Author’s note: From the PT: a Look at Chronic Exertional Compartment Syndrome is a good introduction to the current article and includes a more detailed description of the anatomy, pathophysiology, and associated research. Since it was published on FasterSkier in 2022, that article has served as a resource for the Nordic skiing community, and I have fielded multiple requests for guidance from skiers around the world with CECS. In that article, I suggested that conservative treatment has potential; however, I was still more optimistic about surgical intervention based on the available research. The published research hasn’t changed, but my experience has, and now I’d like to make the case for non-surgical treatment of CECS. As with any medical information found on the internet, this article should be taken as the opinion of the author and not a replacement for direct consultation with a medical provider.
The primary symptoms of Chronic Exertional Compartment Syndrome (CECS) include pain, weakness, and/or numbness that only occurs with exertion. These characteristics are fairly distinct, although there can be enough overlap with other soft tissue disorders, namely tendinopathies, that CECS remains a diagnosis of exclusion when everything else has been ruled out. In Nordic skiers, symptoms affect the anterior, lateral, and/or posterior compartments of the lower legs and are most common with (often exclusive to) skating. Typically, or at least initially, these skiers will be symptomatic with high-intensity skating, but will be asymptomatic with classic skiing and running even at the same intensity.
The physiology is relatively straightforward: our muscles are wrapped in a thin layer of connective tissue called fascia. As muscles repeatedly contract, especially at high intensities, they become enlarged; however, fascia is not elastic and does not stretch. If the muscle size exceeds the volume of the fascial compartment, blood flow is constricted, oxygen delivery is decreased, and the muscle gets strangled. This hypoxia in the muscle triggers a pain response, which is usually a good defense mechanism to make us stop doing something that the body perceives as harmful.
The why is far more complex: some theorize that the fascia is just wrapped too tightly. Others suspect that the muscles are too big for the fascia. In either case, the common solution is a surgical fasciotomy where an incision is made in the fascia to increase the size of the compartment and decrease its stranglehold on the muscle.
The why with skiing is even more complex. With CECS occurring with skate vs. classic, the initial theories centered around the ski retrieval phase. This makes sense with the work being done by the tibialis anterior muscle, which dorsiflexes the ankle while the ski is brought back to its glide phase position. Except that CECS can affect other lower leg muscles/fascial compartments which would not be active during the retrieval phase. Arguably the biggest difference between skate and classic techniques, at least as far as the muscles of the lower leg are concerned, is the stability demand of balancing on the gliding ski: the muscles must work much harder with skating.
A case study
The patient in our story is an 18-year-old male skier. He is a very competitive skier regionally and would have qualified for Junior Nationals had his skate races not been disrupted by leg pain. We had our initial physical therapy visit in mid-January, mid-race season. He reported pain, progressing to numbness, in both shins, which only occurred during high-intensity skate skiing. Symptoms were first noticed the previous winter during a skate race in icy conditions, but he didn’t have any additional episodes for the remainder of that season or during the summer. In October, however, symptoms returned during a skate interval session, persisted with any high-intensity skating, and got progressively worse through the race season. He was unable to finish his last skate race due to severe pain.
In physical therapy exams and diagnostics, we are keen on reproducing patients’ symptoms. If we can do this in specific ways, we can begin to rule in or rule out anatomical structures which may be involved. For better or worse, I was unable to reproduce the patient’s symptoms in the clinic. This would likely rule out a muscle strain or tendinopathy, both of which tend to be painful with resisted tests (assuming we can make the tests both hard enough and specific enough). Differential diagnosis still included lumbar radiculopathy (nerve irritation at the spine leading to symptoms in the leg) or a bone stress injury (a.k.a. stress fracture), but neither of these fit the picture of symptoms being exclusive to high-intensity skating and absent at rest or especially with other modes of exercise. The symptoms really fit the pattern of CECS. To confirm, the gold-standard diagnostic would be compartment pressure testing; however, this testing is quite painful, fairly inconvenient (unless you have a rollerski treadmill in the clinic), and primarily aimed at determining if the patient is a candidate for surgery. Since this patient was looking to salvage his race season and avoid, or at least delay, surgery, we opted to skip the pressure testing but assumed that he was dealing with CECS.
