Utilizing a Forefoot Strike Gait Pattern to Decrease Symptoms of Anterior Chronic Exertional Compartment Syndrome

Tibialis anterior muscle

As discussed in my last post on exercise related leg pain, chronic exertional compartment syndrome (CECS) is a condition in which the lower leg experiences an increase in compartmental pressure during physical activity.  This leads to pain, sensory disturbances, and/or muscle weakness.  CECS most commonly occurs bilaterally and most frequently in the anterior compartment. The anterior compartment contains the deep fibular nerve, anterior tibial artery, and the dorsiflexion muscles (anterior tibialis, EDL, EHL).

CECS can be very problematic for runners as the pain resulting from increased compartmental pressure can lead to premature exercise termination.  The symptoms are typically alleviated shortly after resting.

Previous research has suggested that pressure within the anterior compartment is higher with a heel-strike gait pattern.  The authors of this case series sought to examine the effects of altering the running pattern of two heel-strike runners with CECS to a forefoot-landing pattern.


Both patients were 21 years old, one male and one female.  Patient 1 reported lower leg pain with 0.8km of beginning a run that resolved within 10 minutes of rest.  During examination, she was only able to run 0.8 km before stopping secondary to bilateral pain and also complained of tenderness to anterior compartment palpation and dorsiflexion weakness.  Patient 2 had previously undergone a fasciotomies to address CECS, which were unsuccessful in alleviating his symptoms.  After running ~1.5km a foot slap was seen and the patient ended activity.


Both patients underwent similar training strategies under the direction of a physical therapist.  “Training included increasing her running step rate to 3 steps per second and using her hamstrings to pull her foot from the ground versus push her foot from the ground using the gastocneumius.  A digital metronome was also utilized to increase step cadence to 180 steps per minute. Focused training drills and exercises consisted of weight shifting, falling forward, foot tapping, high hopping, and running with a specialized belt (EZ Run Belt, Posetech.com).”  The patients were instructed in forefoot-strike running mechanics and endurance was progressed as they were able to maintain form.


In agreement with previous research, after switching to a forefoot-strike gait pattern, both patients had an increased step rate as well as decreased step length and ground reaction forces.  Patient 1 initially ran 0.8km before ending her session secondary to pain.  Following 6 weeks of physical therapy, she was able to run 5km without any symptoms.   Patient 2 increased running distance from ~1.5km with pain to 4km without symptoms of CECS.  Both patients also had decreased pressures (up to 30%) in the anterior compartments of their lower legs.

The authors believed that the forefoot strike pattern allowed the runners to return to physical activity without pain due to two factors.  First, previous research suggested the when the lower extremity is placed in full dorsiflexion and full knee extension (as seen during initial contact when using a heel strike pattern) the anterior compartment experiences increased pressures.  Secondly, they suggest that a forefoot gait pattern reduces the demands on the muscles within the anterior compartment.



Diebal, A., Gregory, R., Alitz, C., & Gerber, J. (2011). Effects of Forefoot Running on Chronic Exertional Compartment Syndrome: A Case Series. The International

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