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Calf Strain

A pulled calf muscle, also known as a calf strain or torn calf muscle, is an injury to the muscle rather than ligaments as occurs in a sprain. In a calf strain, the muscles are overloaded and overstretched, causing tearing and swelling. Symptoms of a pulled calf muscle can depend on the severity of the injury. A mild strain can leave you with pain and feelings of pulling within the lower half of your leg. You can still walk with a mild strain, but it may be uncomfortable. In the less severe cases, it usually takes up to three days for a pulled calf muscle to start feeling better. In the most severe cases that don’t require surgery, a full recovery may take up to six weeks. In the case that the injury requires surgery the recovery period may extend up to six months to a full year.

Other Names

  • Gastrocnemius Strain
  • Soleus Strain
  • Plantaris Strain
  • GSC Strain
  • Calf muscle strain injuries (CMSI)
  • Tennis Leg
  • Posterior calf injury
  • Calf tear

Causes

  • This page refers to strains and tears of the Calf Muscle Group
    • Achilles Tendonitis, Achilles Tendon Rupture are discussed separately
  • In Soccer players
    • In one study of professional players, 1.32 strains per 1000 exposure hours
    • Among European soccer players with lower extremity injuries, calf strains represented 12% of cases
  • Australian rules football
    • 3 cases per club per season, 16% recurrence rate
    • Second most common muscle injury
  • Tennis
    • Prevalence of 5.2% in collegiate standard players
  • General
    • One of the highest soft tissue injuries and recurrences in sports
    • Common when muscles are not warmed up properly or are fatigued significantly
    • 20% of patients report prodromal symptoms
    • Most common in gastric at myotendinous junction of the medial head
  • Common in sports involving
    • High speed running
    • High volumes of running load
    • Acceleration and deceleration
    • Fatiguing conditions
  • Mechanism of injury
    • Sudden extension of knee with a foot in dorsiflexion, active plantarflexion
    • Examples include sprinting, jumping
  • Strain vs Tear
    • Strain refers to the biomechanical description of the injury
    • Tear describes the structural injury to the muscle fibers

Gastrocnemius strain

  • Most common in the medial head, often referred to as ‘Tennis Leg’
  • Higher risk because it crosses two joints (diarthrodial or biarticular), the knee and ankle
  • The high density of fast-twitch, type 2 muscle fibers
  • More common in middle-aged, poorly conditioned, physically active patient
  • Occurs with the knee in extension and simultaneous dorsiflexion of the ankle
  • Eccentric load of lengthened gastroc can lead to myotendinous injury

Soleus strain

  • Likely under-reported as often lumped with gastrocnemius or calf strain
  • Lower risk as it only crosses the ankle joint has slower twitch type 1 fibers
  • Less dramatic injury pattern, more subacute
  • Tend to occur from overuse with the ankle passively dorsiflexed while the knee is flexed

Plantaris strain

  • Considered largely vestigial, rarely involved in calf strains
  • Isolated strains are difficult to distinguish clinically
  • Occur with eccentric load and forceful dorsiflexion

Pathoanatomy

  • Calf Muscle (Triceps Surae)
    • Consists of 3 muscles: Gastrocnemius, Soleus, and Plantaris
    • These muscles are responsible for plantarflexion of the ankle
  • Achilles Tendon Rupture
  • Acute Compartment Syndrome
  • Thrombophlebitis
  • Sports
    • Soccer
    • Rugby
    • Australian Rules Football
    • Tennis
    • Pole Vault
    • Professional Dancers
    • Triathletes
  • Occupational
    • Military Training
  • Intrinsic
    • Increasing age
    • Previous calf injury
    • Previous ‘lower leg, knee, thigh, ankle/foot and back’ injury
    • History of a Lumbar Radiculopathy of L5
  • Extrinsic
    • Training volume
    • Overtraining/ fatigue
  • Fractures & Dislocations
    • Tibial Shaft Fracture
    • Fibular Fracture
    • Tibial Stress Fracture
    • Fibular Stress Fracture
    • Proximal Tibiofibular Joint Dislocation
  • Muscle and Tendon Injuries
    • Calf Strain
    • Calf Tear
    • Peroneal Tendon Injuries
    • Achilles Tendonitis
    • Achilles Tendon Rupture
    • Syndesmotic Sprain
  • Nerve Injuries
    • Peroneal Nerve Injury
    • Sural Nerve Injury
    • Saphenous Neuritis
  • Other
    • Medial Tibial Stress Syndrome
    • Acute Compartment Syndrome
    • Chronic Exertional Compartment Syndrome
    • Popliteal Artery Entrapment Syndrome
    • Ruptured Bakers Cyst
  • Pediatric Considerations
    • Tibial Tubercle Avulsion Fracture
    • Tibial Tuberosity Apophysitis
    • Toddlers Fracture (Tibial Shaft Fracture)

