Achilles Muscle and Tendon Injuries - A Patient's Guide
Dr Ruth Highet - Sports Physician (New Zealand)
What are calf muscle injuries?
"Doc, it just felt as though someone kicked me in the back of the leg. I turned around but there was no one there. There was just no way I could finish my game. I hobbled off in sheer frustration". Calf muscle injuries are extremely disabling when they occur, as they often do, during a short sprint on the tennis court, or soccer field, at the athletics track or during a high intensity aerobics class.
The most common type of calf muscle injury seen is described as a "tennis calf". This involves a significant strain or partial tear to the medial gastrocnemius muscles which form the inside upper bulge of muscle at the back of the calf. The injury is certainly not exclusive to tennis players but is frequently seen in players of all racquet sports and other ballistic sports. The athlete is often extremely worried that they have ruptured their Achilles tendon at the base of their calf. Both the calf "muscle" injury and the Achilles "tendon" injury are significant injuries and do require intensive rehabilitation afterwards.
In most cases however, the athlete with a calf muscle injury will be back playing their chosen sport sooner than those who unfortunately rupture their Achilles "tendon". A simple test called the "Thompson Test" usually allows us to differentiate easily between the two. As well as being very disabling, the calf muscle strain or tear will usually be accompanied by excessive bruising right down the back of the calf, sometimes leaving the whole foot black and blue for a week or more. Any stretch of the calf muscle such as the normal heel to toe gait during walking will cause pain during the healing phase so the afflicted will usually limp for two weeks or more. Crutches are recommended during this period starting with non-weight bearing, progressing to partial weight bearing as comfort allows.
What is the treatment?
Early appropriate treatment is essential if we want to achieve a good result for this particular injury. The immediate use of (I) ice to reduce the amount of bleeding and subsequent swelling will significantly reduce the amount of muscle damage. This should be carried out several times a day for the first 72 hours. As with other soft tissue injuries it should be accompanied by the other components of the RICE treatment with (C) compression (a double tubigrip bandage including whole of the foot and calf is very effective) and (E) elevation of the lower leg as much as possible in the first two to three days. It is useful at this stage to use a heel raise in shoes. This is easily and cheaply achieved by cutting up a piece of carpet to fit snugly in to the back of the shoe or you can purchase or have a commercial heel raise provided by your physiotherapist.
Ultrasound and other electrical modalities provided by the physiotherapists may also have a role in the early stage to reduce the amount of swelling and pain caused by the muscle damage. After the first five days however, treatment should be concentrated more on exercises to stretch out the healing tissue in the line of the muscle and tendon to avoid a haphazard array of healing muscle units that will predispose to further tears. These exercises should include stretching of both the deep and superficial calf muscles, so will involve stretching the calf with the knee straight and the knee bent.
Depending on the severity of injury, after approximately 10-14 days, muscle-strengthening exercises can usually be started involving toe raises on the affected leg initially supported and then unsupported. These can again be carried out with the knee straight and the knee bent to strengthen both the calf muscle groups. It is beneficial to keep using the compression bandage until all the visible swelling has disappeared which may take two to three weeks. The patients who come in complaining that they tear their calf muscles every time they attempt to return to vigorous activity usually have "never" had adequate rehabilitation, sufficient to restore optimum flexibility and strength to their calf muscle units. The good news, however, is that even these chronic calf muscle injuries usually do very well with structured well-supervised rehab programmes.
Not all pain at the back of the calf, however, comes from calf muscle tears or Achilles tendon ruptures! Low back injuries may refer pain to the back of the calf, sometimes unaccompanied by any actual back pain. Clots (thromboses) in the deep veins in the back of the calf may also masquerade as a calf tear and should be considered, especially following a period of immobilisation e.g. post-op surgery or long plane flight. A posterior swelling of the knee joint called a "Baker cyst" may occasionally rupture and cause acute pain and swelling down the back of the calf. The patient's particular history (sometimes assisted by diagnostic investigation) will allow the appropriate diagnosis to be made so the correct rehabilitation programme can be instigated.
How can calf injuries be prevented?
In summary, calf injuries are best avoided by a good warm-up and regular attention to ensuring good calf muscle flexibility. If you are unfortunate enough, however, to strain or tear a calf muscle, make sure you treat it with appropriate respect in the "early" stages and get the right treatment. In most cases this will prevent you having recurring calf injuries forever after.
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