// Common injuries - Calf strain
by Paul Wright
As an operator of physiotherapy clinics inside health clubs, I
frequently see members limp out of a class half way through, or a
trainer bring a client to the clinic desk with sudden calf pain.
Causes of calf pain can include muscle cramp, delayed onset muscle
soreness (DOMS) and referred pain from the lumbar spine. By far the
most common cause of pain in the lower leg, however, is a strain to the
musculotendinous complex of the gastrocnemius and/or soleus.
In the fitness industry calf tears often occur in typical personal
training activities such as shuttle runs (requiring rapid acceleration
and change of direction), split jumping (where one leg is thrust
backwards on landing), incline running and sprinting. This injury is
common in boxing sessions where participants are jumping and hopping on
their toes and also in beach-based Boot Camp activities during hill
work, due to the unstable surface provided by the sand and the intense
muscle work involved.
Group exercise is often cited as a cause of calf injury, with step
classes (usually on stepping down and pushing the rear leg down to the
floor and then pushing off to complete the next step) and high impact
classes being mentioned when taking patient histories. These injuries
often occur towards the end of the class due to muscle fatigue or a
loss of technique.
ANATOMY AND PHYSIOLOGY
The term ‘calf muscle’ is used to describe the gastrocnemius and soleus
muscle complex. The gastrocnemius is more superficial than the soleus,
with its two heads (medial and lateral) arising from the femoral
condyles and eventually inserting into the Achilles tendon. The deeper
Soleus muscle originates on the tibia and fibula and also inserts into
the Achilles tendon, which goes on to attach into the calcaneous or
‘heel bone’.
Because the gastrocnemius crosses the knee joint as well as the ankle
joint, it is classified as a ‘biarthrodial’ muscle. The complex
interaction of muscles acting over more than one joint is one of the
reasons the gastrocnemius is more commonly injured than the
uniarthrodial (crossing only one joint) soleus muscle.
SIGNS AND SYMPTOMS
Calf muscle strains occur more commonly in the medial head of the
gastocnemius than in its lateral head or the soleus. A common scenario
is one where the patient has tried to accelerate suddenly from a
stationary position and then felt a sharp, stabbing pain in the back of
the lower leg. Patients often say that upon feeling this sensation they
quickly swing around to see who has kicked them in the calf.
Examination will reveal tenderness localised to the site of the tear
and, if severe, a palpable defect or gap may be felt. Stretching of the
gastrocnemius will also reproduce pain, which is why the patient will
usually walk with the foot turned outwards as this limits ankle
dorsiflexion and reduces the need to dorsiflex the ankle while walking.
A significant number of people do not experience the sharp, stabbing
pain associated with the typical calf strain, instead reporting a
sensation of intermittent cramping during exercise. This ‘cramping’
sensation is often due to recurrent minor calf tears which can be
linked back to old scar tissue from a previous (and more severe) calf
tear. This scar tissue is common in patients who have not undergone
adequate rehabilitation following their initial calf injury.
The fitness professional must be aware that the ‘cramping’ feeling may
not be a typical cramp that can be stretched out, thereby enabling the
exercise to continue. The client should be asked about past calf injury
history as continuing to exercise this body part can lead to a more
severe injury occurring. It is advisable for the trainer to stop any
exercise that involves the calf area and seek advice from their local
physiotherapist or sports physician.
MANAGEMENT
As with all episodes of pain it is essential the client is examined by
a physiotherapist or sports physician as soon as possible. The medical
professional will evaluate the extent of the injury, outline an
approximate time line for rehabilitation, and exclude any more serious
problems such as achilles tendon rupture, lumbar spine referral and
deep venous thrombosis (DVT).
Once the calf strain is diagnosed and other problems excluded, initial
management will aim to reduce pain and swelling. This is best achieved
with ice, elevation and compressive bandaging. The patient may also
benefit from a small heel raise in the shoe to prevent excessive
stretching of the calf when walking – females will typically be more
comfortable in shoes with a moderate heel raise.
Gentle stretching to the point of a sensation of tightness and muscle
strengthening can begin after the first 24 hours. The exercise
progressions commence with bilateral concentric calf raises and
gradually progress to unilateral concentric (see photo 1), addition of
weight and finally bilateral and unilateral eccentric lowering over the
edge of a step. Final stage rehabilitation will involve plyometric and
sports-specific drills to ensure complete recovery prior to returning
to sport. Soft tissue therapy is an important component of the
management plan as residual scar tissue can lead to long term problems
and injury recurrence.
Biomechanical factors may play a role in increasing the risk of calf
injury and need to be evaluated to ensure complete recovery. The most
common factors include increased subtalar joint pronation and also any
reduction in the available range of ankle dorsiflexion. The ‘Lunge
Test’ is a very useful screening tool for the assessment of ankle
dorsiflexion (see photo 2).
It is important that the fitness instructor seek medical assistance in
the management, rehabilitation and prevention of this injury as it is
common for this condition to become a recurrent problem which severely
impacts upon the patient’s exercise program.
Paul G. Wright, BAppSc (Physio), DipEd. (PE)
Paul is a leading health educator and director of Get Active
Physiotherapy with clinics inside Fitness First Clubs at St Leonards
(Sydney), Kotara (Newcastle) and the CBD of St Leonards. He has
produced a series of injury prevention and training DVD’s for fitness
professionals. For more information, visit www.getactivephysio.com.au or call 02 9966 9464.
NETWORK • AUTUMN 2008 • PP59-60