Member Case Study: Tightness and Pain in the Calf Muscle

author : AMSSM

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I'm experiencing tightness and pain in my calf muscles including my left achilles tendon. The tendons seem to really stiffen when sitting or sleeping. I'm not doing anything new.

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Member question from kweezen
"Can anyone give me some ideas on the tightness and pain I'm getting in my calf muscles including my left Achilles tendon. I'm not doing anything new, in fact I've had to back off my training schedule. I am stretching as normal. I had pain start during a swim workout last Thursday and they have been tight and painful since. I do push off the wall pretty hard. I did a 25 mile ride and played golf last Friday and I could barely walk first thing on Saturday. The tendons seem to really stiffen when sitting or sleeping."

Any ideas? More water? Calcium? Endurolyte?

Answer by Adam Redlich, M.D., CSCS, CPT

Member AMSSM

CRAMPING
Certainly your initial thinking is appropriate – think fluids and electrolytes (like sodium, potassium, calcium) when it comes to cramps. You want to be sure you are hydrated – before/during/after workouts. Even on cooler days, cloudy days, or less humid days (weather when you might instinctively downplay drinking) - you do lose fluid during training and may not adequately rehydrate – the result can be cramping/strain on your muscles. It is not a bad idea to try to weigh yourself both pre- and post- workout – to get a sense of your sweat-rate or your fluid deficit. You should aim to make up at least as much as you lost and more by days-end by way of fluid replacement (as some fluid is already in your kidneys/bladder unavailable for recirculation throughout your body). Often, a small/moderate sized fluid/electrolyte deficit may occur each day for several days during initial training or a new training environment – leading to a significant overall deficit about a week later or when you “crash” (cramp/lock up).

Certainly fluid rich foods (like watermelon, oranges) and salty foods (like pretzels, V8) post workout help. Of course, the banana (great potassium) and milk (calcium source) should be part of your diet. Some advocate TUMS for calcium supplement, others consider GatorLytes or Endurolytes. A good rule of thumb during your workout/race is 5oz of fluid every 15 minutes (this tends to be the amount the stomach/intestines can absorb most efficiently) – preferably with a Gatorade-like fluid (i.e. with sodium, potassium).

Her is a quick and dirty measure of hydration is your urine frequency and color:

FREQUENCY - You want to return to your usual number of trips to the bathroom as baseline.

COLOR - If it’s more like Sprite...you’re alright...if it’s more like apple juice...drink a few. If your urine is Coca-Cola colored, that is alarming and could be a sign of kidney damage – known as rhabdomyolysis – which can present with cramping as well. Those with medical muscular conditions, those taking statin cholesterol medications or supplements, may be at more risk for this. Negative and positive effects on cramping from creatine and quinine, respectively, are controversial. It is wise to discuss with your personal doctor first before adding/cutting out a particular supplement.
 

STRAIN
You mention you are doing nothing new. It may be your workout regimen is too demanding. It is appropriate to build in 1-2 days rest (or relative rest of the overworked body parts) per week. Also, gradually increasing your workout training volume (time, intensity, frequency) over several weeks after establishing a solid base is the right way to train for an event. Beginner Triathlete has a number of excellent template/guidelines on the site.

Try not to build more than 10% training volume per week then after 2-3 weeks try to plateau or even back down to allow the body to acclimate to the new training load before progressing. Your body (calves) might be screaming for a rest, definitely listen to them. Even if you “miss a day”, remember your first goal is to get to the starting line, not to complete every workout listed in a template – then to have overuse injuries and not be able to compete. Keep in mind too that DOMS (delayed onset muscle soreness) may occur from 1-3 days or so after a workout. Perhaps the bike/golf day was a bit too much after having strained your calves from the swim push off.

Muscle strain – whether it is acute, chronic, or overuse - is really a partial tearing of tissue (at microscopic level) that needs time to heel. Sometimes heel-lifts or gel inserts (in both shoes) can help put the entire calf-achilles tendon complex on slack when walking/running and provide a “relative rest” during recovery.

FLEXIBILITY/STRENGTH
Naturally, muscles/tendons tend to passively shorten when at rest (sitting or sleeping). They also tend to linger in whatever position they were in when last worked – also shortened (but were actively shortened by the repetitive muscle shortening contractions). Thus, it is important to stretch after your workout as well as before. It may be possible that your stretching routine could use a tune-up. It is important to stretch your entire lower body kinetic chain to prepare your body for the workout stress you are putting it through.

Be sure your running/walking footwear is matched for your foot-type, as you may require an insert or orthotic to minimize excess stresses from the ground up (a good specialty running store can help out). Stretching needs to include ankles, gastrocnemus, soleus, achilles tendon, hamstrings, quadriceps, hip flexors, gluts. Because if one area is less flexible or weaker than another area picks up the slack and absorbs the stress and for you it might be the gastroc-soleus-achilles complex. Additionally, certain antibiotic medications can affect tendon function as can localized injections to the area. Consider what’s known as cross-friction massage (masseuse), muscle energy techniques (physician/osteopathic technique), or PNF = proprioceptive neuromuscular facilitation (physical therapy) to help gain flexibility.
 

NEUROVASCULAR
It would be remiss not to mention some more serious causes to consider as well. Like a blockage or clotting/build up of cholesterol type plaque near the heart, blockage can occur down lower in the blood vessels near the abdomen and hips. Some people may have a family history of vascular disease, others may have an acquired element of such (perhaps positioning on the bike causing kinking of blood vessels and suboptimal flow).

Claudication is the medical term for pain due to such cutoff of blood flow. Additionally, if one has pre-existing back problems – such as a spinal stenosis (narrowing of spinal canal) – he/she may present with pain in both calves after prolonged activity which extends the spine – pinching the spinal cord repeatedly. Chronic compartment syndrome is an entity that also may be due to suboptimal flow into/out of the various connective tissue anatomical “rooms” of the calves. This results in abnormally high pressures in the calves. Any of the above neurovascular entities can cause numbness/tingling/weakness and some result in color change such as pale or very red discoloration of toes or feet. Prompt medical attention is needed in any of these situations.

About the Author
Adam Redlich, M.D., CSCS, CPT (A+ Athlete – Sports Medicine, LLC) - (www.APlusAthlete.com) is a board certified Sports Medicine Specialist Physician, with additional certification in strength and conditioning and personal training. He is a faculty physician for Jersey Shore Sports Medicine Fellowship and he considers himself a “beginner triathlete”, having done several sprint races over the years, as well as two marathons. A total body approach – both traditional and complementary treatments (such as musculoskeletal acupuncture and osteopathic approaches) are used. Call (609) 223-2286 for an appointment in his Central New Jersey office.

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date: August 22, 2009