t velasco, n reilly, c hulsopple, k roberts, r boeth, d hoellen, c dickison, d goss, j leggit

Abstract accepted for poster presentation at the 2026 Alexander T. Augusta Military Medical Center Applied Research Training Day

Chronic musculoskeletal injuries are the leading cause of disability among the active-duty service member (ADSM) population. Chronic exertional compartment syndrome (CECS) can significantly hinder ADSMs' physical training, especially running, due to exercise-induced pain, numbness, and muscle weakness in the lower limbs. Many affected individuals ultimately require surgical intervention. Further complicating CECS management is that the condition is often overlooked as a cause for reported lower leg symptoms, leading to diagnostic delays of several months to years following initial onset.

A 23-year-old male ADSM presenting with unilateral lower limb CECS as defined by Pedowitz’s criteria was recruited to participate as part of a larger, multi-site randomized controlled trial assessing non-surgical interventions for CECS. His main complaints were pain and symptoms limiting his ability to run for his physical fitness test. Of the 36 participants recruited, he was the only ADSM diagnosed within 6 months of symptom onset. He received structured gait retraining and botulinum toxin A (BoTN-A) injections to the anterior and lateral compartments of his involved leg. Numerical pain rating scale (NPRS), single assessment numeric evaluation (SANE), and University of Wisconsin Running Index (UWRI) were administered at baseline, 8 weeks, 6 months, and 12 months post injection.

This ADSM started with lower SANE scores (indicating worse function) and comparable lower UWRI scores (indicating worse running ability) at baseline compared to the other groups with a symptom onset of more than 7 months. At 8-weeks, 6-, and 12-months follow-ups, this individual continually scored  higher on these measures (SANE and UWRI), indicating greater improvement compared to his cohort. His NPRS score at baseline was also higher than the groups with a longer symptom duration history and improved to 0/10 by 6-months, which remained at the one-year follow-up. Functionally, at 6-months post-injection, the ADSM was able to complete the running portion of his physical fitness test without limitations, pain, or symptoms.

This case demonstrates that timing of diagnosis and seeking early non-surgical treatments for lower limb CECS can be beneficial for improving function and running capability. Clinicians trained to identify the signs and symptoms of CECS early in ADSMs may positively impact their career longevity. However, further research is needed to confirm that early detection in this population can lead to long-term optimal outcomes.

t velasco, n reilly, c hulsopple, k roberts, r boeth, d hoellen, c dickison, d goss, j leggit

Abstract won first place in poster presentations at the 2026 Alexander T. Augusta Military Medical Center Applied Research Training Day

Chronic exertional compartment syndrome (CECS) presents a significant challenge for active-duty service members (ADSMs), with exercise-induced lower-limb pain, weakness, and in extreme cases, disability impacting military readiness. While various treatments have been described, from surgery to structured exercise programs, no consensus on an optimal treatment approach currently exists for CECS2-6. This randomized, placebo-controlled trial’s objective was to determine how different components of a multifaceted, non-surgical treatment program—specifically botulinum toxin A (BoTN-A) injections and structured gait retraining—were associated with improvements in distinct clinical and biomechanical outcomes.

36 ADSMs diagnosed with CECS via Pedowitz’s criteria were randomized to receive BoTN-A (n=20) or saline injections (n=16) into the anterior and lateral lower leg compartments. All participants received structured gait retraining with corrective exercises and running form instruction.

A multiple regression model was developed to analyze the relationship between the interventions and various biomechanical and clinical metrics over the course of rehabilitation. Biomechanical metrics were collected during treadmill running using instrumented shoe insoles (Loadsol, Novel USA, St. Paul, MN)7 to measure cadence, average vertical loading rate (AVLR), and peak ground reaction forces (GRF). Clinical metrics included self-reported current and worst pain, as well as functional scores during running and day-to-day activities via the University of Wisconsin Running Index (UWRI), and Single Assessment Numerical Evaluation (SANE), respectively. All metrics were collected at baseline, 8 weeks, and 3 months.

The analysis revealed that participation in the structured gait retraining program was significantly associated with reduction in self-reported current pain (Est: -1.52, p=0.03) and worst pain (Est: -2.86, p<0.01) at the 3-month follow-up. BoTN-A use was significantly associated with reduced AVLR during running at 3 months (Est: -10.74, p<0.01). While the overall model was significantly associated with improved UWRI scores (p=0.03), no single intervention independently reached significance for this outcome.

A combined, non-surgical approach is beneficial for treating CECS in ADSMs. The components of the multimodal intervention target different aspects of the condition—structured gait retraining was most associated with pain reduction (clinical outcome), while BoTN-A was most associated with improved loading mechanics (a biomechanical outcome).