L.W. (not his real name) is a 43 (not his real age) year old novice runner from Oklahoma (not his real state) who writes about his recent bout with pain in his legs and feet (his real problem). Seems he started running about a month ago to get in shape for a physical fitness test he needed to pass for his potential new post in a law enforcement agency. Within the first two weeks he had increased his mileage to 5 miles per day, 6 days per week at close to 8 minute/mile pace. L.W. soon began to experience symptoms he self-diagnosed as shin splints pain along the front outer area of his leg just below the knee. He tried all the right measures, including decreasing his mileage and pace and use of ice and aspirin, but the problem persisted. His pain pattern was a consistent one, with onset of a deep, aching sensation within the first 10 minutes of his run. And “oh, yes” for some reason he was also experiencing a burning pain in his feet and tingling in his toes. This was especially worrisome to him, though all symptoms ceased within a few minutes after he stopped running.
L.W. almost had it right when he said he thought he had shin splints. As we saw last month, the symptoms in his leg do fall under the general heading of that diagnosis. However, the symptoms in his feet do not, and are indicative of a more serious and difficult-to-treat problem known as chronic compartment syndrome. [This is differentiated from acute compartment syndrome [ACS] by two factors: (1) the mechanism of onset is usually from trauma (e.g., a direct blow to the leg) as opposed to overuse, and (2) the symptoms do not go away with rest. ACS is a true medical emergency and should be attended to by a physician ASAP!]
Compartment syndrome occurs most often in the leg due to the structure of this segment of the lower extremity. The muscles between the knee and ankle are divided into three separate compartments, each surrounded by a tight connective tissue known as fascia. The muscles in the thigh, arm and forearm are similarly compartmentalized, but the difference in the leg is that the fascia is much tighter and inflexible. As we exercise and the muscles expand due to increased blood flow throughout them, they push outward on the fascial tissue. In most people, the fascia is flexible enough to allow the muscles to comfortably expand, but in others the room for an increase in muscle volume is quite limited. If there is no room for expansion outward, the increased fluid pressure in the muscles is directed inward. This pressure is applied to the nerves and sometime blood vessels passing through the region. The result can be the sensation of burning and tingling in the feet and toes.
Beginning runners and especially adolescents whose body structure is undergoing change and growth most frequently experience compartment syndrome. Mary Slaney, when she was still little Mary Decker, suffered from this problem early in her career and underwent a surgical procedure known as a fasciotomy, in which the connective tissue sheath surrounding the muscles is opened to allow more expansion of the muscles during exercise.
Surgery is not the only option for everyone. Some patients respond well to other treatments that correct biomechanical faults that may be overtaxing a particular muscle group. There is some evidence that massage, in conjunction with a well-designed and implemented stretching program, can help improve symptoms. Persistence of symptoms in spite of these measures, as well as adequate rest, is usually an indication for consideration of surgery.
Some individuals unfortunately seem anatomically predisposed to development of compartment syndrome from distance running. (Studies indicate a clear difference in the structure of the fascial tissue in some subjects relative to stiffness and thickness of the connective tissue fibers.) There are some who can tolerate the discomfort enough to continue running, but those that are forced to stop regularly and at a specific point in their run because of severe pain should probably seek medical advice to determine the exact nature of the problem and options for treatment.
- Gabe Yankowitz, PT Blackman PG et.al. Treatment of chronic exertional anterior compartment syndrome with massage: a pilot study. Clin J Sport Med 1998 Jan;8(1):14-7
- Turnipseed WD et.al. The effects of elevated compartment pressure on tibial arteriovenous flow and relationship of mechanical and biochemical characteristics of fascia to genesis of chronic anterior compartment syndrome. J Vasc Surg 1995 May;21(5):810-6;discussion 816-7
- Hurschler C et.al. Mechanical and biochemical analyses of tibial compartment fascia in chronic compartment syndrome. Ann Biomed Eng 1994 May-Jun;22(3):272-9