REGULAR FEATURE
Common injuries:
AUTHOR’S BIO
CALF STRAIN
Paul G. Wright, BAppSc (Physio), DipEd. (PE)
Paul is a leading health educator and director of Get Active Physiotherapy with clinics inside Fitness First Clubs at
St Leonards (Sydney), Kotara (Newcastle) and the CBD of St Leonards. He has produced a series of injury prevention and
training DVD’s for fitness professionals. For more information, visit www.getactivephysio.com.au or call 02 9966 9464.
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As an operator of
physiotherapy clinics inside
health clubs, I frequently see
members limp out of a class half way
through, or a trainer bring a client to
the clinic desk with sudden calf pain.
Causes of calf pain can include
muscle cramp, delayed onset muscle
soreness (DOMS) and referred pain
from the lumbar spine. By far the
most common cause of pain in the
lower leg, however, is a strain to the
musculotendinous complex of the
gastrocnemius and/or soleus.
In the fitness industry calf tears
often occur in typical personal
training activities such as shuttle runs
(requiring rapid acceleration and
change of direction), split jumping
(where one leg is thrust backwards
on landing), incline running and
sprinting. This injury is common in
boxing sessions where participants are
jumping and hopping on their toes
and also in beach-based Boot Camp
activities during hill work, due to the
unstable surface provided by the sand
and the intense muscle work involved.
Group exercise is often cited as a
cause of calf injury, with step classes
(usually on stepping down and pushing
the rear leg down to the floor and
then pushing off to complete the
next step) and high impact classes
being mentioned when taking patient
histories. These injuries often occur
towards the end of the class due to
muscle fatigue or a loss of technique.
Gastrocnemius
Anatomy and physiology
The term ‘calf muscle’ is used to
describe the gastrocnemius and soleus
muscle complex. The gastrocnemius
is more superficial than the soleus,
with its two heads (medial and lateral)
arising from the femoral condyles and
eventually inserting into the Achilles
tendon. The deeper Soleus muscle
originates on the tibia and fibula and
also inserts into the Achilles tendon,
which goes on to attach into the
calcaneous or ‘heel bone’.
Because the gastrocnemius crosses
the knee joint as well as the ankle joint,
it is classified as a ‘biarthrodial’ muscle.
The complex interaction of muscles
acting over more than one joint is
one of the reasons the gastrocnemius
is more commonly injured than the
uniarthrodial (crossing only one joint)
soleus muscle.
Signs and symptoms
Calf muscle strains occur more
commonly in the medial head of the
Soleus
gastocnemius than in its lateral head
or the soleus. A common scenario is
one where the patient has tried to
accelerate suddenly from a stationary
position and then felt a sharp, stabbing
pain in the back of the lower leg.
Patients often say that upon feeling this
sensation they quickly swing around to
see who has kicked them in the calf.
Examination will reveal tenderness
localised to the site of the tear and, if
NETWORK • AUTUMN 2008 • www.fitnessnetwork.com.au
59
Regular feature
common injuries: calf strain
severe, a palpable defect or gap may be felt. Stretching of
the gastrocnemius will also reproduce pain, which is why the
patient will usually walk with the foot turned outwards as this
limits ankle dorsiflexion and reduces the need to dorsiflex the
ankle while walking.
A significant number of people do not experience the sharp,
stabbing pain associated with the typical calf strain, instead
reporting a sensation of intermittent cramping during exercise. This
‘cramping’ sensation is often due to recurrent minor calf tears which
can be linked back to old scar tissue from a previous (and more
severe) calf tear. This scar tissue is common in patients who have not
undergone adequate rehabilitation following their initial calf injury.
The fitness professional must be aware that the ‘cramping’
feeling may not be a typical cramp that can be stretched out,
thereby enabling the exercise to continue. The client should be
asked about past calf injury history as continuing to exercise
this body part can lead to a more severe injury occurring. It is
advisable for the trainer to stop any exercise that involves the
calf area and seek advice from their local physiotherapist or
sports physician.
Management
As with all episodes of pain it is essential the client is
examined by a physiotherapist or sports physician as soon as
possible. The medical professional will evaluate the extent of
the injury, outline an approximate time line for rehabilitation,
and exclude any more serious problems such as achilles
tendon rupture, lumbar spine referral and deep venous
thrombosis (DVT).
Once the calf strain is diagnosed and other problems
excluded, initial management will aim to reduce pain
and swelling. This is best achieved with ice, elevation and
compressive bandaging. The patient may also benefit from
a small heel raise in the shoe to prevent excessive stretching
of the calf when walking – females will typically be more
comfortable in shoes with a moderate heel raise.
Gentle stretching to the point of a sensation of tightness
and muscle strengthening can begin after the first 24 hours.
The exercise progressions commence with bilateral concentric
calf raises and gradually progress to unilateral concentric
(see photo 1), addition of weight and finally bilateral and
unilateral eccentric lowering over the edge of a step. Final
stage rehabilitation will involve plyometric and sports-specific
drills to ensure complete recovery prior to returning to
sport. Soft tissue therapy is an important component of the
management plan as residual scar tissue can lead to long term
problems and injury recurrence.
Biomechanical factors may play a role in increasing the risk
of calf injury and need to be evaluated to ensure complete
recovery. The most common factors include increased subtalar
joint pronation and also any reduction in the available range of
ankle dorsiflexion. The ‘Lunge Test’ is a very useful screening
tool for the assessment of ankle dorsiflexion (see photo 2).
It is important that the fitness instructor seek medical assistance
in the management, rehabilitation and prevention of this injury as it
is common for this condition to become a recurrent problem which
severely impacts upon the patient’s exercise program.
1
2
Photo 1. Unilateral calf raise
Photo 2. The lunge test
It is important that the rehabilitation program incorporates a combination of
This is a simple and quick way to assess the relative range of ankle dorsiflexion
concentric and eccentric calf raising activities in varying degrees of knee flexion –
between left and right ankles. The client attempts to lunge forward until the knee is
jumping activities are also important for complete rehabilitation.
only just able to reach the wall – while keeping the heel down and the knee in line with
the second toe. The distance of the big toe from the wall at maximal lunge is then
compared to the other side. A difference in range between right and left can increase
the amount of pronation and lead to increased injury risk.
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