Calf injuries not involving the Achilles tendon
- Catherine Rogers Rainbow, MD, SMCAQ
Catherine Rogers Rainbow, MD, SMCAQ
- Clinical Instructor
- University of North Carolina School of Medicine
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Section Editor
- Peter Fricker, MBBS, FACSP
Peter Fricker, MBBS, FACSP
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Exercise, Sports Nutrition, and Miscellaneous; Sports-Related Injuries
- Adjunct Professor
- Griffith University
- Institute of Sport, Exercise, and Active Living
- Victoria University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Posterior calf injuries are common and occur in both competitive and recreational athletes, and active laborers. The major posterior calf muscles include the gastrocnemius, soleus, popliteal, and plantaris muscles. These muscles primarily perform active plantarflexion of the ankle and are typically injured during ballistic movements. Patients with posterior calf injuries present with limping, swelling of the posterior calf, and significant pain at the time of injury.
This topic will review common and important posterior calf injuries, including the mechanisms of injury, diagnosis, and management. Achilles tendon and other leg injuries are discussed separately. (See "Achilles tendinopathy and tendon rupture" and "Ankle sprain" and "Overview of ankle fractures in adults".)
EPIDEMIOLOGY AND RISK FACTORS
Muscle strains of the posterior calf affect both competitive and recreational athletes, but occur most often in poorly-conditioned male athletes in the fourth to sixth decade of life [1-4]. Calf injuries typically occur during sudden ballistic movements involving the lower extremity, such as sprinting or jumping, in sports where these movements are common, such as tennis, football (soccer), basketball, American football, and running on hills . The medial head of the gastrocnemius in particular plays a major role in generating power when athletes jump or sprint, and injuries of the medial head are relatively common. Calf muscle strains usually occur when the muscles are not warmed up properly or have fatigued significantly during exercise. Approximately 20 percent of patients report prodromal symptoms including soreness or tightness in their calf muscle prior to the injury .
Competitive male masters runners, defined as older than age 40, are at higher risk for calf injuries. Survey studies from races reveal that calf injury is among the most common injuries for all male runners and disproportionately affects older runners [5,6]. Calf injuries are also common among tennis players . A case series of medial calf injury in 720 athletes found that 16 percent arose from tennis . A large proportion of such injuries occur at the musculoskeletal junction of the medial head of the gastrocnemius muscle or the aponeurosis between the medial head of the gastrocnemius and soleus muscles . These injuries are often referred to as "tennis leg". For patients diagnosed with "tennis leg" only 14 percent of injuries occur at the lateral head of the gastrocnemius , and 1.4 percent involve plantaris rupture .
The literature pertaining to other risk factors for calf injury is limited. A history of a posterior calf strain is a risk factor for recurrent injury [4,10,11]. Among older soccer players, a history of a lumbar entrapment of the fifth lumbar (L5) nerve root has been associated with an increased risk for posterior gastrocnemius strain, and this condition may be a risk factor for other active adults .
- Gallo RA, Plakke M, Silvis ML. Common leg injuries of long-distance runners: anatomical and biomechanical approach. Sports Health 2012; 4:485.
- Campbell JT. Posterior calf injury. Foot Ankle Clin 2009; 14:761.
- Kwak HS, Lee KB, Han YM. Ruptures of the medial head of the gastrocnemius ("tennis leg"): clinical outcome and compression effect. Clin Imaging 2006; 30:48.
- Green B, Pizzari T. Calf muscle strain injuries in sport: a systematic review of risk factors for injury. Br J Sports Med 2017; 51:1189.
- McKean KA, Manson NA, Stanish WD. Musculoskeletal injury in the masters runners. Clin J Sport Med 2006; 16:149.
- Marti B, Vader JP, Minder CE, Abelin T. On the epidemiology of running injuries. The 1984 Bern Grand-Prix study. Am J Sports Med 1988; 16:285.
- Russell AS, Crowther S. Tennis leg--a new variant of an old syndrome. Clin Rheumatol 2011; 30:855.
- Delgado GJ, Chung CB, Lektrakul N, et al. Tennis leg: clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology 2002; 224:112.
- Weishaupt D, Schweitzer ME, Morrison WB. Injuries to the distal gastrocnemius muscle: MR findings. J Comput Assist Tomogr 2001; 25:677.
- Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med 2001; 29:300.
- Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in professional soccer: the UEFA Injury Study. Am J Sports Med 2013; 41:327.
- Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection? Br J Sports Med 2004; 38:502.
- Bianchi S, Martinoli C. Leg. In: Ultrasuond of the Musculoskeletal System, Springer, New York 2007. p.745.
- Bryan Dixon J. Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries. Curr Rev Musculoskelet Med 2009; 2:74.
- Spang C, Alfredson H, Docking SI, et al. The plantaris tendon: a narrative review focusing on anatomical features and clinical importance. Bone Joint J 2016; 98-B:1312.
- Blake SM, Treble NJ. Popliteus tendon tenosynovitis. Br J Sports Med 2005; 39:e42; discussion e42.
- Millar AP. Strains of the posterior calf musculature ("tennis leg"). Am J Sports Med 1979; 7:172.
- Rohilla S, Jain N, Yadav R. Plantaris rupture: why is it important? BMJ Case Rep 2013; 2013.
- Pollock N, Calder J, Dijstra P, Chakraverty R. 80 plantaris injuries in elite UK track and field athletes from 2009 to 2013. Br J Sports Med 2014; 48:A52.
- Harmon KJ, Reeder MT, Udermann BE, Murray SR. Isolated rupture of the plantaris tendon in a high school track athlete. Clin J Sport Med 2006; 16:361.
- Mayfield GW. Popliteus tendon tenosynovitis. Am J Sports Med 1977; 5:31.
- Rose DJ, Parisien JS. Popliteus tendon rupture. Case report and review of the literature. Clin Orthop Relat Res 1988; :113.
- Naver L, Aalberg JR. Avulsion of the popliteus tendon. A rare cause of chondral fracture and hemarthrosis. Am J Sports Med 1985; 13:423.
- Guha AR, Gorgees KA, Walker DI. Popliteus tendon rupture: a case report and review of the literature. Br J Sports Med 2003; 37:358.
- Baltopoulos P, Filippou DK, Sigala F. Popliteal artery entrapment syndrome: anatomic or functional syndrome? Clin J Sport Med 2004; 14:8.
- Edwards PH Jr, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med 2005; 33:1241.
- McAree BJ, O'Donnell ME, Davison GW, et al. Bilateral popliteal artery occlusion in a competitive bike rider: case report and clinical review. Vasc Endovascular Surg 2008; 42:380.
- Radowsky J, Patel B, Fox CJ. Delayed presentations of popliteal artery entrapment syndrome in a middle-aged military population. Ann Vasc Surg 2013; 27:1184.e1.
- Turnipseed WD. Popliteal entrapment in runners. Clin Sports Med 2012; 31:321.
- Pell RF 4th, Khanuja HS, Cooley GR. Leg pain in the running athlete. J Am Acad Orthop Surg 2004; 12:396.
- Altintas U, Helgstrand UV, Hansen MA, et al. Popliteal artery entrapment syndrome: ultrasound imaging, intraoperative findings, and clinical outcome. Vasc Endovascular Surg 2013; 47:513.
- Brewer RB, Gregory AJ. Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health 2012; 4:121.
- Votapka T, Backer CL, Mavroudis C. Giant popliteal false aneurysm in an 8-year-old child. J Pediatr Surg 1993; 28:1594.
- Woodhouse JB, McNally EG. Ultrasound of skeletal muscle injury: an update. Semin Ultrasound CT MR 2011; 32:91.
- Shah JR, Shah BR, Shah AB. Pictorial essay: Ultrasonography in 'tennis leg'. Indian J Radiol Imaging 2010; 20:269.
- Jamadar DA, Jacobson JA, Theisen SE, et al. Sonography of the painful calf: differential considerations. AJR Am J Roentgenol 2002; 179:709.
- Flecca D, Tomei A, Ravazzolo N, et al. US evaluation and diagnosis of rupture of the medial head of the gastrocnemius (tennis leg). J Ultrasound 2007; 10:194.
- Balius R, Rodas G, Pedret C, et al. Soleus muscle injury: sensitivity of ultrasound patterns. Skeletal Radiol 2014; 43:805.
