How Heel Strike Running Causes Chronic Exertional Compartment Syndrome and How Pose Running May Prevent it!

Running with chronic exertional compartment syndrome is very painful and upsetting because it makes many runners who suffer this condition completely give up on running, when they don’t have to!

Chronic exertional compartment syndrome (CECS) is a condition common in runners who heel strike. The pain includes throbbing cramps that radiate throughout the lower leg and begins as soon as running begins. The lower leg pain gets worse as running increases, but stops when running is stopped.

How Heel Strike Running Causes Chronic Exertional Compartment Syndrome and How Pose Running May Prevent it!
One consistent finding and important scientific conclusion is that heel strike runners are more likely to suffer chronic exertional compartment syndrome than forefoot strike runners. Why? In heel strike running, certain impact forces hit the lower leg harder in intensity and longer in duration as compared with forefoot strike running. Its for this reason that heel strike running may limit your potential to avoid lower leg injuries from runners knee to chronic exertional compartment syndrome. This is another reason heel strike running is losing its standing as a ‘way’ to run.

Just remember that the basic fundamental of the underlying cause of CECS is heel strike running as there’s more rising tides of impact due to the braking effect unique to heel strike running, where the body comes to a dead stop for a prolonged period of time which increases intramuscular leg pressure. This may also lead to consequential changes in circulation in the lower leg which may negatively affect muscular function, too, in addition to amplifying lower leg pain. This is how the lower leg may take on more cumulative stress and strain as compared with forefoot running.  

Cause of Running-Related Chronic Exertional Compartment Syndrome and How Pose Running May Cure it

A number of studies (references provided at the bottom of the article) have shown that running with a heel strike, which often accompanies an over-extended stride, produces an impact shock-wave that persists at unusually high levels and sparks dramatic rises in intramuscular pressure that builds up beyond a tolerable limit in the lower leg as running increases. However, a sizable body of evidence has found that Pose Running, a non-heel strike running technique, has proved be to incredibly effective at bringing full resolve to CECS!

What’s the mechanism behind Pose Running that fixes running-related CECS?

Pose Running simply advises the following:

  • non-heel strike landing
  • leg swing that opens up more behind the body, not entirely in front
  • subtle forward lean from the ankles, not from the hips
Cause of Running-Related Chronic Exertional Compartment Syndrome and How Pose Running May Cure it!
When it comes to running with less impact on the lower leg, a subtle forward lean can go a long way because it pushes your body weight forward, aligning it closer to initial foot strike position. In this way, the distance between your center of mass (upper body) and initial foot strike position shortens which in turn can reduce the amount of braking per step. Less braking means less risk of not only CECS, but boney injuries as well as runners knee.  A slight forward lean also seems to be a normative posture position found across most, not all, but most of the top professional distance runners, especially from East Africa.

This mechanical re-alignment recommended by Pose Running naturally brings your initial foot strike placement much closer to your body and has been scientifically credited with curbing the very same impact forces directly linked to CECS in heel strike runners.

Running with Chronic Exertional Compartment Syndrome
When it comes to preventing running-related chronic exertional compartment syndrome, landing with a non-heel strike, such as a forefoot strike landing should remain a high priority because landing on the balls of the foot (forefoot strike) naturally counters high brake-collision forces during running. This is how forefoot striking helps to alleviate intramuscular pressure buildup in the lower leg as compared with heel strike running.

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In contrast, as I briefly mentioned, many heel strike runners make the mistake of swinging the landing leg too far forward when running, causing the landing foot to land in front of the ankle, knee and hips at touchdown. This is called over-striding which produces an intensive brake force that unleashes compressive forces on the lower leg. This is how lower leg intramuscular pressure can significantly rise to the level of pain. Of course, there are multiple factors that cause running injuries, but an impact-intensive collision force is one well-known common vulnerability you may have if you run with a heel strike, instead of a forefoot strike.

The real potential to run with minimal compressive forces is to employ the 3 mechanical adjustments I mentioned above advised by Pose Running because out of that comes a running stride that involves smaller steps (i.e shortened stride) and a quicker removal (i.e. greater recoil energy) of the foot off the ground. This also results in a shortened ground-contact time duration, leaving less time for both abnormal foot motions to take hold and damaging impacts to rise to painful and dangerous levels. This is how Pose Running effectively eases out mechanical strain overload on the lower leg as well as enables all the opportunities that follow when the legs are able to stay healthy and pain-free. But, where’s the factual proof of this?

Running with Compartment Syndrome
A little forward lean coupled with swinging your leg behind your body, and less in front, is going to be the engine of change that’ll make it easier for you to overcome and avoid CECS

A 2012 study in the American Journal of Sports Medicine provided clear and credible explanations on the full meaning of how Pose Running can be a reliable way to prevent and treat CECS.

