A guide to calf tears and strains
Have you ever felt an unnerving “pop” at the back of your leg when running or even down from a low step
Or maybe you get tighter calves when running rather than sudden acute pain.
Calf muscle injuries are relatively common occurring in many sporting situations that require sudden acceleration and deceleration. They also occur in day to day activity, especially when making a sudden change in direction or stepping down of a height.
Despite being fairly common they can be difficult to manage due to their role in standing, walking and running. They also tend to be a bit slower regarding healing times.
Calf muscle anatomy
Sometimes referred to as the triceps surae complex, the calf muscle is actually a complex of three muscles:
- Gastrocnemius, outer muscle. Lies across the knee joint and ankle joint. Most vulnerable to injury.
- Soleus, inner muscle lying behind gastrocnemius. Crosses the ankle joint only.
- Plantaris, small thin muscle that has a short muscle belly and long tendon. Sandwiched between gastrocnemius and soleus.
Gastrocnemius and Soleus muscles.
The main action of these muscles is to plantar flex or point the foot. Since the gastrocnemius crosses the knee joint it is also involved in flexing the knee.
Both muscles have a large cross sectional area and are involved in being able to accelerate and decelerate the body, ( mainly gastrocnemius) and also in sudden change in direction such as cutting left or right, ( mainly soleus).
Recent studies have shown that soleus involvement as the main muscle injured is about 85% of all calf strain presentations.
This is not only important in sport but also in daily life especially if we suddenly have to get out of the way of an obstacle in our path.
is present in about 80% of the population and may have more of a role in perception of movement at the ankle and knee rather than a producer or absorber of force.
These muscles blend into the Achilles tendon and have a clever connective tissue framework within them known as an aponeurosis. This tendon and aponeurosis structure attaches to the heel and blends in to the plantar fascia.
Role of the calf muscles in running and walking.
- Help us plantar flex the foot to push off the floor / ground . This is important in propelling us forwards when running and walking.
- The main action of these muscles is to plantar flex or point the foot. Since the gastrocnemius crosses the knee joint it is also involved in flexing the knee.
- They absorb ground reaction forces, when the foot hits the ground in walking about 50% of force is absorbed by the gastrocnemius and the rest by the soleus muscle.
- The connective tissue component of the muscles,(aponeurosis), is designed to help distribute the absorbed forces throughout the muscle complex helping reduce injury and store energy for forward propulsion.
Calf muscle tear diagnosis.
In acute calf injuries there is usually a sudden onset in pain often associated with a sudden change in action at the foot and ankle. This can be a simple as suddenly having to step out of the way of an oncoming object, starting to increase pace when running or jumping and landing.
Grading and Treatment of calf tears.
Grade 1 Calf tear.
- Pain during or after activity
- ROM normal at 24hr
- Normal power and initiation
- Pain on contraction
- Myofascial – injury in the peripheral aspect of the muscle
Grade 2 Calf tear.
- Pain during activity and restricts participation
- Limitation with ROM
- Pain on contraction
- Reduced power on testing
- Musculotendinous – Injury within the muscle belly most commonly at musculotendinous junction (MTJ)
Grade 3 Calf tear.
- Extensive tear
- Sudden onset of pain
- Significantly reduced ROM
- Pain on walking
- Obvious weakness on testing
- Intratendinous – An injury which extends into the tendon
Grade 4 Calf tear.
- Sudden onset of pain
- Significant limitation to activity
- Palpable gap in muscle
- May be less painful than Grade 3
- Complete tear of muscle or tendon
Best way to manage an acute calf tear or strain.
If you have just suffered a calf tear or strain you should go straight here to get info on how best to manage this injury:
Who is most at risk of a calf strain or tear ?
Here are the risk factors for calf related injuries :
- Age: As we get older there is a change in the size and length of the calf muscles. This means they are not as effective as force absorbing / power generating structures they are designed to be.
- Previous history calf injury: This is a quite strong predictor and unfortunately comes back to either not rehabbing the first one well enough.
Alternative Diagnosis for calf pain.
There are other conditions that create pain in the calf that need to be excluded when presenting with calf pain.
Biomechanical overload syndrome
Calf pain that gradually develops with exercise may be more acurately defined as biomechanical overload syndrome.
This is based on the idea that pain is caused by fatigue failure which occurs when a muscle is overloaded due to lack of strength endurance and inefficent running mechanics. The treatment of this is to try and improve the running biomechanics as well as increasing the strength endurance of the calf muscle complex and lower limbs to tolerate repetitive loading, i.e running.
It is not unusual to find individuals with acute calf pain that it is actually due to a sensitized tibial nerve rather than a tear in the muscle.
This can be a result of a local injury to the area, ironically can be a calf tear, or it can be related to issues in the lumbar spine that sensitize the nerve and cause the painful symptoms.
Unlike a calf tear the pain in this presentation is more likely indicating that the tissue is hurting rather than any damage being done and hopefully resolves faster than an actual tear with appropriate management.
Baker’s cysts are a relatively common finding in athletes presenting with intra-articular knee pathology. They usually develop in the postero-medial popliteal fossa due to the lack of anatomic support in this area of the synovial capsule and can often be seen as a swelling at the back of the knee. They are not really a cyst but more a swelling of the knee capsule.
If the “cyst” ruptures this can create swelling and pain in the calf which usually improves with time and appropriate management.
Calf tears and Deep Vein Thrombosis, (DVT)
DVT on the left leg. Red, swollen and firm
DVT is another potential vascular cause of calf pain, which must not be missed. Symptoms in the calf will be red, hot, firm, swollen and tender to touch.
It usually occurs after surgery or following a period of immobilisation, but can also present in association with calf injuries. This is due to a combination of lack of movement, disuse of the muscle pump, and the compressive effect of swelling on the blood vessels.
Likely hood of a DVT can be assessed using the Wells score for DVT
A score of 3 or higher is an indicator of high risk of DVT
A score of 1- 2 is an indicator of moderate risk of DVT
A score of 0 is an indicator of low risk of DVT
If your score indicates you have a risk factor for DVT then additional testing is required to assess for presence of a clot.
Exercises for calf tears,
See how best to manage calf tears and get back to running in our next blog
If you have suffered a calf tear or have a history of calf problems you can book in to see one of us here
For more information surrounding this topic check out the running physio blog on calf tears here