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.

Running with Arthritis? Here's All You Need to Know to Stay Healthy

One of the most common complaints of pain for most adults is caused by arthritis. This condition can become extremely debilitating and limit the ability to enjoy even the simplest activities. It has been a common thought that running is harmful to joints and causes arthritis. Recent research has shown the opposite results. Running can actually help control the symptoms of arthritis. Early signs are often ignored as they are usually short-lived and infrequent and can mimic other conditions such as overuse symptoms and muscle soreness. If you are a runner or partake in other activities, it is beneficial to understand the causes, symptoms, and management options available in order to avoid requiring invasive treatment.

What is Arthritis?

According to the Arthritis Foundation, the condition is just a term used to described joint disease and includes over 100 different types. It is most common in adults, but many of these types of arthritis can be found in children, as well. The cartilage located in between bones, which acts as a “cushion”, is lost creating constant pressure during activities. The earliest symptoms include joint stiffness, pain, and swelling. As mentioned, these can last a short time and occur infrequently. Stiffness is usually felt the most after prolonged positioning such as sitting or when getting out of bed in the morning. When in motion, the stiffness is usually relieved. In more advanced stages of arthritis, significantly prolonged activities can make the pain worse. Over time, arthritis can cause visible joint changes such as enlarged knuckles. Other joint deformities are only visible with X-rays.

Unfortunately, arthritis cannot be cured, but there are several management strategies available that can allow you to live comfortably without sacrificing your desired activities. The most important treatment approach, especially in the early stages, is balancing aggravating activities with rest. The key is to control the buildup of inflammation in order to avoid extreme pain to the point where you must take too much time off. For runners, this means if you are beginning to feel symptoms during or after a 10-mile run or longer, than you should be cutting back to shorter runs and adding in other cross-training activities, including strength training.

Strength Training is a Must

The constant grinding of bones with arthritis is what naturally causes pain and swelling. Getting the surrounding muscles stronger can help relieve this pressure. Stronger muscles also mean you can tolerate activities for a longer period of time, such as getting back to those 10-mile runs and racing marathons. Yes, this is possible, but runners must understand that strength training needs to become part of their regular training regimen. It is also the best way for non-runners to help control their symptoms and possibly avoid worsening arthritis and requiring surgery.

For hip and knee arthritis, which is one of the most common areas affected, especially in runners, it is important to alternate between bodyweight and resistance exercises. Both offer strength gains but give the joints a break from too much impact. Exercises should incorporate the larger muscle groups such as the quads, hamstrings, glutes, and calves, as well as smaller muscles that play a role in hip and knee stabilization. These smaller groups are the hip abductors and adductors, internal and external rotators, and the core muscles. Besides squats, lunges, heel raises, and step-ups, which all target the larger muscle groups, floor exercises for the lower body are an easy way to get in strength training at any time. Bridges, clamshells, and hip extensions are all great exercises that can be done with or without a resistance band. Core exercises such as planks and leg raises are also good additions.

Management for Runners

Besides alternating runs with lower impact cross training, there are several other strategies to help relieve symptoms. Using hot packs before activities can help ease pain and stiffness and the use of ice afterward can help control inflammatory buildup from your workout. Over-the-counter anti-inflammatory medications can also help manage symptoms. Below are other methods specifically for runners with arthritis.

• Use a run-walk method during most runs

• Eat a low-inflammatory diet. Examples of foods that help lower inflammation in the body include fruits, vegetables, whole grains, nuts, beans, and fish. Foods that can increase inflammation include fried foods, high gluten foods, processed and high-fat meats, dairy products, and foods with trans fats.

• Run on softer surfaces. Consistent road running causes repetitive pounding on joints. Try alternating running on trails, grass, and the treadmill.

• Warm-up properly. Getting right into running on stiff joints can exacerbate symptoms. Incorporate dynamic stretches such as leg swings, lunges, hamstring and quad pulls, and ankle rolls before every run.

• Exercise consistently. Avoid taking long breaks in between workouts. Even if you do not have time for your training runs due to a busy work and family schedule, you can increase the amount of walking during the day by parking further from your destination, stretching while cooking dinner, or waking up 15 minutes earlier to add in a few exercises before starting your day.

