Forefoot Running Resolves Chronic Exertional Compartment Syndrome in Heel Strike Runners

When it comes to positive outcomes in treating and preventing running-related chronic exertional compartment syndrome (CECS), forefoot strike running matters most because it has proved to be incredibly effective for reducing all the risk factors tied to CECS as compared with heel strike running.

For instance, forefoot running was found to naturally provide more effective impact protections by reducing both ankle dorsiflexion at touchdown and the ground reaction force. It also led to a safer weight shift transfer on the foot and prompted an increase in step-rate, all of which had the most positive effect in preventing dangerous rises in intramuscular lower leg pressure.

Forefoot Running Resolves Chronic Exertional Compartment Syndrome in Heel Strike Runners
One of the most successful approaches in treating and preventing running-related chronic exertional compartment syndrome (aka throbbing lower leg cramps during running) is to run with a forefoot strike (shown above) because it seems to engage the foot and leg in a uniquely mechanically safe manner that stops the inflow of pain-inducing impact forces as compared with heel strike running.

Comparatively, correlational data suggests that heel strike runners are more susceptible CECS compared to other running styles, such as forefoot running.

How Heel Strike Running Causes Chronic Exertional Compartment Syndrome
What can you do to avoid running-related chronic exertional compartment syndrome (CECS) of the lower leg? Avoid heel strike running (shown above) because it was shown to produce nearly all the forms of impact linked to CECS as compared with forefoot running.

CECS results in lower leg pain that escalates with running duration and is actually a condition exclusive to running. However, reports of CECS in forefoot strikers is VERY rare, suggesting the legs could be less burdened in forefoot strike running and that the mechanical properties of forefoot running may best suit the purpose of completely walling off the condition. And, results from the following studies make that clear!

In recent studies, forefoot running was a tremendously effective tool for improving CECS symptoms in heel strike runners. For example, a recent study by Diebal et al., published results that gels with the research about the positive effects of forefoot running on reducing leg pain, namly CECS.

The participants in the study were heel strike runners with anterior CECS which increased in severity after running 1-km. The pain resulted in the total cessation of running and symptoms subsided after 5 – 10 minutes of rest.

As an intervention strategy to reduce anterior CECS symptoms, the participants were trained to adopt the forefoot running technique with the aid of drills that reinforced the mechanics of a forefoot strike landing. Most of the drills in the study were from the Pose Method of Running which involved the following movement drills:

  • foot taping and pulling the foot up to increase flight time and decrease ground-contact
  • pressure and weight shifting to improve perception of landing and to reduce peak pulses on the foot
  • mental cues such as “land quietly” to reduce the ground reaction force
  • falling forward to prevent braking
  • the EZ Run Belt developed by Joe Sparks to aid in self-correction of running gait and helps prevent over-striding

The researchers results revealed that the participants returned to running pain-free after adopting the forefoot running technique with the help of the Pose Running drills which altogether made the most positive difference in long-lasting improvements in impact-reduction and completely countered pain-inducing rises in intramuscular lower leg pressure.

  • Another optimistic finding of the study was that two of the participants who could not run 1-km without CECS symptoms before intervention could now run 4 and 5-Km with greater ease!

Precisely, what was it about the forefoot running technique that made it so successful at eliminating CECS in the heel strike runners?

In forefoot running, leg swing mechanics and foot-ground interactions naturally become more optimized to produce a smoother, softer interaction between the foot and the ground and it also increases step-rate which collectively reduces loading time on the leg and curbs high ground reaction forces, sparing the leg of pain-triggering rises in intramuscular lower leg pressure. This may explain why the heel strike running CECS sufferers responded best to forefoot running.

Moreover, other work has pointed out that reduced eccentric muscle activity of the anterior leg compartment musculature associated with forefoot running may also prevent anterior compartment pressures from accumulating as well!

These results make it clear that heel striking may most likely be the greatest risk factor for running-related CECS since initial contact made on the heel is by all measures the most forceful aspect of running gait, resulting in too much high levels of the ground reaction force with a marked impact spike that is not produced in forefoot running.

So when it comes to running-related CECS prevention, there’s a strong relationship between foot strike pattern and the dreaded condition such that forefoot strike running most definitely gets a stamp of approval in staving off the condition as forefoot running really helps foot strike and leg swing mechanics participate in the way they should in keeping mechanical disturbances and high impact loads to a bare minimal.

Last but not least, the strong link between heel strike running and CECS is nothing new and I’ve written other posts about the compelling evidence on how the cause and prevention of running-related CECS all circles back to foot strike:

If you’ve enjoyed this content, you’ll LOVE my content over at my YouTube channel, here, where I talk more at lengths about the endless performance and injury prevention advantages of forefoot running vs heel strike running!


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.

Gershuni et al. (1984). Ankle and knee position as a factor modifying intracompartmental pressure in the human leg. J Bone Joint Surg Am,66:1415-20.

Tsintzas et al.(2009). The effect of ankle position on intracompartmental pressures of the leg. Acta Orthop Traumatol Truc,43:42-8.

Tweed, JL and Barnes, MR. (2008). Is eccentric muscle contraction a significant factor in the development of chronic anterior compartment syndrome? A review of the literature. Foot, 18:165-70.

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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!