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