Table 1

Standard care for exercise-related leg pain: criteria for application (version 2018)

StretchingGastrocnemius tightness=minimal angle compared with a vertical line: 70° or more.
Soleus tightness=maximal distance of the big toe 5 cm from the wall or less.
See online supplementary material 4, with two illustrations.
StrengtheningCalve strength insufficient: not able to perform 30 consecutive calve raises on one leg.
Massage hypertonic m. plantarism. plantaris palpation painful (patient in prone position).
Dry needling of trigger pointsMedial and lateral gastrocnemius: if patient identifies the calve as a pain location.
Compression stockings/sleevesNot given to patients with proven anterior CECS (ICPM ≥35 mm Hg).
ESWTFor MTSS only: once a week, 4 sessions; each session 2000 radial shocks, frequency eight per second and intensity 2.5 bar, on the medial tibial border.
Vitamin D supplementationIf MTSS is present: criterion: <50 nmol/L means insufficient, supplementation required; optimal 75 nmol/L.
New running shoesEvery year or 500 miles (800 km).
If patient describes a relation between symptoms and shoes.
Minimalist shoes are discouraged.
Customised antipronation inlaysIf navicular drop is positive (>0.5 cm) and if overpronation is established with slow motion video analysis of barefoot running.
Maintaining fitness with low impact trainingResume three moments of low impact exercise per week. Keep leg pain scores≤3 (on a Numeric Pain Rating Scale 0–10).
Gait retraining while running in sports shoes and bootsFour cues for running:
  1. Change to a ball-of-foot strike (reduce heel strike), when applicable.

  2. 10% reduction of stride length.

  3. Strive for cadence 180/min.

  4. Increase knee lift 1–2 cm.

Gait retraining while marching in bootsTwo cues for marching:
  1. 5% increase in cadence from preferred.

  2. Reduce force and dorsal flexion angle of heel strike.

Progressive running scheduleWeeks 1–6: run twice a week, end goal=a 15 min uninterrupted run, pain free with new running technique.
Weeks 7–12: run twice or three times per week, end goal=a 30 min uninterrupted run, pain free, with new running technique.
  • CECS, chronic exertional compartment syndrome; ESWT, extracorporeal shockwave therapy; ICPM, intracompartmental pressure measurement; MTSS, medial tibial stress syndrome.