Should we transition all anterior compartment syndromes to forefoot striking?

Anterior compartment syndrome or chronic exertional compartment syndrome (CECS) is a condition that I never usually like seeing as it is difficult to manage and most would be better off having surgery. This is a problem that occurs to the expanding muscle in the tight fascial compartment of the leg. A recent study on forefoot striking and this condition has raised some interesting questions about how much evidence is needed to change clinical practice.

The study:

Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome
Angela R. Diebal, Robert Gregory, Curtis Alitz, and J. Parry Gerber
Am J Sports Med published 16 March 2012
Background: Anterior compartment pressures of the leg as well as kinematic and kinetic measures are significantly influenced by running technique. It is unknown whether adopting a forefoot strike technique will decrease the pain and disability associated with chronic exertional compartment syndrome (CECS) in hindfoot strike runners.
Hypothesis: For people who have CECS, adopting a forefoot strike running technique will lead to decreased pain and disability associated with this condition.
Study Design: Case series; Level of evidence, 4.
Methods: Ten patients with CECS indicated for surgical release were prospectively enrolled. Resting and postrunning compartment pressures, kinematic and kinetic measurements, and self-report questionnaires were taken for all patients at baseline and after 6 weeks of a forefoot strike running intervention. Run distance and reported pain levels were recorded. A 15-point global rating of change (GROC) scale was used to measure perceived change after the intervention.
Results: After 6 weeks of forefoot run training, mean postrun anterior compartment pressures significantly decreased from 78.4 ± 32.0 mm Hg to 38.4 ± 11.5 mm Hg. Vertical ground-reaction force and impulse values were significantly reduced. Running distance significantly increased from 1.4 ± 0.6 km before intervention to 4.8 ± 0.5 km 6 weeks after intervention, while reported pain while running significantly decreased. The Single Assessment Numeric Evaluation (SANE) significantly increased from 49.9 ± 21.4 to 90.4 ± 10.3, and the Lower Leg Outcome Survey (LLOS) significantly increased from 67.3 ± 13.7 to 91.5 ± 8.5. The GROC scores at 6 weeks after intervention were between 5 and 7 for all patients. One year after the intervention, the SANE and LLOS scores were greater than reported during the 6-week follow-up. Two-mile run times were also significantly faster than preintervention values. No patient required surgery.
Conclusion: In 10 consecutive patients with CECS, a 6-week forefoot strike running intervention led to decreased postrunning lower leg intracompartmental pressures. Pain and disability typically associated with CECS were greatly reduced for up to 1 year after intervention. Surgical intervention was avoided for all patients.

This was quite a dramatic study. All 10 subjects were spared surgery after the transition to forefoot striking. Is this enough evidence to transition all those with CECS to forefoot striking to manage it?

At one end of the spectrum, you have people who change clinical practice on a whim based on a n=1 experience (ie it worked for me, so it must work for everyone else) and at the other end of the spectrum there are those that argue we should wait until there is enough randomized controlled trials to inform the clinical decision making process (for eg, see Bø & Herbert). If you had a medical condition and was on a powerful drug for that, which end of that spectrum would you like your doctor to sit before changing the drug? Where does the above study sit on that spectrum? Unfortunately it sits way down the end of not much evidence at all (which the authors admit: ‘Level of evidence, 4′ – there are only 5 levels).

The big problem with this study is that despite the very significant reduction in pressures in the anterior compartment and all 10 subjects avoiding surgery, there was no control group. Without a control group we know from experience that effects are often overestimated and all the effects could have been due to placebo. (And obviously all those who thought 36 was too small a sample size in the bone stress injury and minimalism study should immediately dismiss the above study with 10 only subjects!).

What should a clinician do, especially in the context of evidence based practice, when confronted with a patient with CECS in the anterior compartment? Obviously those who promote the minimalism agenda will of course say yes, transition them to forefoot striking. Obviously those who who promote evidence based practice agenda will, of course say no, do not transition them to forefoot striking as we do not have enough evidence. Clinicians need to make reasoned clinical decisions and not be taken in by propaganda and rhetoric of agendas¹. This is why we need to rely on the strength of the scientific data to avoid that trap.

In the absence of evidence, what should we do? What I like to apply are 3 criteria: is the intervention biologically plausible, is it theoretically coherent and is it consistent with the available evidence? In this context we know that in forefoot striking that the anterior tibial muscle is not used to lower the forefoot to the ground like it does in heel striking, so it is biologically plausible and theoretically coherent that forefoot striking will not work the anterior tibial as much as heel striking. This is also consistent with the evidence of Giandolini et al that showed a significant decrease in tibialis anterior EMG activity in forefoot vs heel striking, so yes it looks as though the anterior tibial muscle is used less in forefoot striking and this could potentially explain the mechanism by which forefoot striking could have helped CECS (ironically, this also makes a mockery of all those claims that barefoot running and minimalism strengthen the muscles of the foot and leg – the anterior tibial muscle will theoretically become relatively weaker with this as its less active!).

So what do we have: some weak evidence from a small uncontrolled study but with dramatic results (all subjects spared surgery) and a theoretically coherent and biologically plausible mechanism that is consistent with the evidence (and there is not a hint of contradictory evidence or any evidence the putative mechanism is inconsistent with). Is that enough to change clinical practice? I think it probably is².

