Calf muscle tears and their diagnosis.

Ever felt an unerving "pop" at the back of your leg when running or even down from a low step ? Maybe you get tighter calves when running rather than sudden acute pain.

Calf muscle injuries are relatively common occuring 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.

Unfortunately they can be difficult to manage in the early stages due to their role in standing, walking and running and also they do tend to be a bit slower regarding healing times.

First some calf muscle anatomy

Sometimes referred to as the triceps surae complex, the calf muscle is actually a complex of three muscles:

  1. Gastrocnemius, outer muscle. Lies across the knee joint and ankle joint. Most vulnerable to injury.

  2. Soleus, inner muscle lying behind gastrocnemius. Crosses the ankle joint only.

  3. Plantaris, small thin muscle that has a short muscle belly and long tendon. Sandwiched between gastrocnemius and soleus.

Plantaris 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 achillies tendon and have a clever connective tissue framework within them known as an aponneurosis.

gastrocnemius and

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.

Role of the calf muscles in running and walking.

  1. Help us plantar flex the foot to push off the floor / ground . This is important in propelling us forwards when running and walking.

  2. 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.

  3. They absorb ground reaction forces, when the foot hits the gound in walking about 50% of force is absorbed by the gastrocnemius and the rest by the soleus muscle.

  4. 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 sudddenly 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

Pain during or after activity

ROM normal at 24hr

Normal power and initiation

Pain on contractionMyofascial - injury in the peripheral aspect of the muscle

Grade 2

Pain during activity and restricts participation

Limitation with ROM

Pain on contraction

Reduced power on testingMusculotendinous - Injury within the muscle belly most commonly at musculotendonous junction (MTJ)

Grade 3

Extensive tear

Sudden onset of pain

Significantly reduced ROM

Pain on walking

Obvious weakness on testingIntratendinous - An injury which extends into the tendon

Grade 4

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

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.

Neural sensitization.

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.

Bakers cyst.

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.

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

Wells score for DVT

Next time we will look at the management of acute calf tears through to return to sport / activity.

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