How Heel Strike Running May Cause Chronic Exertional Compartment Syndrome

How we use our foot strike when we run may have big implications for lower leg chronic exerional compartment syndrome (CECS), a painful condition in which the main symptom is increased throbbing lower leg pain that increases with running distance and/or intensity. The pain stops as soon as running is stopped. Essentially, CECS is a condition that namely affects runners, but its becoming well-reported that an overwhelming majority of runners who suffer CECS are heel strike runners. Whats the reason for this and how can running-related CECS be treated and prevented?

Strong evidence for the relation of CECS in heel strike runners is grounded in that fact that its the high impact magnitudes uniquely generated in heel strike running that sparks dangerous rises in pain-triggering intramuscular pressure of the lower leg. Its these rises in intramuscular lower leg pressure in which CECS stems from. 

Heel Strike Running and Chronic Exertional Compartment Syndrome
More research is showing that running-related chronic exertional compartment syndrome (CECS) is directly connected to heel striking whereby in many cases, heel strike running was found to spark higher-than-normal levels of the ground reaction force which in turn caused the lower leg to be heavily bogged down with increases in intramuscular pressure, making CECS a looming problem.

To get a clear picture of what effect heel strike running has on causing CECS, landing heel first during running was found to generate unusually high levels of the ground reaction force, causing soft tissue compartments to vibrate at a high frequency, beyond on a tolerable limit which in turn prompts swelling throughout the lower leg (Friesenbichler et al 2011, Wakeling et al., 2002).

  • Increased lower leg intramuscular pressure beyond the threshold may be preceded by swelling of soft tissue compartments due to prolonged exposure to high vibrational frequencies produced by a higher dose rate of the ground reaction force that’s uniquely generated at heel strike during running. 

Such clear and convincing evidence demonstrates that to avoid damaging rises in intramuscular lower leg pressure, running with a heel strike may be of little help because of the unusual mechanical stress it puts on the lower leg as well as the hard evidence and anecdotal reports showing that heel strike running has no preventive effects on CECS.

Obviously, the new prevailing view holds firm that reducing the ground reaction force is the first stage of treating running-related CECS in which forefoot strike running was found to be most helpful in achieving safer, normal, more tolerable levels of the ground reaction force which resulted in FULL resolve of CECS (Diebal et al. 2011)! 

Bottom line, the most novel solution known to date in dropping your risk of running-related CECS is to reduce the ground reaction force when running whereby eliminating initial ground-contact on the heel (heel strike) and instead make initial ground-contact on the forefoot (forefoot strike), plays a powerful role in that ( Nigg,1997).

Is Forefoot Running a Cure for Running-Related Chronic Exertional Compartment Syndrome?
If you run consistently into trouble with chronic exertional compartment syndrome (CECS), you might be able to get more done in fully resolving the condition with forefoot running! How? Most evidences to date suggest that there are several things about forefoot running that makes it so effective at preventing CECS. For one, making initial ground-contact on the balls of the foot (forefoot strike), not the heel (heel strike) during running, seems to work best in keeping the ground reaction force (which is linked to causing the condition) within a safer range and may all that may be needed in greatly improving the odds of avoiding CECS for good!

Study after study has found that heel strike runners who suffered from CECS showed remarkable improvements in symptoms after adopting the forefoot running technique ( Diebal et al. 2011).

  • Forefoot running was found to not only markedly lower the ground reaction force, it also eliminated the rapid spike in impact measured in a heel strike landing, suggesting that running with a heel strike may all that may be standing in your way of fully resolving CECS and that  running with a forefoot strike may make more efficient use of the foot in removing the deep currents of impact that fuel CECS.  

The risk factors contributing to running-related CECS has always been an active area in research on running injuries of the lower leg, and much of the focus has been intensively on running shoes as the first-line therapeutic strategy to combat the painful condition. Yet, with all the advancements in running shoe technology and with all the magical gizmos most running shoes have, consistently the data shows that an overwhelmingly majority of runners still injure at a high rate! Therefore, running shoes seem to be an imperfect solution for preventing injuries, including CECS.

What’s even more concerning is that certain types of footwear (thick cushioned running shoes) may greatly contribute to CECS by encouraging a more forceful heel strike during running! It is very important to always remember that material properties of a shoe (thick underfoot cushioning and an elevated padded heel) powerfully influences foot strike pattern during running whereby the thickly padded heel in most traditional running shoes pulls the foot out to land heel first during running and a lot of injuries may stem from this. 

Nonetheless, its only until recently that a big bright line has linked foot strike pattern (i.e. heel strike) to causing CECS and that its the forefoot strike that helps you secure a safer, impact-protective interaction with the ground needed to prevent damaging levels of intramuscular lower leg pressures.

Overall, when it comes to preventing impact-related injuries in running, like CECS, foot strike is growing increasingly important! We have more convincing empirical evidence about the progress that can be made with forefoot running in how it naturally gives you the mechanical help you need to renew your capacity to keep rolling along injury-free!

Last but not least, I’ve written other posts that drive deeper into the connection on how heel strike running causes CECS and how forefoot strike running resolves and prevents it:


[1]. Diebal et al. (2011). Effects of forefoot running on chronic exertional compartment syndrome: a case series. Int J Sports Phys Therapy, 6(4):312-21.

[2]. Nigg, BM. Impact forces in running. Current Opinion in Orthopedics (1997); 43-47.

[3]. Friesenbichler B., Stirling, LM., Federolf P and Nigg BM. Tissue vibration in prolonged running. J Biomech(2011);44(1):116-20.

[4] Wakeling, JM and Nigg, BM and Rozitis, AI. Muscle activity damps the soft tissue resonance that occurs in response to pulsed and continuous vibrations. J of Appli Physio(2002);93(3):1093-1103

[5]. Wakeling JM., Pascual SA and Nigg BM. Altering muscle activity in the lower extremities by running with different shoes. Med Sci Sports Exerc (2002); 34(9):1529-32.

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Bretta Riches

"I believe the forefoot strike is the engine of endurance running..."

BSc Neurobiology; MSc Biomechanics candidate, ultra minimalist runner & founder of RunForefoot. I was a heel striker, always injured. I was inspired by the great Tirunesh Dibaba to try forefoot running. Now, I'm injury free. This is why I launched Run Forefoot, to advocate the health & performance benefits of forefoot running and to raise awareness on the dangers of heel striking, because the world needs to know.
Bretta Riches

P.S. Don't forget to check out the Run Forefoot Facebook Page, it's a terrific place to ask questions about forefoot running, barefoot running and injury. I'm always happy to help!