Symptoms

  • History
    • Patients typically report a sudden onset of injury or pain
    • Often describe a “pop” that feels like someone kicked the back of the leg
    • Trouble weight-bearing, inability to continue playing sport
    • Gets worse with walking, jogging, running, jumping, or any plantarflexion activity
  • Physical Exam: Physical Exam Leg
    • In more severe injuries, swelling and ecchymosis may be present
    • Palpate along with the entire muscle including proximal attachments, belly, and into the Achilles
    • Palpable defects suggest a more severe injury
    • Gastroc tenderness is commonly at the medial belly or musculotendinous junction
    • Soleus strains are more commonly tender laterally
    • Knee in flexion: Soleus provides most of the plantarflexion (can isolate to this muscle)
    • Knee in extension: Gastroc provides most of the plantarflexion (can isolate to this muscle)
    • Inability to do single-leg raise on the affected leg
  • Special Tests
    • Thompson Test: squeeze calf to reproduce plantarflexion (exclude Achilles tendon injury)

Diagnosis

Radiology

  • Standard Radiographs Tib Fib, Standard Radiographs Ankle
    • Not typically need to make diagnosis
    • Screening tool when other pathology is being considered

Ultrasound

  • General
    • Useful early one when the exam is difficult due to pain and swelling
    • Can be performed rapidly after injury to consider the broader diagnosis
    • Can trend recovery and stage the healing process
  • Findings
    • Disruption of the normal regular linear echogenic and hypoechogenic appearance of tendon components
    • Hematoma may be present (hypoechoic or anechoic fluid collection)
    • Increased doppler flow suggests acute inflammation
  • Plantaris tear
    • May show fluid collection or defect in the plane between the medial head of gastroc and soleus
  • Soleus tear
    • Acute: small focal tear or region of hypoechoic change in the area of maximal tenderness
    • Chronic: More generalized hypoechoic changes

MRI

  • General
    • Not typically needed or indicated unless the diagnosis is uncertain
  • Findings that predict a delayed RTP[13]
    • Involvement of multiple muscles
    • Deep tissue injury involving the soleus
    • Large fascial defects
    • Tears at a musculotendinous junction

Classification

Classification System for Calf Strains

Grade Symptoms Signs Pathologic Correlation Radiology Correlation
Grade 1: 1st degree mild Sharp pain at the time of injury or pain with activity. Usually able to continue the activity Mild pain and localized tenderness. Mild spasm and swelling. No or minimal loss of strength and ROM <10% muscle fiber disruption The bright signal on fluid-sensitive sequences. Feathery appearance <5% muscle fiber involvement
Grade 2: 2nd-degree moderate Unable to continue the activity A clear loss of strength and ROM >10–50% disruption of muscle fibers Change in myotendinous junction. Edema and hemorrhage
Grade 3: 3rd degree severe Immediate severe pain, disability Complete loss of muscle function. Palpable defect or mass. Possible positive Tompson’s test 50–100% disruption of muscle fibers Complete disruption of discontinuity of muscle. Extensive edema and hemorrhage. Wavy tendon morphology and retraction

Treatment

  • Timeline
    • Healing typically takes 3-6 weeks[14]
  • The medial head of gastroc
    • Healing is slow, taking 3-16 weeks[15]
  • Recurrence
    • High mean time in return to sport
    • more likely to occur during critical competitive periods, such as the end of the competition season in football[16]
  • MRI Findings that predict a delayed RTP[17]
    • Involvement of multiple muscles
    • Deep tissue injury involving the soleus
    • Large fascial defects
    • Tears at a musculotendinous junction
  • Prakesh et al found MRI findings correlated closely with time to RTP[18]
    • Grade 0: 8 days
    • Grade 1: 17 days
    • Grade 2: 25 days
    • Grade 3: 48 days

Nonoperative

  • Indications
    • Vast majority of calf strains

Acute management (3-7 days)

  • Rest and discontinuation of activities
  • Limiting plantarflexion or calf stretching
  • Ice Therapy
  • Compression Wrap or [[Calf Sleeve]
  • Consider Heel Wedge and Crutches
  • Analgesia with NSAIDS, Acetaminophen
  • Avoid Heat Therapy, Soft Tissue Massage as they may worsen bleeding[19]

Subacute management

  • Physical Therapy
    • Emphasis on passive stretching, range of motion
    • Soft tissue techniques, range of motion
  • Consider
    • Low Level Laser Therapy
    • Therapeutic Ultrasound
    • Electrical Stimulation

Operative

  • Indications
    • Consider in grade III strains
    • Prolonged symptoms refractory to conservative management with evidence of contracture
    • Large intramuscular Hematoma
  • Technique

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