The study found that participants who replaced their heel strike running style with the Pose Running Technique showed a significant reduction in the vertical ground reaction force which directly led to a sudden drop in pain-triggering intra-compartmental pressure levels in the lower leg, suggesting that increases in the vertical ground reaction force during running may be one of the main culprits that keeps feeding CECS.

This line of evidence is also suggestive of the fact that because heel strike running produces a significantly greater vertical ground reaction force than forefoot strike running, heel strike runners may be at the greatest risk for CECS.

How Heel Strike Running Causes Chronic Exertional Compartment Syndrome and How Pose Running May Prevent it!
Raw data from the study showing the significant reduction in leg pain (right) when a non-heel strike landing was utilized under the instruction of Pose Running (Diebel et al. 2012)

To give you a clearer sense of how Pose Running can make the most positive difference in remedying CECS, perhaps the most optimistic part of the study was additional results showed the Pose Running/non-heel strike running intervention led to improved run performance such that 2-mile run times were significantly faster compared with the pre-intervention values. Even better, running distance increased by 300%! Two participants even went on to complete two half-marathons shortly after!

Here’s more information about the exact Pose Running training method used in the study.

More on the Value of Proper Foot Strike in Running

Researchers are convinced that lower leg anterior compartment pressures in running is directly influenced by foot strike pattern. This relation was clearly articulated in an 1984 study in the Journal of Bone & Joint Surgery which found that anterior compartment pressures significantly increased in healthy patients who used a heel strike landing during running.

More specifically, it was the full knee extension coupled with the full ankle dorsiflexion at heel strike that resulted in increased lower leg anterior compartment pressures. The researchers reached this conclusion after finding that landing this way during running led to a constant escalation in eccentric activity in the lower leg which elevated anterior compartment pressures to an entirely new level, causing pain to the related area.

This is in stark contrast to forefoot running with the Pose Running Technique which reduces CECS-related mechanical strain on the lower leg, as well as the entire body, because the knee of the landing foot is also bent at touchdown which helps pull the ankle of the landing foot to be positioned closer to the knee as well as the center of gravity at touchdown. Meanwhile, a slight forward tilt from the ankles scales back braking by keeping the center of mass more closely aligned over-top of initial foot strike position.

How Heel Strike Running Causes Chronic Exertional Compartment Syndrome and How Pose Running May Prevent it!

  • Left, shows a heel strike landing where the knee of the landing foot is fully straightened out (unbent) as well as the ankle is positioned in front of the knee at touchdown. This mechanical arrangement results in an over-stride that increases weight-bearing loads on the lower leg, causing compressive loads to be greater and more immediate as well as longer in duration as compared with Pose Running. Right, shows the Pose Method which involves a slight forward lean and the knee of the landing foot is softly bent and flexed at touchdown which taken together, naturally helps prevent an overstride by enabling the landing foot to be positioned closer to the body (center of mass) at touchdown, thus reducing braking and compressive loads on the leg.

The interplay between a slight forward lean, slight bent knees and a non-heel strike landing in Pose Running reduces impact naturally and improves joint cushioning. This is how this pattern of modification is highly protective against CECS.

Overall, at this point, researchers examining the effects of heel strike running on intramuscular lower leg pressure have gathered enough evidence to conclude that heel strike running undoubtedly increases the susceptibility to CECS. Knowing all this seems like a particularly good time to consider Pose Running as it helps keep your stride within a shorter, safer range and produces a quiet, more of a low amplitude impact and may work best to prepare your legs for high mileage running.

If you want to learn more about forefoot strike running vs heel strike running, you’ll enjoy the informative content over here at my YouTube Channel, where I talk at lengths about the health benefits of barefooting and how barefoot running can help you get a better handle on your overall running form.

If the thought of going barefoot doesn’t interest you, here are my reviews on the minimalist footwear that are similar to the barefoot experience and are great for foot strength revitalization as well as proprioceptive (movement awareness control) training.

If you’d like, you can support Run Forefoot and help keep it going strong by by shopping at the following:

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Diebel et al. Forefoot running improved pain and disability associated with chronic exertional compartment syndrome. Amer J Sports Med, 2012; 40(5): 1060-67.

Gerahuni et al. Ankle and knee position as a factor modifying intracompartmental pressure in the human leg. J Bone Joint Surg Am, 1984;66(9):1415-1420.

Kirby, RL and McDermott, AG. Anterior tibial compartment pressures during running with rearfoot and forefoot landing styles. Arch Phys Med Rehabil, 1983; 64:262-99.

Romanov, N and Fletcher, G. Runners do not push off the ground but fall forward via a gravitational torque. Sports Biomech,3007; 6(3):434–52.

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!