Calf Strain

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Definition/Description

A calf strain is an injury to the muscle (or tendon of the muscle) of the lower leg. Strains or tears mean that muscle fibers are ripped as a result of overstretching. Strains are often called “pulled muscles”. In more severe cases the calf muscle(s) can rupture at the Achilles tendon.(Achilles Rupture)

Clinically Relevant Anatomy

The “calf muscle” consists of three different muscles: gastrocnemius, soleus, and plantaris, which all have the same Achilles tendon insertion on the calcaneus.
The gastrocnemius is located in the posterior compartment of the lower leg. It consists out of two “heads”. The medial head finds its origin on the medial condyle of the femur and the lateral head originates from the lateral condyle. Its function is flexing the leg at the knee joint, but also plantar flexing the foot in the joints of the ankle.
The plantaris also finds its origin on the lateral condyle of the femur and on the oblique popliteal ligament. Its function is plantar flexing the foot (in the ankle joint).
The soleus originates from the head of the fibula and the facies posterior of the tibia and fibula. The function of this muscle is plantar flexion of the foot.

Epidemiology /Etiology

Internal and external factors can contribute to the forming of muscle strains. Bruises often come along with strains. There are different internal causes of strains. It can be due to an explosive power transmission without enough preparation or training. Another cause are movements of which the coordination isn’t optimal. Because of this, the antagonists can’t relax on time, and so the muscle has to work against a great resistance and tears.
An external cause usually is a direct trauma. It makes a huge difference if the muscle was hurt in condition of contraction, or if the muscle was relaxed. When the ankle is in full dorsiflexion and with the knee in extension, the gastrocnemius is stretched and is more liable to tear as it contracts.
   

Characteristics/Clinical Presentation

Calf strains usually are a common injury. Differentiating strains in these muscles (gastrocnemicus and soleus) is very important for a correct prognosis, an appropriate treatment and prevention of recurrent injury.

• Gastrocnemius strains
  It is widely accepted that the muscles that are the most susceptible to this kind of injury are the two-joint (or biarticular) muscles. The gastrocnemius is considered to be a high risk for strains because it crosses two joints: the knee and the ankle. This muscle also has a high density of fast twitch muscle fibers and the combination of these two factors often results in strain. These factors also allow eccentric contraction, which is when muscle fibers are at risk to injury. . Calf strains are usually found in the medial head of the gastrocnemius. Because of its more prolonged attachment, the medial head may generate higher forces than the lateral head and so the medial head more is susceptible to muscle tears. The patient feels an immediate pain, disability and there can be swelling.

• Plantaris strains
  However the plantaris crosses the knee and ankle joint too, it is rarely involved in calf strains. The recommended treatment is identical to gastrocnemius strains.

• Soleus strains
  Strains of the soleus vary in reported cases from rare to common. This kind of strains can be underreported because people often confuse soleus strains with strains of the gastrocnemius. The soleus crosses only the ankle and has a high density of slow twitch muscle fibers. This muscle is considered low risk of strains, unlike the gastrocnemius.
  Soleus strains are also considered to be less dramatic and more subacute when we compare them to strains of the gastrocnemius. The patient finds his muscle to be rather stiff and he also feels a pain that worsens over days to weeks. Swelling and disability are mostly mild.

 

Strains are categorized as first, second and third degree, according to their severity.

• First degree strains include some pain, but they involve only micro tearing of the collagen fibers. There are no direct symptoms to indicate. It is possible that there is a mild discomfort, local tenderness, mild swelling and ecchymosis, but no loss of function.
• Second degree strains are accompanied by more severe pain. There is more extensive rupturing of the tissue and also joint instability can be detected. Furthermore, muscle weakness and limited joint range of motion can occur. 
• Third degree injuries of these tissues produce severe pain, loss of range of motion, a major loss of tissue continuity and complete instability of the joint.

 

Diagnostic Procedures

The athlete (often athletes in sports in which jumping ability and speed are important factors, such as volleyball, basketball, tennis, squash) can sport again once he achieves a full range of motion in which he does not feel any form of pain. It is also important that the range of motion is symmetric on both sides. Furthermore, the muscle must have fully restored strength.
If intermuscular bleeding has occurred the patient will need 2 or 4 weeks to be fully recovered, but it often takes 8 or 12 weeks for the patient to heal. If the area has healed with a permanent area of inflexible scar tissue, a recurrent strain injury may easily be caused.
 

Outcome Measures

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Examination

Calf pain is reproduced when the gastrocnemius is passively stretched in dorsiflexion. The range of this movement is often limited because of spasm in the gastrocnemius. It’s also possible that pain is provocated when the patient tries to stand up on his toes, or when the plantar flexion of the ankle is tested against resistance of the therapist. There are other signs that can vary, depending on the degree of the tear. In the calf, the muscle can be swollen and there can appear a bruise. It is also possible that a gap may be palpable in a severe degree of tear. In minor degrees, an area of tender thickening can be palpated in the muscle.
  

Medical Management

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== Physical Therapy Management
== Acute treatment needs the use of RICE (= Rest, Ice, Compression, Elevation) and NSAIDs (Nonsteroidal anti- inflammatory drugs) during the first 2 or 3 days. If major bleeding had occurred, it is necessary to be careful with the use of NSAIDs.
The underlying skin can be ecchymotic if there is an intermuscular bleeding (which indicates a rupture of the muscle fascia). Also the flexibility of the muscle(s) should carefully be tested. On the third day after injury, the rehabilitation starts.
The task of the physiotherapist contains settling down the pain (1). After pain and swelling have decreased, physical therapy should start with restoring flexibility and strength (2)+(3).
Because of the particular way of stretching, it is important to differentiate between the two muscles. To stretch the gastrocnemicus, the knee must be in straightened position. To stretch the soleus, the knee must be in flexion.
Strains may cause long lasting pain, even if there have been an adequate early treatment. An injection of local anesthetic and cortisone in and around the area, followed by a right stretching and stretch training treatment, will often take away some of the symptoms.
 

Key Research

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Resources

- Pubmed
- Web of Knowledge
- Pedro
- Books

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

 Brain Corrigan, G. D. Maitland; 2004; Musculoskeletal & Sports Injuries; Elsevier Limited; 1994. 

 Stanley Salmons; 1997; Muscle Damage; Oxford University Press; 1997.

 Dr. H. R. Kriek; 1985; Sportletsels; Bohn, Scheltema & Holkema, Utrecht/ Antwerpen; 1985.

 Marcia K. Anderson, Susan J. Hall, Cheryl Hitchings; 1997; Fundamentals of Sports Injury Management; Williams and Wilkins; 1997.

  Roald Bahr, Sverre Maehlum; 2004; Clinical guide to sports injuries; Human Kinetics; 2003.
( This book is an English version of “Idrettskader”; published in 2002 by Gazette bok)

 J. Bryan Dixon; Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries; Curr Rev Musculoskelet Med (2009) 2:74–77.
Level of evidence: B

  P. Tabrizi, W. M. J. McIntyre, M. B. Quesnel, A. W. Howard; Limited dorsiflexion predisposes to injuries of the ankle in children; J Bone Joint Surg [Br] 2000;82-B:1103-6.
Level of evidence: A1

 J Petersen, P Holmich; Evidence based prevention of hamstring injuries in sport; Br J Sports Med 2005;39:319–323.
Level of evidence: A1