase all of that hard effort by running 26.2 miles. You finish the race, refuel with the goodies provided at the finish line, and feel accomplished. But now what? Whether you have an amazing race and set a personal record or have a disappointing one, your body goes through the same workload. The biggest mistake most marathoners make is not giving their bodies enough recovery time after the grueling training months and a demanding race.

After getting used to running most days of the week, or everyday for some, it is not the easiest task to take time off. It ends up being unenjoyably miserable and creates a sense of not feeling like oneself even after just a few days. If you had an amazing race and set a PR, you will feel anxious to continue the streak and get back on the training wheel as soon as possible. On the opposite spectrum, if the race did not go so well, you may feel like you need to start harder training right away, or worse—feel like you don’t deserve much time off. But this break is a very important step to improve performance for the next race.

Why Do I Need Such a Long Break?

The marathon and all of those hard training sessions damage the body in so many ways. Of course, if you trained properly, gradually increasing mileage over time, taking rest days as they should be, and fueling properly, the damage to the body is reversible and not detrimental. You do not have to be an elite athlete training 100+ miles per week to get this damage. Since most plans go up to twenty miles at the most training for the marathon, the extra six miles completed at the race, with most likely faster paces, is enough to damage the body just on race day alone.

Muscle Damage

The most obvious damage is done to the muscles. The significant amount of inflammation accumulated in the body after hard training runs and races is a normal process. The temporary inflammatory response to training is necessary in order to improve different fitness components such as strength, stamina, and VO2 max, but only if proper recovery is included in the mix. If you do not let your body recover effectively after a hard workout, then the next hard workout will only pile on more inflammation. Eventually, this stacking on of inflammation will turn into chronic inflammation and lead to injury. The key is to recover properly from every hard workout, especially the hardest workout in the entire plan—race day.

Cellular Damage

There may be times where you run a race, and do not even feel sore afterwards. This is probably the most dangerous time because it will be more likely that you will return to harder running too quickly. Although one may not feel sore or fatigued following a race, it is important to note that the race still induced muscle damage. Creatinine kinase (CK) is a substance that is measured in the blood that indicates skeletal muscle and cardiac damage. Increases in CK in the blood are usually brought on by intense or prolonged exercise, especially in the case of eccentric-type exercise, such as running downhill. Some studies show that this increase can last 3-4 days post-race, while others show it can take longer than seven days to bring these levels back to normal. Given this information, it is important to make sure to not judge your recovery time on how sore you are from your race.

Immune Suppression

Yet another reason a good break after racing is recommended is the impact of hard training on the immune system. The tissue damage that occurs during training and racing leads to the production of cytokines, which are basically substances secreted by the immune system that affect other cells in the body. This development of cytokines then increases the lymphocytes responsible for suppressing immunity. This process is what makes athletes, especially endurance athletes, more susceptible to infections. Although you may not get sick right after racing, this bodily response to the months of hard marathon training will increase your risk of getting sick and having to put a break on your training plan later down the line.

Reverse Taper

A good method to determine your plan to returning back to running after racing is to simply take your taper plan from before your race and reverse it. If your training plan called for a two week taper, then the reverse taper would also be two weeks in length. The few days leading up to your race were mostly easy, short runs, so the first few days back to running should be the same. A few speed sessions fall within these two weeks as well, but overall the mileage is much lower than peak mileage. The third week after the race is finally a good time to start weaning back into the type of running you were doing before. Of course if you follow this approach and your taper was longer, say three weeks, then this plan will take three full weeks until you are back to your prior training level.

It is a good idea to include some light strength training by week two to slowly begin getting your muscles used to exercising. It is important to keep these strengthening exercises similar to what you were doing before. Flexibility exercises and massage/foam rolling should begin as soon as possible to help keep sore and tight muscles flexible and circulated.

You Won’t Lose Fitness

During the reverse taper, runners feel they will lose fitness and get out of shape. There are several studies out there concluding that there is a minimal drop in fitness levels within the first couple of weeks of inactivity. VO2 max is a main indicator of fitness in athletes. It is the measure of the maximum amount of oxygen one is able to utilize during intense exercise. Within the first week of inactivity, there is an insignificant drop in VO2 max (up to 3%), and it will go as high as a 6% drop after two weeks. This is for athletes who decide to take the weeks off completely, instead of incorporating easy runs and other cross-training. Therefore, the drop is even less for those who get back into those easy runs within the first few days as explained above.

The reverse taper is an excellent strategy to use when recovering from a marathon. It lets you continue your running while giving you ample time to rest and incorporate other recovery methods such as massage and cross-training. Not planning adequate time after racing will only lead to overtraining syndrome and a higher risk of injury. It is important to listen to your body during these few weeks post-race and gradually increase mileage. A proper break from intense training will only lead to better performance in your next race!

Sources

Hikida RS, Staron RS, Hagerman FC, Sherman WM, Costill DL, Muscle Fiber Necrosis Associated with Human Marathon Runners, Journal, Oct 16, 2019

Marianne F. Baird, * Scott M. Graham, Julien S. Baker, and Gordon F. Bickerstaff, Creatine-Kinase- and Exercise-Related Muscle Damage Implications for Muscle Performance and Recovery, Journal, Oct 16, 2019

Lakier Smith L., Overtraining, Excessive Exercise, and Altered Immunity: Is This a T Helper-1 Versus T Helper-2 Lymphocyte Response?, Journal, Oct 16, 2019