Unfortunately, injuries are a part of sport. Whether you’re a weekend warrior or a professional athlete, chances are you’ve experienced the frustration and pain that comes with an injury. Calf injuries are particularly common, often occurring suddenly during activities that involve running, jumping, or rapid changes in direction. These injuries can range from mild strains to severe tears, significantly impacting your ability to participate in sports and daily activities. Understanding how to properly diagnose and manage calf injuries is critical for a quick recovery and to prevent future issues.
Understanding Calf Strains
The calf muscles, located at the back of the lower leg, consist of two primary muscles: the gastrocnemius and the soleus. These muscles play a vital role in activities involving leg movement, such as running, jumping, and rapid changes in direction. Unfortunately, they are also susceptible to injury due to their involvement in almost all athletic movements. The soleus is highly active at all speeds of running, while explosive movements like accelerating and jumping place a heavy demand on the gastrocnemius muscles.
Grades of Injury
Calf injuries, like most muscle injuries, are generally categorised into three grades:
• Grade 1: Mild strain with minimal fibre damage and discomfort.
• Grade 2: Moderate strain with partial tearing of muscle fibers, resulting in pain, weakness, and limited mobility.
• Grade 3: Severe strain or complete tear, causing intense pain, significant loss of function, and difficulty walking or bearing weight.
There are also subtleties within each injury grade which can influence recovery time. The following two characteristics are thought to influence time taken to return to unrestricted activity:
Myofascial Injury: A myofascial injury typically involves the sleeve surrounding the muscle, without actual involvement of the muscular tissue itself.
Myotendinous Junction and/or Muscular Injury: This injury refers to an injury to the muscle fibres and/or the junction where the muscle transitions to tendon.
Connective Tissue Injury: Dense connective tissues form a scaffold to support the muscle fibres within the calf. This scaffold is composed of the epimysium, the connective tissue sheath surrounding the muscle, and the aponeuroses, a tough, fibrous sheet-like structure that connects the calf muscles to the Achilles tendon. This structure is important in distributing the force generated by the muscles during movement, The integrity of this aponeuroses scaffold is therefore vital for the calf muscle to function normally. Injury to this structure in particular is often associated with a longer to healing time and may have a higher risk of recurrence.
Identifying these subtleties can be especially useful for individuals participating at a high level of sport where it’s critical to minimise missed games or events due to injury. These can be identified with a medical imaging and can then be used to inform management decisions.
Consideration should also be given to the specific muscle involved. This will influence rehab exercise selection and the time needed to recover and safely return to training and competition. Clinical testing by an experienced sports physio or sports doctor can give a reasonably accurate indication of which muscles are involved. These muscles include:
The Gastrocnemius: The Gastrocnemius muscle is the larger, more superficial muscle in the calf. Gastrocnemius tears typically cause sudden pain and are sometimes accompanied by a popping sensation. This muscle is divided into a medial and lateral part, with the medial part most commonly injured.
The Soleus: The Soleus muscle is a deeper calf muscle that lies beneath the gastrocnemius. Strains in the soleus are often characterised by a more insidious onset, with athletes often describing a gradual onset of symptoms during physical activity.
Mixed: Sometimes, both the Gastrocnemius and the Soleus are involved.
Other Considerations
There are other structures which share the posterior compartment of the leg. These should also be considered when pain arises in this area of the body, with the most common being:
Plantaris Tendon: The plantaris tendon is a small but non-essential tendon located behind the knee which runs down the middle to inside of the lower leg.
Achilles Tendon: The Achilles tendon is a strong fibrous cord that connects the calf muscles to the heel bone. It plays a vital role in walking, running, and jumping.
Flexor Hallucis Longus Muscle: The Flexor Hallucis Longus muscle is a deep muscle that runs from the back of the leg across the inside of the ankle, under the foot, and to the big toe. It functions to flex and stabilise the big toe.
Medial Tibia (Shin Splints): Shin splints, also known as medial tibial stress syndrome, is a common condition characterised by pain along the inside of the shinbone (Tibia).
Vascular: Deep Vein Thrombosis (DVT) is a condition where a blood clot forms within a deep vein, typically in the leg. It can cause pain, swelling, and redness in the affected area. This condition can develop after surgical procedures, long plane flights, and, less commonly, without an obvious cause.
How Would A Different Diagnosis Influence My Recovery?
Each structure requires a specific, targeted rehabilitation plan and carries a different recovery time and risk of re-injury. This makes an accurate initial diagnosis critical, especially with any indication of a more severe injury/condition requiring immediate medical attention such as an Achilles Tendon rupture or DVT.
Diagnosing a Calf Strain
Signs and symptoms of calf injuries can vary depending on the specific type and severity of the injury. One common indication is pain localised in the calf muscle or along the back of the leg. This pain can range from mild discomfort to a sharp, intense sensation that worsens with movement. Swelling, tenderness, and bruising in the affected area may also be present. In more severe cases, individuals may experience difficulty walking or bearing weight on the injured leg. Additionally, calf injuries can manifest as a popping or tearing sensation at the time of injury, accompanied by a sudden inability to continue exercising or participating in sporting activities. A skilled sports physio can often diagnose with good accuracy the presence of a calf injury through a physical assessment and discussion of how it happened. Typical signs that may indicate a calf muscle strain are:
Loss of Strength: Loss of strength due to pain and/or weakness when testing the calf muscle.
Loss of Range of Motion: Loss of range of motion at the ankle due to pain and tightness in the calf muscle.
Mechanism of Injury: A clear mechanism e.g. pain onset in the back of the leg during of just after activity increases the likelihood of a strain being the cause of pain.
Should I get a scan?
There are a number of factors to consider when deciding if a scan is necessary. With the understanding that each structure in the lower leg carries with it a different prognosis, it highlights the importance of an accurate diagnosis, and this is where medical imaging may be required. The following questions should be asked:
Is there any indication of a severe injury/condition requiring immediate medical attention such as a ruptured achilles tendon or a DVT?
Has the injury occurred in a professional or semi-professional athlete that needs an accurate diagnosis to ensure a return to sport as quickly and safely as possible?
In either of these cases, imaging techniques such as ultrasound or magnetic resonance imaging (MRI) by an appropriately trained and experienced health professional should be undertaken.
Why did it happen?
Calf injuries can occur due to various factors. Those that have been proven to have a significant contribution to injury include:
Sudden increase in activity level or intensity
Overtraining (training or exercising more than your body can recover from)
Under-training (not preparing your body adequately for the demands of your sport or activity)
Inadequate warm-up routine
Calf muscle weakness
Prior history of calf injury
Age (older = increased risk)
Insufficient recovery
Some factors which may contribute to the occurrence of a calf injury include:
Inefficient biomechanics/running technique
Improper footwear
Muscle imbalances around the ankle, knee, hip and core
Impaired calf flexibility
An appropriate management plan should consider these factors and implement strategies to mitigate future risk as best as possible.
Calf injuries can be very frustrating, leading to unwanted time on the sidelines. By understanding the causes and getting an accurate diagnosis, an appropriate rehab plan can then be implemented. Keep an eye out for a future article which will discuss the principles of managing a calf injury to return to sport.
If you're currently experiencing pain related to a calf injury or have a history of recurrent calf strains, engaging with a health professional with an intricate understanding of the above factors should be your first step to recovery. Feel free to reach out to us on 0415 889 903 or send us an email at hello@prosportphysio.com.au to schedule an appointment for a thorough assessment and personalised plan.
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