// 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