I have been running for a few years now, but have never had such a strange injury as the one I currently have a “working diagnosis” for, Chronic Exertional Compartment Syndrome (CECS).

Chronic exertional compartment syndrome is an exercise-induced muscle and nerve condition that causes pain, swelling and sometimes disability in the affected muscles of the legs or arms. Anyone can develop the condition, but it’s more common in young adult runners and athletes who participate in activities that involve repetitive impact. Mayo Clinic

It all seems to make sense now and as a regular runner, it’s a bit depressing especially when I’m only two weeks out from my next race, the Cocodona 250.

Chronic Exertional Compartment Syndrome

The cause of chronic exertional compartment syndrome isn’t completely understood. When you exercise, your muscles expand in volume. If you have chronic exertional compartment syndrome, the tissue that encases the affected muscle (fascia) doesn’t expand with the muscle, causing pressure and pain in a compartment of the affected limb. Mayo Clinic

To put it more simply, the fascia encasing my lower leg muscles are not flexible enough to allow the muscles to expand. This leads to pinching of nerves and reduced blood flow, resulting in pain while running. The following image shows the fascia encasing the lower leg muscles.

Lower Leg Compartments Beckie Palmer, CC BY 4.0, via Wikimedia Commons

My signs and symptoms

This injury was a bit unusual for me in that it just felt like something was off in my lower right leg.

• Referral pain down and into my right foot
• An odd sensation in the middle of my lower leg that I do not know how to describe
• Feeling like I only had 70% of my normal strength in that leg
• A feeling of tightness in my calf muscles after activity
• Pain in the lateral portion of my lower leg (I think this is from my gait being abnormal while running)
• Soreness in the medial portion of my knee (I think this is from my gait being abnormal while running)

The symptoms were present after only a couple minutes of running (mostly trail). From the research I have seen, it’s suggested that it takes between 20-30 minutes.

Patients will generally complain of discomfort that they describe as squeezing, cramping, aching, or burning that typically begins within 15 to 20 minutes of an exertional type activity, i.e., running, marching, etc.[5][6]

Possible cause

My non-expert opinion is that this was all caused by a charley horse, or a muscle spasm or cramp that occurred about 4 weeks ago. This led to imbalance and tightness throughout my lower leg. A week later, I ran a 50k and struggled a bit, but didn’t feel that much of a setback. 😇

You can read my Behind the Rocks 50k Race Report for more information on the outcome.

Diagnosis 🩺

So after some additional long runs, and another race, I finally went to the doctor to see what was going on. I can only take so many days off running before something must change; I made it 7 days! :grimace: (Prior to these injuries I had a 70+ day run streak going back to the beginning of the year.)

When going to the orthopedic office, it always feels like I shouldn’t be there and need to go back home. I think this is because of the nature of a chronic injury due to activities that I chose to partake in. I don’t have an acute injury. I don’t have a job that causes me a repetitive stress injury. I just run a lot and for very long distances.

Going through the diagnosis, these feelings of wasting everyone’s time were amplified.

Does this hurt?

The doctor applies pressure over entire lower leg.

No.

Can you press down? Does that hurt?

I extend my foot against the doctor’s hand.

No.

Can you pull up? Does that hurt?

I pull my toes towards my shins while restrained by the doctor’s hand.

No.

Your X-Rays don’t show anything to be concerned about.

Good.

In my head, I’m thinking “Why am I here again?”.

Physical exam of patients with CECS is often unremarkable. https://doi.org/10.2147/OAJSM.S168368

The key point that the doctor was able to figure out is that the pain and sensation I experience only happens during activity. The doctor gave me a brief description of exertional compartment syndrome and went to see if there was a treadmill available; the idea being that I would run until I was symptomatic. There was, and after about 2 minutes, I hobbled back in pain to the exam room.

From my understanding, a confirmed diagnosis involves measuring the pressure using a special needle inserted into the muscles with a pressure gauge.

To confirm the diagnosis, 83% (55/66) use intra-compartmental pressure measurements (ICPs). Of these, 42% use maximal ICP during exercise greater than 35 mmHg as a criterion for anterior CECS diagnosis and 35% use Pedowitz’s modified criteria. Pubmed

What I’m going to do

So back to my predicament. I have an injury that I didn’t know existed. I haven’t been running. I have a race in a little over two weeks. My options are the following.

Non invasive treatment

1. Stop taking creatine. Not regular taken anyway. Big muscles == bad. 💪

2. Get into see a physical therapist ASAP. My normal PT, which I haven’t been seeing, is booked out for two weeks, but I picked another for an appointment Monday at 8:30 (its Friday now and I saw the doctor Thursday).

3. Use my TheraGun percussion massage tool, foam roller, and whatever balls (dog kongs?) I have to try and loosen the fascia. Read up on self-myofascial release.

4. Bike instead of run. Nothing is going to happen to my endurance in two weeks, but this will help me feel a little better. Going to keep it fairly tame as to not cause any other issues. I might also try some steep hikes.

5. Get a better understanding of risk factors and how chronic and acute compartment syndrome differ. I can always stop activity to relieve pressure in the lower leg.

6. Decide on the race two days before (when I need to load up the travel trailer and drive to Arizona). This a multi-day event, 250+ miles, but at very low intensity with lots of walking. Maybe it will be possible?! 🤞 I’m going to be in pain anyway! 😬

This literature review of Chronic Extertional Compartment Syndrome defines some treatment options and this case study lays out some other management approaches.

Surgery 🔪

I think it is way too early to consider a fasciotomy.

Unlike acute compartment syndrome, the treatment of CECS is non-emergent. Furthermore, the surgical approach may be less extensive, involving only the involved compartments. The suggested resting pressure considered significant and that indicates the need for surgery for those with CECS is debated in the literature.

And continues to list the improvement from surgery as the following.

Reports of improvement following anterior or lateral compartment release range between roughly 80-100%. Release of the deep posterior compartment has not been as successful with success being reported in only 50-65% of those who undergo the procedure. NIH

Outcome

TBD 🙏

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