Calf pain is relatively common and is usually caused by musculoskeletal injuries, however you should be aware of less common disorders that masquerade as these. Here is a break down of causes of calf pain.
Below is a table that outlines causes of calf pain, from common, to less common, and not to be missed.
|Common||Less Common||Not to be missed|
Delayed Onset Muscle Soreness
|Compartment Syndrome |
– Lumbar Spine
– Myofascial Structures
– Superior Tibiofibular Joint
– Knee (Baker’s Cyst, PCL, Posterior Capsular Strain)
– Popliteal Artery
– Endofibrosis External Iliac Artery
– Tibial Nerve
– Sural Nerve
– Posterior Tibia
|Deep Venous Thrombosis|
Causes of Calf Pain
Gastrocnemius Muscle Strains
Acute strain of the gastrocnemius muscle occurs when there is a sudden acceleration force exerted on the muscle, commonly from the extending knee in a stationary position with the ankle in dorsiflexion, along with lunging forwards while playing sport like tennis or squash. Another common mechanism is a sudden eccentric stretch, such as running onto a kerb and the ankle drops into dorsiflexion. The onset of pain is acute and often described as tearing or popping.
The medial head of the gastrocnemius has greater proximal attachment and a longer distal insertion into the Achilles tendon than the lateral head. Moreover, the medial head has a greater capacity for force generation, and therefore makes it more susceptible to injury.
Examination reveals tenderness at the site of injury and depending on the severity of injury a palpable defect may be present. The patient will often limp with walking. There may be swelling and bruising present. Active plantar flexion, passive and active dorsiflexion will be provocative for pain. Single leg calf raises will likely be too painful in the acute phase but may be beneficial to assess symmetry in later stage of rehab and return to sport. Measuring calf girth may also present benefit for later stage of rehab.
Soleus Muscle Strains
Another common cause of calf pain is the soleus muscle contains a high proportion of type 1, slow-twitch muscle fibres. This allows the soleus muscle to have a significant role in postural control, such as in standing.
Soleus muscle strains are more common at the musculotendinous junction. Soleus muscle strains are becoming increasingly more recognised with increased imaging, such as ultrasound or MRI.
Patients with acute soleus strains may present with sudden onset of pain, or alternatively with a history of increasing calf tightness over days or weeks. Walking and jogging are usually worse than sprinting.
Examination often reveals tenderness deep to the gastrocnemius, usually in the medial aspect of the soleus muscle. Soleus stretches and active resisted tests are provocative and differentiate between gastrocnemius injury.
The calf is a common site of contusion (bruising) caused through contact with playing equipment or another athlete in sport. Contusions are caused by a direct blow to the calf, which in turn causes bleeding and the development of a bruise.
The calf is the most common site for cramps. Cramps may occur at rest, during or after exercise. Cramps are probably the result of alterations in the spinal neural reflex activity by fatigue in susceptible individuals.
Delayed Onset Muscle Soreness
The calf is also a common site for delayed onset muscle soreness (DOMS). This usually occurs after the first training session following a period of rest or introduction of a novel exercise. Plyometric and eccentric exercises are most likely to cause DOMS.