Treatment for Anterior Exertional Lower Leg Pain (compartment syndrome)

I know, the name’s a mouth full, but it’s because we’re not entirely sure what the mechanism behind this injury is. There are many different things that can cause pain in the front of your shin, but the important clue that you may have Anterior Exertional Lower Leg Pain (or compartment syndrome) is that the pain is only present with exercise and eases within a minute or so of you stopping the exercise.

It is felt in the muscles in the front of the shin and is often described as a constricting pain or severe tightness. It tends to build slowly as you run and gets so intense that you have to stop and rest. It usually settles after a few minutes of rest and you may even be able to continue your run for a bit, but then it stops you again.

In some cases people can also describe a tingling or that their foot drops. These symptoms can also indicate other nerve injuries, but the big difference is that the tingling and foot drop recovers after a few minutes of rest. This is not the case if you have a nerve injury like sciatica. Patients with this condition usually don’t have any pain at rest – only when they exercise.

I've discussed this all in more detail in this video:

What causes compartment syndrome?

We used to think that it was caused by the fascia sheath that surrounds the muscles in the lower leg being to tight. When we exercise our muscles swell and expand. If the fascia sheath around the muscles don’t allow them to expand, it can cut off the blood and oxygen supply and compress the nerve which gives you the symptoms. When you rest, the muscles’ demand for oxygen decreases and the compression decreases and as a result the pain decreases.

But in recent years researchers have started to question this traditional model of compartment syndrome. Some now argue that it is actually a chronic over-load of specifically the Tibialis Anterior muscle.

What treatments work for compartment syndrome?

Conservative treatments (stretching, myofascial release, dry needling etc.) have traditionally been aimed at trying to improve the flexibility of the fascia in the lower leg as it was argued that that would alleviate the compression. But these treatment have been proven to be very ineffective and the patients usually had to undergo surgery.

Surgery, however, has also not proven to be massively successful in that a larger number of patients would still experience symptoms.

Recently researchers have shifted their focus away from hands-on and surgical treatment and started to look at ways that they could reduce the work load on the muscles in the anterior shin (Tibialis Anterior specifically) when someone runs. We still need a bit more research on this, but the available studies suggest that running retraining may be an effective way of treating anterior compartment syndrome.

Running retraining for Anterior Compartment Syndrome

Your Tibialis Anterior muscle is the main one that flexes your foot and ankle up (into dorsiflexion) when you run. What the research is showing is that we may be able to decrease the load on the Tib Ant by getting runners to land with their ankles in less dorsiflexion and that increasing a runners’ step rate can decrease the activity of the Tib Ant throughout the swing phase of running.

These are some of the things you can do that may help your pain:

• Increase your step rate. I’ve written a whole blog post on how you can do this.

• Try not to over-stride or land on your heel with your foot making contact far in front of your body. Instead, try to lean forward slightly and make contact with the ground underneath your body (see the video for a demo of this).

• Shift to using a mid-foot or forefoot strike pattern.

You have to introduce these changes very slowly and build it up as run/walk sessions. If you do it too aggressively, you can easily end up with other injuries e.g. Achilles tendinopathy. I explain this in detail in the video.

Let me know if you have any questions. Need more help with your injury? You’re welcome to consult me online via video call for an assessment of your injury and a tailored treatment plan.

Best wishes

Maryke

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram.

References:

1. Barton, C. J., et al. (2016). "Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion." British Journal of Sports Medicine 50(9): 513-526.

2. Breen, David T., et al. "Gait re‐training to alleviate the symptoms of anterior exertional lower leg pain: a case series." International journal of sports physical therapy 10.1 (2015): 85.