Say goodbye to re-occuring calf injuries
Persistent calf injuries are a common complaint amongst runners and sports people. Second only to the knee, the lower leg accounts for approximately one-third of running injuries in long-distance runners (1, 2). There are numerous causes of lower leg pain, with diagnoses varying in frequency and severity. The most common causes include; calf strains, medial tibial stress syndrome (MTSS), chronic exertional compartment syndrome (CECS), stress fracture, nerve entrapment, and popliteal artery entrapment syndrome (PAES) (3). These lower leg injuries can often be a persistent cause of frustration for any athlete if not promptly diagnosed and managed. If you have had calf troubles, whether it be pain, cramping or tightness it is time to get it sorted.
What is the diagnosis?
A common mantra around the practice is “diagnosis determines prognosis.” There is no overstating the importance of the vital first step – diagnosis, alongside a thorough assessment will determine best management and give realistic time frames for return to running, sport and full function.A common mantra around the practice is “diagnosis determines prognosis. #performbetter @pogophysio Click To Tweet
The ‘‘calf muscle’’ consists of three separate muscles; the gastrocnemius, soleus, and plantaris which unite to form the Achilles tendon. Differentiating strains in the gastrocnemius and soleus is particularly important for an accurate prognosis, appropriate rehabilitation (4). The gastrocnemius has a higher portion of fast-twitch muscle fibres (type 2) and crosses two joints (the knee and ankle). It is classically injured by quickly and powerfully extending the knee with a dorsiflexed (bent ankle), for example trying to accelerate quickly from a stationary start into a run. The plantaris is a small accessory muscle which also crosses the knee and ankle. It is difficult to isolate from gastrocnemius injuries without imaging and is rarely injured in isolation (4). The soleus crosses only the ankle and is largely comprised of type one slow twitch muscle ﬁbers. Soleus strains also tend to be less dramatic in clinical presentation and more subacute when compared to injuries of the gastrocnemius. The classic presentation is of lower calf tightness, soreness and stiffness aggravated by walking and running, particularly of a longer duration. Additional details from your history and clinical assessment of strength, mobility and palpation will help in determining diagnosis.
Calf strains can also present similar to other forms of lower limb pain. Some common differential diagnosis for calf injuries can include:
- Medial Tibial Stress Syndrome – often the true diagnosis behind ‘shin splints,’ it involves changes to the peristeoum (bone surface) of the lower inside border of the tibia.
- Stress fractures – following on from a stress reaction the next step in the bony stress continuum is a stress fracture. These can occur along the medial or posterior border of the tibia and can occur following spikes in lower limb loading.
- Chronic Exertional Compartment Syndrome – CECS is characterised by recurrent, often bilateral severe muscle compartment pain that occurs with exercise and subsides with rest. Often there are no other clinically significant signs such as loss of movement or strength decreases (5). Often conservative treatment is unsuccessful and fasciotomy (surgical resection of the fascia surrounding the muscle belly) is treatment of choice.
- Nerve Entrapment – The common peroneal, superficial peroneal, and saphenous nerves are most commonly at risk for entrapment. These are quite rare and are often preceded by trauma. Burning pain, sensory and/or motor (strength) changes may occur (4).
- Popliteal Artery Entrapment Syndrome – PAES is an important and often over-looked differential diagnosis in the assessment of exertional leg pain. PAES is defined as a group of conditions in which compression of the popliteal artery, popliteal vein, and/or tibial nerve, in the popliteal fossa by surrounding musculoskeletal structures occurs to a degree sufficient to cause vascular and neurogenic symptoms (6).
Recovery time frames are dependent on degree of calf injury. Healing timeframes will be influenced by grade of muscle tear; commonly referred to as either a minor partial tear (Grade 1), moderate partial tear (Grade 2) or complete muscle tear/tendon avulsion (Grade 3) (4). These classifications are based off clinical signs and symptoms, combined with diagnostic imaging (US or MRI). Recovery time frames will also be influenced by injury involvement to the musculotendinous junction, age, past history of injury and need to address contributing factors.
What are the risk factors?
Athletes, coaches, trainers and physiotherapists alike are always looking to reduce injury risk. Predictors of calf injury are tough to find in the literature. However a study by Van Middelkoop et al. found that a lower extremity injury in the previous 12 months was a risk factor for a knee injury, and that an injury at another location (hip, groin, thigh, knee, ankle, or/and foot) was a risk factor for calf injury (8). In addition to previous injury (calf or other), other factors that may increase risk of injury include; older age, calf muscle weakness, increases in training loading (find your optimal training load) or altered loading mechanics (see below).
