Calf pain that just won’t go away is actually a fairly common complaint.
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Frustration with persistent pain often comes from difficulty in figuring out what’s causing your pain.
“It should be simple”, you say.
“Calf pain is probably a calf muscle strain”, you say.
Quick fixes: shoes, exercises and training with calf pain
Why does it feel like a knot in your calf muscle?
The feeling of a “knot” in the middle of your calf muscle is a common description of calf symptoms.
It feels like the muscle is twisted into a ball, or “knot” which just won’t go away.
The feeling of a knot in your calf muscle that just won’t go away often comes from a small area of muscle that is damaged or reactive.
That small area doesn’t move and stretch like the surrounding muscle bundles, so it feels like a knot in the muscle when you use the muscle.
It can cause calf pain as it pulls on the surrounding areas of the muscle or, if it’s torn, as the damaged area tightens up.
Nerve can cause a section of the muscle to fire continuously, creating a knot in the calf muscle with a localised reaction and calf pain.
What’s the best way to work out what’s causing your pain?
As Physiotherapists, we’ve devised a simple approach to confirming your own diagnosis, detailed in the section below.
If you are looking for something more accurate, obviously a trip to your local physiotherapist would be your best bet.
If you would rather not spend your cash on a physio visit, the next best option would be a diagnosis via e-medicine.
Our app, for iOS and Android, is due to launch mid 2022. It can diagnose calf pain using a custom algorithm, to think like a real Physiotherapist and to determine the cause and management plan for your pain.
Best of all, it costs you nothing to get an accurate diagnosis! Because we want as many users as possible so we can refine the algorithm, there’s no cost to obtain a diagnosis and find out what’s causing your calf pain.
How to diagnose your calf pain
To narrow down the possible causes of your calf pain, you need to start with the pattern of pain over the course of a run or fast walk.
Does your pain starts as soon as you start and improves over the course of the run/walk?
Likely diagnosis: an inflammatory response from a tendon or even a muscle attachment point on the edge of the shin bone.
Does your calf pain gets worse as the run/walk goes on and last 1-3 days after the session?
Likely diagnosis: Bone stress will typically ache for 1-3 days after every run. It will ache even when you’re not putting pressure on the leg.
Does your calf pain gets worse as the run/walk goes on, eases soon after you stop and get worse as soon as you start again?
Likely diagnosis: Muscle fatigue will usually be sore when the muscle is active or stretched but the pain goes away if you’re not loading or stretching the muscle. This will also occur in compartment syndrome.
Does your calf pain gets worse as the run/walk goes on, eases when you stop and only get worse after another extended period of exercise?
Likely diagnosis: Blood flow issues (we’re not talking about DVT or acute vascular issues) will usually get progressively worse as the duration of exercise increases. The calf pain eases soon after you stop running and gradually builds again as you return to running.
What scans can help diagnose calf pain?
Generally speaking, most calf pain can be successfully and accurately diagnosed based on a clinical assessment alone (that’s what your doctor or Physiotherapist does in their rooms).
However there are times when a scan or imaging is useful:
- Calf pain that hasn’t responded to treatment – despite doing the right thing, it’s just not improving after a few weeks
- Calf pain that’s slow to respond to treatment – it’s improving but much slower than expected
- Any concerning symptoms or symptoms that might have a nasty cause – the type of pain, swelling, numbness, weakness or other symptoms might indicate a more serious cause like a blood vessel issue or nerve issue
Knowing the right scan to go for is the domain of your treating practitioner.
It’s not as simple as “this is the best scan for calf pain” – every scan picks up different pathologies so it really depends what they’re suspecting or what they’re trying to exclude.