Sources

Paul T. Williams, Effects of Running and Walking on Osteoarthritis and Hip Replacement Risk, Journal, Sep 2019

Ponzio DY, Syed UAM, Purcell K, Cooper AM, Maltenfort M, Shaner J, Chen AF, Low Prevalence of Hip and Knee Arthritis in Active Marathon Runners, Journal , Sep 2019

Arthritis Foundation, What is Arthritis?, Website, Sep 2019

Finding the Right Running Shoe for You

Finding the right running shoe can get tricky. We all want to go for the most stylish pair with attractive colors and designs, but many times these nice-looking kicks end up destroying our feet. As a runner and physical therapist I have learned along the way that the single most important gear to be picky about for running (or really any activity that has you standing or walking for long periods of time) are shoes. If you are an occasional runner who gets in a few miles every week just to stay active, one pair at a time is sufficient. But runners training for a distance event, especially those who incorporate different types of runs require a couple of pairs to rotate through. And it involves more than just “cushioned” or “light” when shopping around. 

Know Your Foot Type

The first thing every runner should do when selecting shoes is figure out their foot type. Are you a pronator? Do you excessively supinate when you land? Do you have high arches? What does this all mean anyway?!

Pronator: This is when you land on the inner part of your foot when running. Most of the time runners initially land on the outer border of the foot, but quickly roll inward excessively. Those with low arches usually fall in this category.

Supinator: This is when you land on the outer border of the foot and remain with the majority of the pressure on this area throughout the midstance and even into the push-off phase of running. Those with high arches will fall into this category.

There are several running shoe stores that offer a gait analysis that can give you an idea of your foot type, but the best analysis would be by a podiatrist or sports medicine professional that specializes in gait and has access to the technology. A great way to analyze your foot type that can be done at home is checking the wear on your current or an old pair of running shoes. If you notice the wearing is excessive on the outer border, you can assume you are a supinator and you underpronate when you land. A pronator would have excessive wear on the inner border. If your shoes have even wear, you most likely have a neutral arch and pronate a normal amount.

Next Step: Shoe Type

Cushioned: Supinators should opt for cushioned shoes (at least for the majority of their runs). They provide optimal comfort (cushioning) with the least amount of firmness in order to promote a bit more pronation when landing. Cushioned shoes are made to be more flexible, but not all flexible shoes are cushioned! Some cushioned shoe examples are New Balance Fresh Foam, Brooks Adrenaline, and Saucony Omni.

Motion Control: This shoe type is made with more rigid materials in order to control the foot from rolling inward too much. Overpronators or runners with flat feet will benefit from motion control shoes since they include a more dense midsole, which helps raise the arch of the foot. Saucony Kinvara, New Balance 1540, and Brooks Ravena are all great shoes for low arches.

Stability: If you are a neutral runner, then stability shoes are your go-to. Most will have a firm rear and flexible forefoot with a moderate amount of cushioning. Some examples are the Saucony Guide Iso 2 (one of my favorites!), Adidas Ultraboost, and Nike Air Zoom Pegasus. 

Shoe Rotation

If you are an everyday runner, alternating between faster paced running, track sessions, and easy runs, it is best to rotate between two or three pairs. Opting for lightweight, flexible shoes are best for speed sessions. Shoes made for the track or even most “racing” shoes such as the Nike Vaporfly 4%, generally do not have much cushioning. As long as you limit the use of this type of shoe to short track repeats and racing, your feet won’t be affected too much. For the majority of your weekly runs (which should be at a conversational/easy pace), it is ideal to use the shoes that are best for your foot type as explained above.

Everyone has different feet and running form varies greatly, so what works for one person may not work for another. Just because you see a “fast” runner using a pair of the brand new Nikes does not mean you should go out and spend the money to use the same style. Well, first of all, a shoe does not necessarily make you faster. If you find you run faster in a given pair of shoes it is your better foot mechanics that are making you faster, not the actual shoe. The best advice if you are having any foot, knee, hip, or back pain during or after running, is to definitely evaluate your running mechanics and foot type. Switching to the right shoe for you can be a simple fix to a nagging problem.