As always, I go where the evidence takes me until convinced otherwise.

¹See the Tweet mentioned down in the discussion on this topic here, that claimed there were 12 studies that support this. No there is not!

²And for other injuries, it would be a bad option. See: Which injuries are probably more common in which foot strike pattern? (Also, see the comments on the article on PTTD in runners!)

Diebal, A., Gregory, R., Alitz, C., & Gerber, J. (2012). Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome The American Journal of Sports Medicine, 40 (5), 1060-1067 DOI: 10.1177/0363546512439182

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8 Responses to Should we transition all anterior compartment syndromes to forefoot striking?

  1. Brian Martin April 2, 2013 at 11:27 pm #

    Hi Craig,

    Good food for thought here. I think in this case even reducing the angles a bit could help? What most people term a mid-foot strike (but I call neutral i.e. foot parallel to the ground or even retaining a light heel-strike) seems less risky than instructing runners to move onto the forefoot. I worry about the long term impact of moving runners up onto their forefoot without reference to their overall strength and total running technique.

  2. Craig April 3, 2013 at 3:17 am #

    Thanks Brian; You are probably right. When I said ‘forefoot striking‘, I probably should have said something like ‘move away from frank heel striking‘ – anything to reduce the activity of the tibialis anterior muscle is probably what is going to help anterior compartment syndrome. It was just the study used the term ‘forefoot striking’.

    What I like about the study is that it is a good one to put before the students to consider issues of the evidence needed to change clinical practice.

  3. Admin April 3, 2013 at 9:51 pm #

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  4. Jason Eade April 3, 2013 at 9:58 pm #


    Thanks. I first heard you talk about this mid-last yr. I have since had 3 patients with ACS and did just this and it worked fine in all 3.


  5. blaise Dubois May 18, 2013 at 3:53 pm #

    Hi craig, like your clinical reasoning,
    You can add:

    Arch Phys Med Rehabil. 1983 Jul;64(7):296-9.
    Anterior tibial compartment pressures during running with rearfoot and forefoot landing styles.
    Kirby RL, McDermott AG.

    Acta Orthop Belg. 1995;61(3):190-8.
    Influence of the running shoe sole on the pressure in the anterior tibial compartment.
    Jerosch J, Castro WH, Halm H, Bork H

  6. Rick Osler June 14, 2013 at 8:49 am #

    Another success today, thought i would share it since i recall your post Craig. 12/12 hx ACS. Fasciotomy looming secondary to pressure test positive. He presented for what was going to be his 4th pair of orthotics, convinced that a different set might help…after all everyone to date told him that was the solution with calf stretching and massage, (NOT the Sports Physician though). Changed him 6/52 ago from an overstriding heavy heel strike to midfoot strike with higher cadence, and reduced shoe heel pitch (ex 12mm) now in Pure project FLOW and a Saucony mirage. Threw his orthoses in the bin.

    He is one happy runner. (pain at 4 minutes prior to no pain now at 8km). Bottom line, is there was not much to lose (other than an achilles injury yet to present from a ++ transition quicktime)…fingers crossed on that one!

  7. Kevin August 5, 2014 at 5:04 am #

    Hi, happy to have found your site. I’ve recently found my way into running from competitive cycling. I used to play a lot of soccer and would run for fitness in the past. I like it because it is so simple and I can run worry free, compared to racing a bike which is an exercise in stress the entire time.

    20 or so years ago I had fasciotomies on both anterior chambers due to CECS. (And then did both ACLs, three years apart as well. Oops.) The surgery worked for me. Mind you, I was racing bikes and so there was never really much worry about pressures – cycling didn’t bring anything on.

    I’m fit, but I’m heavy – 200lbs. I’ll get lighter, likely down to just below 190lb. I wasn’t sure what to start running in – forefoot or heel strike shoes. I decided to try some 4m drop Sauconys with good cushion.

    I’m 4 weeks into training for a marathon on Oct 18. My CECS sure feels tight for the first 30 minutes of every run. I’ve been stretching and attacking the area with a massage stick. I also apply a cycling embrocation to the area as I believe it helps loosen things up with the heat.

    Last night I was able to run 21k in just over 2hrs, something that felt great. I had pain at the start, but, as has been the situation, it calmed down and I was able to run comfortably.

    I can attest to the functionality of the forefoot shoe. In fact, in the past, I tended to run that way instinctively. I didn’t have any education on what forefoot running was, it was just the way my body preferred to hit the pavement. I would sort of shuffle my feet forward and avoid landing on the heels.

    Anyway, I have quite a bit more work to do to make my goal of a 4hr marathon, but I think I’m on my way. Last night’s effort was an eye opening experience into the possibilities of distance. I feel like if I just keep shovelling food and water into my face I can make it.

    Just wanted to share my experience! Cheers.


  8. Sean Parker February 9, 2015 at 1:10 am #

    I agree, go with what the evidence suggests; but I also suggest other criteria that supports the intervention of running gait modification in treating running related CECS:
    1. Low cost.
    2. High clinical safety
    3. (without wishing to fall foul of the naturalistic fallacy) we have evolved as midfoot strikers – it seems reasonable to suggest a return to the norm given 1&2

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