As a guide to the available imaging for calf pain:
- Looks at bone and bone repair, so it will pick up big fractures or recovering stress fractures
- It does not show muscles or swelling and any “soft tissue” structure as a cause of calf pain
- It won’t detect early stage bone stress fractures, as it can’t see the tiny crack in the bone and there’s no bony repair to see until after 4-6 weeks
- Overall, not a very useful scan for calf pain but often a starting point for doctors to exclude some pathologies
- This looks at soft tissue and swelling so it’ll spot most muscle tears and swelling, two common causes of calf pain
- It can be useful to detect tendon issues, although it will miss some types of tendon injury
- It can also detect blood vessel reactions, although there is a better type of ultrasound for this group of issues (see Doppler Ultrasound below)
- It won’t detect any bone issues
- Overall, a good scan for many sports-related types of calf pain
- A variant of the standard ultrasound above, this also measures the rate of movement of fluids
- That’s particularly important when looking for blood clots, such as DVT, which can cause calf pain and become life-threatening
- Overall, very good for blood vessel issues but very specific to these issues and some muscle/tendon pathologies
- Very accurate imaging of bone pathologies, so it’s great at picking up tiny cracks associated with bone stress fractures
- It also delivers high doses of radiation, so CT scans are used sparingly
- Won’t spot soft tissue damage specifically but it can spot pockets of fluid associated with soft tissue injury (as it provides a 3D assessment)
- It can’t see inflammation or reactions, only physical damage
- Overall, very specific to bone stress fractures and very detailed assessment of bone
- This shows almost all causes of calf pain, with detail of bone, muscle, tendon, ligaments and more
- It also shows reactions in structures without damage, so it can spot a bone stress reaction before it becomes a bone stress fracture
- It can see nerves and blood vessels but will only detect reactions or physical changes, it can’t detect blood flow rates or nerve conduction
- It does not have any radiation, making it suitable for use in pregnancy, children and other at risk populations
- Overall, great scan for almost all pathologies but can be very expensive (depending on who refers you and your insurance cover)
- As the name suggests, this looks at bones – more specifically the reaction inside a bone when it’s undergoing a healing process
- It involves the injection of a radioactive dye, so radiation dose needs to be taken into consideration
- It can’t specifically diagnose a calf injury, only highlight the location and severity of a reaction
- Overall, great at screening for bone stress reactions in multiple locations but limited in its findings (no specific diagnosis)
Nerve conduction studies
- This involves zapping the nerves with high voltage and seeing how fast the signal gets through
- Very unique scan that can test nerve function, information which no other scan can provide
- But it’s quite uncomfortable to perform and it only tells us about nerve function
- Overall, very detailed findings on nerve function but that’s it
How to relieve persistent calf pain
Much like any injury, we need to take a multi-pronged approach to relieving calf pain.
Step 1 – modify your current workload
In this step, we need to figure out the most provocative activity for your calf pain, such as running.
Score your pain out of 10 (called a pain scale) at a key point in the day – this might be one hour after the run, or pain at the 5km mark.
You’ll then need to adjust one of the parameters to begin to reduce the load on the calf.
In the example of running, that may be distance or time, or it could be elevation change (hills v flat).
This may mean that you have to keep running the same route for a while as it’ll be hard to compare one route to the next for difficulty.
Stick to the reduced loading for a week and then score your pain on the pain scale again.
If your pain has reduced by 2/10 or more, you’re on the right track.
Continue with the same restrictions until your pain gets to 3/10 or less, then begin to gradually return to more loading.
If your pain hasn’t reduced after a week, you’ll need to restrict your training further for the next week.
Repeat this process until your pain has eased and you’re back to full capacity.
Step 2 – rehab exercises for the calf
This isn’t as simple as doing 1000s of calf raises a day – that often makes calf pain worse.
If your calf muscle is overworked, adding fatigue from calf raises only makes that worse.
And by making it stronger, it becomes more dominant and even more overloaded.
This includes gluteal exercises, like a Bulgarian squat, and hip stability exercises, like a lateral step down.
Focus on building strength in other areas to relieve the load in the calf muscles.
It’s a slow build so be patient and consistent – strength improves within a few weeks but you won’t suddenly run faster and your calf pain won’t just switch off.
Step 3 – additional support
This step refers to anything that might help support the cause of the pain.
It might be taping to help foot stability, if your cause of calf pain is overloaded stabilisers.
It might be heel inserts, if your cause is a lack of ankle range.
You get the idea – each approach only works for a specific cause of calf pain.
There’s no generic, fix-all approaches to calf pain.
So if a friend mentions that orthotics fixed their calf pain, that would be because it fixed whatever was causing their injury.
We hear of many disheartened people who tried all the “guaranteed” fixes and ended up wasting time and money.
So for this step, I’d suggest you invest in a session with a good Physiotherapist and take their advice on what’s causing your calf pain.
Otherwise it’ll be more expensive to experiment with fixes in the long run.
What if the knot in my calf keeps happening or doesn’t settle?
Persistent or recurrent calf problems are one of the most frustrating problems faced by runners and footballers.
Just when you think you’ve got on top of the issue….BAM! It gets you again.
It’s important not to get too overwhelmed with the emotion of the situation. Take a few days and a few deep breaths
Don’t push it for the 2-3 days after you feel the tweak. This is critical to figure out how it’s going to respond.
Most tweaks will pass within a day or so and you’re back on track. If it feels normal after a day, aim to slowly rebuild your training intensity over the next two weeks.
If it’s still troublesome after 3 days, start your basic rehab exercises – double leg strength work, hip strength exercises and some trunk work. Prolonged rest after a tweak makes it more likely to get overloaded on your return.
After a week, if you’re not feeling it, test it gently with some single leg calf exercises and a light jog. If it responds well, rebuild your intensity over the next 2-3 weeks.