The remainder of the physical exam focused on ski technique, or at least the static components we could observe in the clinic: hip strength (fair), balance (compensated with lateral trunk lean), ankle dorsiflexion range of motion (appropriate), and foot stability (notable flexibility and forefoot varus). These findings were significant enough to suspect that the patient’s lower leg muscles were working very hard to maintain balance on his glide ski. The hip weakness and compensated single-leg balance made me suspect that if he was lacking stability from the top down, then he was having to work much harder from the bottom up, thus overloading the muscles at the ankle and leading to CECS.
The root cause of any musculoskeletal symptoms can be described as an imbalance between load being placed on the body and the body’s ability to tolerate that load. In physical therapy, we are looking to balance that equation. Sure, we can decrease load by telling patients not to do things that are painful, and some of that may be required in the short term, but we’re not in the business of telling people to stop doing fun things. Thus, much of the work we do is aimed at improving the patient’s ability to tolerate load. The trick becomes sorting out where there is room for improvement and how to get there.
His first round of exercises focused on balance without compensation (single-leg stance with a Pallof press and lateral hops to balance on one leg) and hip strength (side plank variants and fire hydrants). On the load mitigation side, we discussed using more supportive insoles, which he had only recently acquired, and training modifications with skating limited to short bouts of low-intensity skating and all high-intensity work done in the classic tracks.
At his second PT appointment, we were very fortunate to have the involvement of his ski coach who attended the visit with the patient. We continued exercise progressions for balance and hip strength; but we also got much more technique specific, identifying areas for improvement and providing corresponding cues: “heel down” (when asked to stand as if he was balancing on the glide ski, he was over-exaggerating the very common “hips forward” cue and shifting his weight so far forward that his heel was no longer on the floor. Arguably this is okay on steep terrain but not in this context), “tripod foot” (equal pressure on the inside, outside, and heel of the foot), and “weight shift with the hips” (get the center of mass over the glide ski via the pelvis vs. leaning to the side). He and his coach then took these cues to technique sessions and eventually higher intensity intervals.
At our next appointment a few weeks later, the patient reported zero symptoms with hard L4 skate intervals. Unfortunately, the rapid melt-off of snow in the West ended the race season before he could fully test the effectiveness of the intervention. However, as of the time of this writing, he has been skiing and training for five months without symptoms.
The critical reader (and all readers should be critical) might point out that we have a false sense of accomplishment because he hasn’t raced. I would argue that he has had plenty of pain-free training sessions that would have previously been symptomatic. The reader might say that this is simply a case study and an N=1 is pretty weak research. That is certainly true. A randomized, double-blind, placebo-controlled study with a very large population would be ideal. But a case study is not nothing. Not all skiers with CECS are going to respond to the same intervention. But if we have seen that it is possible to effectively treat CECS without surgery, then we might want to consider exhausting our non-invasive options first. The reader might further pick holes by saying that without compartment testing, we don’t even know for sure if this skier had CECS. That is also very true and should be acknowledged. In the name of science, I should have subjected the patient to the very unpleasant testing before and after our intervention to both establish a baseline and to prove that he was cured. But in the name of practicality and the patient’s well-being (along with the patient’s and family’s input), I declined.
Again, the story of one skier’s ability to overcome CECS without surgery does not mean that all skiers with CECS will have the same success. But it’s very much worth a try. If you are reading this article because you are a skier with CECS, I would encourage you to take a very detailed look at your skating technique and be very specific about your approach to changing it. This likely means working on the component parts in a low-complexity setting (not on skis) and progressing to technique sessions on skis with a heavy emphasis on the cues that you and your support team (coach, PT, trainer, etc.) have identified. Hopefully this can be a path back to fun, fast, and pain-free skiing.
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