I have a calf muscle tear.  What should I do?

This was a question from a friend of mine.  He is a tennis player.  He is also a physician.  So, he recognized that he had sustained calf muscle tear during tennis.  While examining him, I noticed that he had a dent in his calf.  This indicated that he had a significant tear in the calf muscle.  He would not be returning to tennis or running in the next several weeks.  Read on to learn about calf muscle tears and how to treat them.  Let’s start with anatomy.

So, what is the calf?

The calf muscle is a complex of three muscles that are located on the back of the lower leg.  These muscles are the gastrocnemius, soleus, and plantaris.  The gastrocnemius is the outer or most superficial layer of the calf muscle.  It attaches to the end of the femur (thigh bone) while the soleus attaches to the top of the tibia and fibula (the lower leg bones).  The soleus lies underneath the gastrocnemius.  They both extend down the back of the leg to form the Achilles tendon which then attaches to the calcaneus (the heel bone).  The plantaris attaches to the femur and extends down to become part of the Achilles as well.  However the plantaris is a very small muscle that is largely vestigial in nature.  It is rarely involved in calf strains.

These muscles plantarflex the foot which means that they point the foot down.  They are very important in pushing the foot off the ground.  Push off is a vital part of walking, running, and jumping.

What is a strain?

A strain is an acute injury to the muscle and/or tendon.  The muscle that is most involved in calf strains is the gastrocnemius.  This muscle crosses two joints: the knee and the ankle.  This makes it more susceptible to injury.  The injury commonly occurs at the inner upper area of the muscle or it could also occur at the musculotendinous junction.  This is were the muscle transitions into tendon in order to attach to bone.  The musculotendinous junction for the gastrocnemius is about halfway down the calf.

How bad is my injury?

Not all strains are the same.  Some are more severe than others.  There are grades that describe the severity of a strain.

• Grade 1: This is the mildest strain with only a small area of injury.  Walking will, most likely, not be affected.  The muscle is tender and painful but there is no loss of strength.  Recovery takes an average of 1-2 weeks.
• Grade 2: This is a moderate strain with about half of the muscle fibers torn.  Walking will be affected.  There is more tenderness and pain with a significant loss in strength.  Bruising could be present.  Recovery takes an average of 2-3 weeks.
• Grade 3: This is a severe strain in which more than half to all (complete rupture) of the muscle is torn. A “popping” sound may have been heard during the injury.  A dent where the muscle is torn could be present.  There is a complete functional loss of the muscle.  Putting weight on the leg will be extremely difficult and painful.  A person will need crutches to aid in walking.  Recovery could take up to 6 months.  Surgery could be required with a complete rupture.

How does the gastrocnemius get injured?

Calf strains usually occur when the knee is straight and the ankle is in dorsiflexion (ankle is flexed up moving closer to the shin).  This position puts maximal stretch on the gastrocnemius.  Contracting the muscle in this position puts increased tension on the muscle fibers and could cause a tear.  A gastrocnemius strain is also called “tennis leg” because serving the ball involves a straight knee and a dorsiflexed ankle.

Who usually gets calf strains?

Anyone can strain their calf.  People are more susceptible to strains as they get older.  As we get older, we tend to lose muscle mass.  This makes the muscles weaker and less flexible which increases the risk of injury.  However calf strains often occur in young people as well.  Calf strains are common in the following sports or activities:

• Tennis
• Running
• Dance
• Basketball
• Football
• Skiing
• Rugby
• Volleyball

What are the symptoms of a calf strain?

There are several symptoms associated with a  gastrocnemius strain.  These include:

• Sudden sharp pain or tearing at the calf – an audible “pop” might be heard
• Swelling in the calf
• Bruising
• Weakness in the calf
• Limping or inability to walk
• Pain with stretching the calf
• Pain with pushing off with the foot
• Tightness in the calf

Are there risk factors for calf strains?

There are some risk factors associated with calf strains.  These include:

• Previous injury to the calf – This is the greatest risk factor.
• Increased age
• Weak calf muscles
• Muscle fatigue
• Tight calf muscles

Who should I see?

• Physical therapy – This would be my first stop. Physical therapy can help decrease pain and swelling in the calf.  Also, your physical therapist will slowly introduce strengthening and stretching exercises as the tear heals.  Your PT will aid you in a gradual return to sport.  Acute, less severe, strains might return to sport in 1-3 weeks.  However, severe strains can take many months to recover and return to activity.  Reoccurrence is common.
• Orthopedic physician – An orthopedist might be necessary if your condition is not responding to physical therapy or if a complete rupture or tear is suspected. Your physician can prescribe medication, give an injection, or order imaging if needed.  Surgery might be needed to repair a complete rupture of the muscle.

What can I do?

• Relative rest – Resting the area to decrease further pain and damage is required for healing. Depending on the severity of the strain, this might mean no activity or it could mean activity that does not cause further pain.  For milder strains walking, biking, and swimming could be alternate forms of activity.  Returning to some form of cardiovascular exercise that does cause any further damage to the muscle is important in maintaining aerobic capacity and strength for eventual return to sport.
• Ice – Ice can help decrease pain and swelling in the muscle. Ice the painful area for 15 to 20 minutes at a time.  I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity.  Ice immediately after activity.
• Compression socks – Compression socks can help decrease swelling and pain by improving circulation. It is important to put on compression socks after first waking up in the morning.  This is usually when there is the least amount of swelling.
• Using a heel lift – Wearing a heel lift can shorten the muscle as you walk which will decrease the pull on the calf.  It can help you walk with improved form and less pain.  Wear the heel lift on both feet to prevent a leg length discrepancy.  Once you can walk without a limp or pain, then remove the lifts.
• Stretching – Gentle stretching is appropriate during the initial stages of healing. However, once the pain and swelling have decreased, you can gradually become more aggressive with your stretching.  See the videos below for gentle and then more aggressive stretching of gastrocnemius and soleus.

• Strengthening – It is important to slowly strengthen the calf muscles. The load placed on the muscles should be slowly increased.  It is also important to strengthen the muscles of the knee and hip.  All these muscles work together to stabilize the ankle while running, cutting, and jumping.  Using loop resistance bands can help increase difficulty and strength.  See video for gentle calf strengthening and ROM.  Then proceed to heel raises video when you no longer have pain with gentle strengthening.

In review

• The calf muscle is a complex of three muscles that are located on the back of the lower leg.
  • These muscles are the gastrocnemius, soleus, and plantaris.
• They are very important in pushing the foot off the ground.
  • Push off is vital part of walking, running, and jumping.
• A strain is an acute injury to the muscle and/or tendon.
  • The muscle that is most involved in calf strains is the gastrocnemius.
• Calf strains usually occur when the knee is straight, and the ankle is in dorsiflexion (ankle is flexed up moving closer to the shin).
• There are grades of muscle strain from grade 1, which is very mild, to grade 3, which is severe.
• Physical therapy is very successful in treating calf strains.
• An orthopedist would be necessary if the strain is not responding to physical therapy or a complete rupture is suspected.
• There are things that you can do:
  • Relative rest
  • Ice
  • Compression socks
  • Heel lift
  • Stretching
  • Strengthening

As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.

Additional resources

https://www.physio-pedia.com/Calf_Strain

https://www.ncbi.nlm.nih.gov/books/NBK534766/

https://www.choosept.com/guide/physical-therapy-guide-calf-strain