- Howard CB, Bonneh DY, Nyska M. Diagnosis of popliteus tenosynovitis by ultrasound. J Orthop Sports Phys Ther 1992; 16:58.
- Sun X, Liu C, Wang R, et al. Dual source CT angiography in popliteal artery entrapment syndrome. J Med Imaging Radiat Oncol 2013; 57:156.
- Hai Z, Guangrui S, Yuan Z, et al. CT angiography and MRI in patients with popliteal artery entrapment syndrome. AJR Am J Roentgenol 2008; 191:1760.
- Miller KC, Stone MS, Huxel KC, Edwards JE. Exercise-associated muscle cramps: causes, treatment, and prevention. Sports Health 2010; 2:279.
- Yim ES, Friedberg RP. Case report: lower extremity deep vein thrombosis following an intense calf workout. Curr Sports Med Rep 2012; 11:282.
- Bradley WD, Fields KB, Delaney MJ. Leiomyosarcoma of the femoral vein in a marathon runner. J Am Board Fam Pract 1992; 5:219.
- Theiss JL, Fink ML, Gerber JP. Deep vein thrombosis in a young marathon athlete. J Orthop Sports Phys Ther 2011; 41:942.
- Maalla R, Youssef M, Ben Lassoued N, et al. Peroneal nerve entrapment at the fibular head: outcomes of neurolysis. Orthop Traumatol Surg Res 2013; 99:719.
- Erdil M, Ozkan K, Ozkan FU, et al. A rare cause of deep peroneal nerve palsy due to compression of synovial cyst - Case report. Int J Surg Case Rep 2013; 4:515.
- Peck E, Smith J. Lower extremity nerve entrapments. In: ACSM’s Sports Medicine: A Comprehensive Review, O’Conner FG, Casa DJ, Davis BA, et al (Eds), Lippincott Williams & Wilkins, China 2013. p.479.
- Fabre T, Montero C, Gaujard E, et al. Chronic calf pain in athletes due to sural nerve entrapment. A report of 18 cases. Am J Sports Med 2000; 28:679.
- Bryan BM 3rd, Lutz GE, O'Brien SJ. Sural nerve entrapment after injury to the gastrocnemius: a case report. Arch Phys Med Rehabil 1999; 80:604.
- Krafczyk MA, Burkey SM. Popliteal tendonitis. In: The 5-Minute Sports Medicine Consult, 2nd ed, Bracker M (Ed), Lippincott Williams & Wilkins, Philadelphia 2011. p.480.
- Whitfield BJ, Klimkiewicz JJ. Soft tissue knee injuries (tendon and bursae). In: ACSM’s Sports Medicine: A Comprehensive Review, O’Conner FG, Casa DJ, Davis BA, et al (Eds), Lippincott Williams & Wilkins, China 2013. p.436.
- Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med 2007; 41:211.
- Nyland J, Lachman N, Kocabey Y, et al. Anatomy, function, and rehabilitation of the popliteus musculotendinous complex. J Orthop Sports Phys Ther 2005; 35:165.
- Obadina ET, Blankenbaker DG, Davis KW, Heiner JP. Orthopaedic case of the month: Ossified calf mass in a 32-year-old woman. Clin Orthop Relat Res 2012; 470:1522.
- Hallén A, Ekstrand J. Return to play following muscle injuries in professional footballers. J Sports Sci 2014; 32:1229.
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL ANATOMY AND BIOMECHANICS
- MECHANISM OF INJURY AND CLINICAL PRESENTATION
- Gastrocnemius strain
- Plantaris strain and tendon injury
- Soleus strain
- Popliteus tendinopathy
- Popliteal artery entrapment
- DIAGNOSTIC IMAGING
- Musculoskeletal injury
- - Plain radiographs
- - Ultrasound
- - Advanced imaging
- Neurovascular injury
- INDICATIONS FOR SURGICAL CONSULT OR REFERRAL
- DIFFERENTIAL DIAGNOSIS
- Initial assessment and treatment
- Severe gastrocnemius strain
- Non-severe gastrocnemius injury, and plantaris and soleus injuries
- Popliteal tendinopathy
- Popliteal artery entrapment
- RETURN TO SPORT OR WORK
- SUMMARY AND RECOMMENDATIONS