Calf strain/sprain

Significant History/Physical Symptoms

Calf injuries are common, particularly in sport, and occur with an increased frequency with increasing age.

The medial head of gastrocnemius is the most common site of calf injury. Most calf muscle injuries involve the musculotendinous junction (MTJ) either the intramuscular tendon or the distal MTJ.

Sudden movement or acceleration is a common cause of injury. Usually presenting with an immediate onset of pain, tenderness and swelling. A palpable defect may be felt in higher grade injuries. The calf is also a common site for muscle contusions in sport, delayed onset muscle soreness (DOMS), and muscle cramps.

Risk factors include prior calf injury, higher BMI, previous lower limb injuries, lumbar radiculopathy. 

Differential Diagnosis

Included in this pathway

• Calf Muscle Injury
  • Gastrocnemius
  • Soleus
  • Plantaris

Not Included in this Pathway

• Posterior Compartment Syndrome
  • Deep
  • Superficial
• Referred pain
  • Lumbar Spine
  • Myofascial pain
  • Superior tibio-fibular joint
  • Knee
• Vascular entrapment
• Nerve entrapment
• Stress fracture
  • Fibula
  • Tibia
• Varicose Veins
• DVT
• Local infection/cellulitis
• Ruptured bakers cyst

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available. NHS resource links: 

• Calf Problems (NHS Inform)
• Exercises for Calf and Ankle Problems (NHS Inform)

Initial Patient Directed Treatment Options

• Acute Phase (up to 1-2 weeks)
  • Relative rest
  • Load modification
    • Use of crutches and/or heel wedges
  • PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
  • Pain limited range of motion exercises

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Onward referral
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for Analgesia Advice 
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
  • Give leaflet to reinforce verbal advice - Analgesia Advice
  • Alternative Shoe Lacing Options

Progressive strengthening and loading

• Progression through isometric to isotonic loading, then to heavy resistance and plyometric exercises
• Functional testing to monitor progress e.g. number of single leg calf raises, hopping, change of direction tests.
• Return to activity should focus on clinical signs and functional assessment. 

Running and change of direction progressions

• Introduce linear running when walking and low level hoppin are pain free, and symmetry in calf endurance is achieved
• Progress with speed, volume and terrain, and add as required lateral movements, acceleration/deceleration and sport specific training

Biomechanical assessment and potential prescription of Foot Orthoses

• Address biomechanical deficit if indicated by assessment.
• Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
• The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records

Manual therapy

• Consisting of joint and soft tissue mobilisation

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include, hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further Investigation

The other reason for referral to Orthopaedics is for “Further Investigations”.

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to Orthopaedics

Before referring to orthopaedics ensure the following:

• Vascular status – palpable pulses (for surgery)
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic clinician if you are unsure whether to refer.

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