Calf Pain: Causes, Symptoms, Treatment and Prevention

Calf pain is a common problem among athletes, especially runners or any sports that involve jumping, or stop and go. It occurs in varying degrees of pain and recovery time. For some, the calf tension affects them when they start to run but goes away during the run, or the tension turns into excruciating pain after a certain distance and they have to stop. So, what causes the pain and what can you do to prevent it?

Anatomy and function of calf muscles

The calf muscle consists of 3 muscles: medial gastrocnemius, lateral gastrocnemius, and the soleus. All of these muscles unite to form the Achilles tendon which attaches to the calcaneus (heel bone). Both of the medial and lateral gastrocnemius originates on the femur (thigh bone), where as the soleus originates from the back of the tibia (shin bone). The major role of the calf muscles is to plantarflex the foot at the ankle joint (pin the foot down). The gastrocnemius also assists to bend the knee.

Causes of calf pain

There are many reasons for calf pain but tight calf muscles tend to be the most common, especially among athletes. Tightness can be linked to various other causes.

Lack of flexibility and muscle imbalance throughout the body
Fatigued calf muscles
Inappropriate footwear
Running form

Lack of flexibility and muscle imbalance throughout the body

Our body is a kinetic chain. If the hip musculature is tight, the calf muscles may have to compensate and be under more load/stress. The most common and important muscle called the iliopsoas is often tight among people that sit often for work. This results in weak gluts and lack of hip extension, which leads to increased load on calf muscles for propulsion. To learn more about this negative cascading effect, click on this link.

Fatigued calf muscles

There are many reasons for calf pain but tight calf muscles tend to be the most common, especially among athletes. Tightness can be linked to various other causes.

Lack of flexibility and muscle imbalance throughout the body
Fatigued calf muscle
Improper footwear
Poor running technique

Improper footwear

Would you ever consider driving a car with Nascar tires in the winter in Minnesota? Same principle applies for wearing the correct footwear for your body. The most common problem in runners is overpronation. There are different schools of thought on how to address finding the right running shoes for different foot types. Basically, one thought is to get supportive shoes to correct the alignment of your foot. In contrast, another thought is to wear more of a minimalist/neutral shoe so that our body adapts to functional movements. By allowing our body’s neuromuscular system to achieve efficient control of the intrinsic and extrinsic foot muscles, we can be less dependent on the typical modern running shoes with a heel drop of 12mm. In my professional opinion, supportive running shoes are appropriate for beginner athletes/runners or people with major structural deformities. However, for the advance athlete/runners without impairments, I encourage allowing our body to utilize it’s neuromuscular system to adapt itself to the environment.

Also, wearing high heels daily contributes to tight calf muscles.

Poor running technique

This topic can be a book in itself. Most of us run however feels natural to us. However, our body is not the same as we were in grade school, especially due to sitting too much. Many people suffer calf pain and strain due to poor running form. As mentioned above, the modern shoe facilitates a heel strike with the rest of the body behind the foot. Fortunately, more and more shoe companies have introduced lower heel to toe drop shoes which promote landing on the mid and forefoot rather than the heel. This is a good start. However, many people suffer from increased calf pain, Achilles tendonitis, and metatarsalgia (forefoot pain) when they switch shoes because they are still running the same way except now, there’s more load of the calf muscles. Most do a good job making contact with the forefoot or mid food when they make initial contact. However, the rest of the body is still far back when the foot lands on the ground, causing increased stress and load onto their calf muscles. Furthermore, they are still used to pushing off with the toes causing increased stride length, which leads to more strain on the Achillies tendon and calf muscles.

Most likely, if you are a high level athlete, these transitional symptoms won’t occur at all or they will occur later down the road when the volume increases with incorrect form. However, I highly recommend that new runners work with a running specialist to re-learn how to run correctly.

Gastrocnemius strain vs Soleus strain

Muscle strains are often the result of pulled or torn muscle fibers. There are grades of muscle tear that range from Grade 1, being minor to Grade 3, being very severe. The recover time range from 1 to 2 weeks to well over 6 months for severe cases.

Most calf strains are found in the medial head of the gastrocnemius. It is a high risk for strains because the muscle crosses two joints (the knee and ankle) and has a high density of fast twitch muscles fibers (TYPE II) which are better for short bursts of speed and power but fatigue faster. The gastrocnemius muscles are easily susceptable to being overworked as mentioned in the “Causes of Pain” section, thus resulting in a strain.

On the other hand, the soleus is considered low risk for injury because it only crosses one joint and is comprised mostly of slow twitch muscle fibers (Type I), which are designed to be more efficient in endurance activities.

Differentiating calf muscle strain

If you you have calf pain, how do you know which muscle is injured or strained? Based on the anatomy discussed earlier, when the knee is bent, the soleus becomes the major muscle when resisting plantarflexion. Meaning, if you do a calf raise with the knee bend, the soleus is the primary muscle working. On the other hand, if the knee is completely straight, the gastrocnemius is the primary muscle causing plantarflexion. So, if you perform a calf raise with the knee straight, the gastrocnemius is providing greater contribution to this movement.

Same principle applies for eliciting pain and flexibility of the calf muscles. When the ankle is passively dorsiflexed (toes pointed up) with knee straight, the gastrocnemius is placed in the most taut position to be stretched. Whereas if the knee is bent, the soleus is being stretched. Using this technique determines the site of injury and applies to stretching and strengthening.

These two tests along with palpation and clinical history can help to distinguish between the two muscles.

Treatment

Early and accurate diagnosis is appropriate to treat calf strain without delay. Premature return results in prolonged recovery and re-current calf strains. Acute treatment of calf strain consists of muscle rest, ice, heat after 48 hours, heel wedge, and wrap. After the acute state, rehabilitation can consist of:

Wearing a night splint
Wearing a boot for moderate to severe strain
Gentle active range of motion of the ankle
Acupuncture
Passive and active intermuscular and fascia release
Stretching (See below)
Cupping
Foam rolling
Isometric strengthening progressing to eccentric strengthening and dynamic training

When to seek care

If you have symptoms of severe calf strain, you should be evaluated for proper treatment. These signs include:

Difficulty walking
Pain while sitting or at rest
Pain at night

Severe calf strains should be evaluated because early because in some very rare situations of complete muscle rupture, surgery may be necessary to reattach the torn muscles. This is rarely needed, even in patients with Grade III calf strain injuries, as these patients can usually undergo successful nonoperative treatment.

If you are unsure if you have a calf strain or the symptoms do not quickly resolve, you should seek medical care immediately.

Prevention

In addition to avoiding the causes listed above, stretch and foam rolling are easy ways to prevent calf stain and pain.

Soleus stretch

Keep back leg slightly bent and heel flat on floor. Lean into wall until stretch is felt in the lower calf. Hold for 30 seconds and repeat 3 times.

Gastrocnemius stretch

Keep back leg straight and heel flat on floor. Lean into wall until stretch is felt in the lower calf. Hold for 30 seconds and repeat 3 times.

Foam rolling

Summary

Calf strain injuries occur often in middle-aged athletes and weekend warriors. Luckily, most symptoms of calf strain settle down quickly with proper treatment. Complete healing of a calf muscle injury can take several months, but the vast majority of people are able to return to most activities much sooner. Premature return to sports can result in re-current calf strain.

If you are currently suffering from calf pain and want help immediately or have any questions, visit us at www.fpphysicaltherapy.com.