Acute management aligns to the management of muscle injuries. Over the ﬁrst 3–5 days, muscle rest by limiting stretch and contraction, cryotherapy (ice), compressive wrap or tape, and elevation of the leg are generally recommended (4). Depending on degree of injury and pain a heel wedge or crutches may be useful. Heat, massage and NSAIDS are often avoided in early stage of management. Over the coming days to weeks strengthening and stretching are commenced. Return to running or activity is often begun after full range and strength is returned. Strengthening should be targeted to both gastrocnemius and soleus (by altering degree of knee extension), with additional focus on the injured muscle. It is then important to consider the demands of your chosen sport, do you need to work on power, endurance, multi-directional stability or particular surfaces/terrain.
How well do you know your running body? (compensations/biomechanics)
For many people a calf injury can be a simple as the above, you strain the muscle, rest then stretch and strengthen, then you get back to normal activity. In other cases the calf pain returns, it is re-injured or continues to niggle feeling tight or sore. This is where knowing your body’s biomechanics and running patterns become important. Forward propulsion can occur in three ways, you fall forward, you get pushed forward, or you push yourself forward. How do you do this? Your posterior chain – glutes (glute max with some help from glut med/min), hamstrings and calf (gastrocnemius, soleus). Changes or imbalances from left to right side can lead to one calf working harder, fatiguing quicker, tightening and resulting soreness or injury. Looking biomechanically some reasons may include:You strain the muscle, rest then stretch and strengthen, then you get back to normal activity #performbetter… Click To Tweet
- Tight hip flexors – reducing hip extension, calf is working harder for propulsion
- Glut max weakness – as above, tight at the front weak at the back, means the calf is compensating.
- Hamstring Weakness – again, propulsion is hamstrings, glutes and calf – need all three to help
- Excessive ‘bopping’ – increased vertical oscillation (up and down) – pushing ‘up’ is more challenging than pushing forward (try a single leg calf raise standing upright, then at a 30 degree lean and tell me the latter it isn’t easier?)
- Early heel rise – it may be a loss of ankle (dorsiflexion) range, midfoot stiffness, early engagement of the gastrocnemius/soleus, overactive long toe flexors, midfoot pathology forcing early heel rise to avoid pain, reduced 1st MCP joint (big toe) range – numerous strategies can cause this early heel rise, forcing more of a vertical ‘toe off’ phase, reducing the propulsive help of the glutes and again increasing calf loads.
- Anterior compartment weakness – the calf (posterior compartment) and the anterior compartment of the leg are a pair and a balance of anterior – posterior strength is needed.
So if you’re managing a first time calf injury, or an eighth make sure you know it’s your calf, strengthen it and match it to the demands of the sport. Importantly consider what contributed to it and look closer at your biomechanics, so you can say goodbye to future calf troubles.
Lewis Craig (APAM)
Masters of Physiotherapy
- MacIntyre JG, Taunton JE, Clement DB, et al. Running Injuries: a clinical study of 4,173 cases. Clin J Sport Med. 1991;1:81-87
- van Gent R, Siem D, van Middelkoop M, van Os A, Bierma-Zeinstra S, et al. (2007) Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. Br J Sports Med 41: 469–480. PMID: 17473005
- Brewer, R. B., & Gregory, A. J. (2012). Chronic Lower Leg Pain in Athletes A Guide for the Differential Diagnosis, Evaluation, and Treatment. Sports Health: A Multidisciplinary Approach, 4(2), 121-127.
- Dixon, J. B. (2009). Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries. Current reviews in musculoskeletal medicine, 2(2), 74-77.
- Shah, S. N., Miller, B. S., & Kuhn, J. E. (2004). Chronic exertional compartment syndrome. American journal of orthopedics (Belle Mead, NJ), 33(7), 335-341.
- Hislop, M., Kennedy, D., & Dhupelia, S. (2014). Functional popliteal artery entrapment syndrome: A review of the anatomy and pathophysiology. Journal of Sports Medicine & Doping Studies, 2014.
- Van Middelkoop M, Kolkman J, van Ochten J, Bierma-Zeinstra S, Koes BW (2008) Risk factors for lower extremity injuries among male marathon runners. Scand J Med Sci Sports 18: 691–697. doi: 10. 1111/j.1600-0838.2007.00768.x PMID: 182667