Have I strained, pulled or torn my calf muscle?

The calf is the main muscle which runs from the back of the knee inserting into the heel via the Achilles. The calf is often injured in sports and there are various pathologies that can present as a calf injury. People will typically feel a tightness in the back of the calf or even sometimes the more severe pain or sudden pop in the back of the calf and are unable to carry on playing sports.

Not the calf?

One of the diagnoses you need to rule out that masquerades as calf pain is referred pain from the lumbar spine. Many times, patient’s for complain of recurrent calf strains where they feel a tightness or a pain in the back of the calf, however over a few days this resolves and they can continue with their sporting activities again. This is not likely to be a true calf injury and simply assessing the lumbar spine and performing a slump and a straight leg raise test will help to rule out if this is nerve compression that is then causing the calf pain. If it is referred from the lumbar spine then directing treatment here with mobilisation, nerve glides and core stability exercises will help.

True calf injury

When we think about true calf pain there are several structures that can be injured namely:

• The gastrocnemius muscle
• The soleus muscle
• The plantaris tendon
• The Achilles tendon

Each will present slightly differently.

Management of calf injuries

It’s always important to rule out an Achilles tendon rupture as this is slightly more of an emergency and would need to be seen in A&E to prevent any long-term problems. People that have ruptured an Achilles often described feeling and hearing a pop in the bottom of the calf when they try to accelerate or jump such as taking a basketball shot or volleyball shot. They will often be unable to continue playing sport but may be able to lamp off and get themselves home. It’s very important that you check the integrity of your Achilles tendon and working from the heel bone you should be able to feel whether the Achilles tendon is intact until the lower mid leg. This is usually quite easily assessed by a healthcare professional by performing simple test like a calf squeeze test which should make the foot move. In an Achilles rupture the foot will not move. We can also ultrasound scan the Achilles tendon and identify the site and size of the rapture. This injury will require you to be placed into a boot with wedges and you will also need crutches to walk. This injury may also need surgery and this is a discussion with a surgeon based on the severity of the rupture and whether there is a large gap between the tendon stumps or not. Rehabilitation from an Achilles rupture will around 6-9 months.

Two less serious injuries that can also present as a severe tightness to a sudden pop in the back of a calf or a plantaris tendon rupture and a significant medial gastrocnemius muscle strain (also termed tennis leg). These can be very nicely assessed on ultrasound as we can see the damage to the medial gastrocnemius muscle and whether the plantaris tendon is intact or not. We can determine the type and severity of injury using an ultrasound scan. Depending on the severity of the injury this may also need to be managed with an aircaist boot and crutches as if there is a large intramuscular haematoma it may need to be aspirated under ultrasound guidance. A low-grade calf strain may take 4-6 weeks to recover from, however a significant strain or plantaris tendon rupture may take 10-12 weeks to recover from.

Perhaps the least commonly injured muscle is the soleus muscle. This is often tricky to diagnose as due to the muscle type. You can sustain a reasonably significant injury but can start to feel better quite quickly and you are able to move and even do a little activity. However, it is not fully healed and cannot sustain high-level activity and will re-injure quite easily. The soleus muscle injury is very difficult to see on ultrasound with only about 30% of them being visible, so having an MRI would be the imaging of choice for a soleus muscle injury. Research shows that solues muscle injuries take longer than gastrocnemius strains with some injuries take 10-12 weeks to resolve.

Regardless of the Injury you will need to be seen by a physiotherapist who will give you acute injury management advice such as ice and pain medication, some manual therapy where required and you will certainly need to be guided back to your sport with a progressive rehabilitation program.