Gait retraining as part of the treatment programme for soldiers with exercise-related leg pain: preliminary clinical experiences and retention

Exercise-related leg pain (ERLP) is a common problem in the military. Healthy young men can have pain in both legs only weeks after starting a training course, leading to them dropping out of the military. The most common diagnoses in the Armed forces of the Netherlands are: 1. Medial Tibial Stress Syndrome (MTSS), 2. Chronic Exertional Compartment Syndrome (CECS), or 3. A combination of MTSS+CECS.[1] The highest reported incidence of MTSS in a military setting was 35% of 124 naval recruits participating in basic military training in Australia.[2] An estimation of the incidence of CECS in the military is one in every 2000 US military service members per year.[3] MTSS is an overuse injury involving the interface of the tibial bone and soft tissue. The patient with MTSS reports pain over the tibia during and after leg loading activities.[4] The definition of CECS is pathologically elevated intracompartmental pressure during exercise, which returns to normal with cessation of exercise.[5] The patient with CECS reports a fullness or cramp like sensation over the involved muscular compartment, often after a specific amount of exertion (time, distance, or intensity).[5] If an intracompartmental pressure measurement (ICPM) in the first minute post-exercise is above 35 mm Hg and the patient reports pain, the diagnosis CECS is confirmed.[6] If the pressure measurement is below 35 mm Hg, a new diagnostic term can be applied: Biomechanical Overload Syndrome (BOS).[7] For both MTSS and CECS, the exact pathophysiological mechanism is not known.[1] A previous episode of leg pain and the biomechanics of walking and running are a few of many risk factors identified for these conditions in the military.[1] Gait retraining, as a treatment for overuse injuries of the lower extremities is presumably widely practiced but until now, was scarcely reported in the literature.[8] Gait retraining regimens generally focus on a transition from rear foot to midfoot or forefoot strike, increasing cadence, or altering proximal mechanics.[8] The rationale for gait retraining for overuse injuries of the tibia is the reduction of vertical impact forces [9] and for gait retraining in CECS is the reduction of tibialis anterior activity.[10] Gait retraining as a treatment for CECS shows promising results in the first publications on this topic.[11,12] There are no publications on gait retraining as a treatment for MTSS, but recent research indicates its positive effects.[8] In the sports medicine department of the Armed forces of the Netherlands gait retraining as a part of the treatment programme for ERLP was introduced in 2013, using sophisticated tools, such as high-speed cameras and an instrumented treadmill, to analyse walking and running biomechanics. The goal of this study is to evaluate the treatment results and to describe preliminary clinical experiences and the retention of gait retraining in a military setting. This study is retrospective in design.