Calf pain refers to pain at the back of the lower leg and can be acute (sudden onset) such a muscle strain or contusion, or chronic (gradual onset). It is important to be aware of a deep vein thrombosis which if missed can cause serious heath problems including heart attack or stroke.
- On this page:
- Calf strain
- Posterior compartment syndrome
- Lateral compartment syndrome
- Fibula stress fracture
- Deep vein thrombosis (DVT)
A calf strain is a tear in either the gastrocnemius muscle or the soleus muscle which together make up the calf muscle group and is probably the most common cause of sudden onset pain at the back of the lower leg. A sudden sharp pain is felt, usually in the middle of the calf muscle area at the point where the gastrocnemius muscle connects to the Achilles tendon. The calf muscle will often be tender to touch at the point of injury and swelling and bruising may appear within hours or days.
A calf muscle strain is graded from 1 to 3, with grade 3 being the most severe. A grade 1 injury will not normally need professional treatment and the athlete may be able to continue exercising, although they will often have some discomfort or tightness during or after the session. Grade 2 or 3 injuries, depending on their severity, may require more specialist treatment and rehabilitation advice from a sports injury professional.
Treatment consists of immediate first aid, applying cold therapy and compression as soon as possible, followed by rest and when pain allows a full rehabilitation program. Rehabilitation should include progressive stretching, sports massage, strengthening, and sports specific exercises.
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A contusion occurs following a direct impact or trauma to the calf muscles, for example being kicked in the back of the leg in a game. The force of the impact crushes the muscle against the bone, causing bleeding and swelling. Contusions can range from very mild where the player can continue to play up to a severe crippling pain. The area will be tender and bruising may appear, but if the bleeding is contained within the muscle sheath it may not be visible.
Although contusions may not at first appear serious it is essential they are treated with as soon as possible with cold therapy PRICE principles (protection, rest, ice, compression, and elevation). It is important that during the acute phase heat and massage are NOT applied to a contusion as this may lead to Myositis ossificans, where bone tissue begins to grow within the muscle causing long-term problems. Once the acute phase has passed and pain allows, rehabilitation exercises should be done as they would with a calf strain.
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Another common sports injury which affects the calf muscles is cramp. Cramp is a powerful and painful involuntary contraction of the muscles. The muscle suddenly goes into spasm and tightens up, usually towards the end of a particularly hard training session or competition. Immediate treatment is to try and stretch the muscles gently to release the spasm, often the help of a partner is needed. Potential causes include dehydration and low carbohydrate levels so taking on fluids and energy may help.
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Posterior compartment syndrome
Posterior compartment syndrome occurs when the muscle swells up too big for the sheath surrounding it causing pain and restricted movement. An acute compartment syndrome occurs suddenly and may develop following a contusion. The muscle bleeds within the muscle sheath causing increased pressure within the muscle sheath. An acute compartment syndrome needs urgent medical attention, especially if the pain becomes progressively worse as it can result in long-term damage.
A chronic compartment syndrome occurs because the muscle gradually grows too big for the sheath surrounding it. A deep aching pain or tightness in the back of the lower leg occurs gradually during a run, but then eases off with rest. Experienced runners may find the pain comes on at the same point in a run consistently. Various treatment options include rest, applying ice and massage, however, some injuries may require surgery to release the surrounding muscle sheath.
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Lateral compartment syndrome
Lateral compartment syndrome can be acute or chronic the same as a posterior compartment syndrome, only the pain is over the outside of the calf muscles. It is probably more common as a chronic injury in long distance runners.
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Tight calf muscles
Although not a specific injury, tight muscles at the back of the lower leg is a widely seen problem among athletes, and can lead to other related injuries. The tight muscles can be caused by poor biomechanics, lack of stretching, and wearing high heeled shoes. If the calf muscles are contracted, the blood can't get to the area so easily which can cause discomfort and pain. If left untreated, this can increase the risk of suffering from a more severe and acute injury.
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Deep vein thrombosis
(DVT) is another possible cause of calf pain. Although it is not as likely as the injuries above, it is a condition that should not be missed or overlooked. It is a blood clot in the veins and is most likely to happen in the calf area, especially after long flights and surgery. This is a serious condition and medical help is needed if this is suspected.
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Fibula stress fracture
A fibula stress fracture may cause calf pain. The calf muscles attach to the fibula bone, so the traction and twisting forces of the muscles can cause a stress fracture. This injury would make putting weight on the leg painful, and the calf pain is likely to increase with exercise.
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Other causes of calf pain:
Pain may be referred from other body parts and produce pain in the calf. It may originate from injuries to the spine, the knee (including Baker's cyst and PCL injuries) and myofascial tissue structures (particularly in the gluteal muscles). Calf pain may also be caused by trapped arteries or vessels, such as the popliteal artery. Trapped tibial and sural nerves in the calf may also make the lower leg area painful.
Immediate first aid
Calf pain should be treated using the P.R.I.C.E. principles (protection, rest, ice, compression & elevation).
Protection- Stop training or playing immediately to prevent the calf injury from getting worse.
Rest - Resting the calf is important and vital for recovery. Try to reduce the demands of your daily activity and stop doing any sports that exacerbate the pain. Continuing to train with a calf injury and not allowing it time to heal can result in a more serious injury.
Ice - Apply ice or cold therapy to the calf to help reduce the symptoms of pain and any inflammation. Apply for 10 minutes every hour for the first 24 to 48 hours after injury, reducing to 3 or 4 times a day as symptoms improve. Do not apply ice directly to the skin as it may burn. Use a commercially available cold pack or wrap ice in a wet tea towel.
Compression - Wearing a compression support or compression bandages on the calf can reduce swelling.
Elevation - Keeping the lower leg elevated above heart level can help to reduce swelling, due to the effects of gravity.
Read more on PRICE principles.