Member Case Study: Chronic Tight Calves

author : AMSSM

comments : 0

When I was only a runner, I didn't have this issue. But now, going into my third year as a triathlete, my calves and occasionally my Achilles are tight and painful throughout most of my mileage.

Member Question from Cindaroo

I am having a chronic problem with tight calves during my runs. When I was only a runner, I didn't have this issue. But now, going into my third year as a triathlete, my calves and occasionally my Achilles are tight and painful throughout most of my mileage. I notice that when doing leg curls in the gym, my calves are tightening when I am contracting my hamstrings; I don't know how to disengage my calf muscles. I tore my calf in two different races last year. The last time it was in the last half mile of a duathlon, so I was plenty warm, and it tore enough to bleed. Occasionally, during cycling, when I am pulling up on the back stroke of my pedal cycle during a steep hill, I will feel a tug in these muscles as well.

I have tried the Chi Running technique for the last few months, which helps a bit. I am working on being a midfoot striker since this feels a bit better than heel striking. I stretch my calves at least once a day, including negative stretches and calf raises. I also roll them on my foam roller. I rarely wear high heels.

Answer by Dr Christopher Meyering, DO
Member AMSSM

There are several possibilities to explain the symptoms you are having with varying severity. I will go through these from the most benign to most serious, and then discuss the management.

The first possibility is that your symptoms come from overtraining and not allowing the muscles to adequately recover. Adding cycling training to a running-only regimen is difficult due to time constraints, and athletes commonly alternate days of cycling and running in order to log adequate mileage. Although cycling can be seen as cross training, the calf muscles are still working hard, particularly during the pull through at the end of the power stroke. The added training plus weight lifting may be overworking the muscles, and an initially minor strain may have continued into the chronic stages as no repair time has been allowed.

The second potential cause stems from the injury you mentioned with the calf tear. I’m not sure if both injuries were in one calf or you had two injuries in each calf, however, so this may not explain why you have bilateral symptoms. After injuring the muscle your body will repair itself with collagen fibers as scar tissue. Scarring can remodel for a year after injury and can be a point of irritation with activity. As I mentioned, if you didn’t have a disruption in both of your calves this would not explain your symptoms.

The most concerning possible cause for your muscle tightness and pain is called exertional compartment syndrome. There are four compartments of the lower leg which each have two or three muscles plus nerves and blood vessels surrounded by a tough tissue called fascia. When the muscles are being exercised and begin to swell, the fascia is unable to expand, and the muscle, nerves, and vessels are compressed. Symptoms are exercise-induced aching, squeezing or sharp pain in the affected compartment(s), and occasionally numbness in the foot or leg. Symptoms will often start at the same distance while running and will resolve with cessation of activity. You mentioned that your calves and occasionally your Achilles tendons “are tight and painful most of (your) mileage,” so pay attention to the timing of when the pain starts.

The initial treatment for you is activity modification and stretching, and I’ll review each component for you.

It sounds like you are already using stretching to help with your problem, but I’d like to review stretching anyway. Invariably, when I see patients in the office and watch them perform their stretches, they use incorrect form. To start the calf stretch, have your feet shoulder width apart and take one large step forward. Your front knee should stay over the top of the foot and your back heel should stay on the ground with the back knee in a straight position. Your feet should still be shoulder width apart (not on a tightrope) and your hips pointing forward. I recommend keeping your shoulders above the hips, but you can lean forward slightly touching a wall for balance. The key feature is that the toes of both feet (especially the back foot) are straight ahead and not pointing to the side. Hold the position for 20-30 seconds and then relax. To stretch your soleus muscle (the lower portion of the lower leg), you bend your knee to 45 degrees and repeat the process.

Timing of stretching is controversial, but I recommend you stretch at least several times throughout the day to get the most benefit. The stretching session does not have to coincide with your activity.

For your strength training, I recommend you perform eccentric exercises for the calf. An eccentric exercise is when the muscle is contracting while it is being lengthened (a.k.a. “negatives”). Start with just your body weight initially. Rise up on both toes then lift one leg. Lower yourself down on the one foot as far as your heel will go. Perform 20-25 repetitions initially. Remember to use both feet to rise up and lower with the one.

When performing the hamstring curl you may be using too much weight and your calf muscles may be tensing up during the effort. Use a lighter weight while working on form and that will help you learn to disengage your calves. You can also use the straight-leg deadlift as a hamstring strengthening technique. When performing the deadlift, keep your back in a straight position and slowly bend forward at the waist. The potential for injury with this exercise is high, so if you have not performed this lift previously, ask a certified trainer to help you at the gym.

You may need to discontinue running briefly, as this seems to be the aggravating activity. The Chi Running technique is probably helping some because you may not be pushing off as much with your stride. If the symptoms are still there, though, I recommend pool running over not running altogether. You can purchase a waist floatation belt for your own use, or some pools may have some available for you. Wear the belt in the deep end and then run using the same form you would usually use. Pool run for the same amount of time you would on a regular run. This activity can be mindnumbing since you’re not really moving, so bring a training partner or music to occupy your thoughts. You can also visualize running a favorite path or race. Hopefully you have access to an indoor or heated pool this time of year, or you’ll be treating yourself to an ice bath at the same time.

Once your symptoms start to improve, gradually return to previous levels of activity. Avoid hill workouts with running and with cycling (if possible). If the terrain for cycling is hilly, use a high cadence and low resistance for the next 500-1000 miles until the pain is resolved. If your symptoms continue or if they seem to match up more with exertional compartment syndrome, you should see a sports medicine physician for a complete evaluation and testing if needed.

Christopher Meyering, DO is a Primary Care Sports Medicine physician and the Director of Sports Medicine for an Augusta, GA Family Medicine Residency program.

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date: January 5, 2009