Causes of Calf Pain and Treatment Options

Everything you need to know about calf pain

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Your calf, located in the back of the leg, just below your knee, is made up of three muscles (gastrocnemius, soleus, plantaris). While injury to any of these may produce calf pain, conditions that affect the blood vessels, nerves, or tissues that envelop your calf muscles may do so as well. There are a variety of possible diagnoses, from muscle strain or rupture to a blood clot, and your doctor will want to know the specifics of your discomfort—like the quality (e.g., sharp, cramping) and intensity (e.g., mild versus severe)—to start getting to the bottom of why you have calf pain.

In the end, your treatment plan will depend on your underlying diagnosis, but addressing calf pain often entails therapies like rest, ice, and anti-inflammatory medication.

Causes of Calf Pain
Illustration by Joshua Seong. © Verywell, 2018. 

Causes

While most causes of calf pain are short-lived and benign, especially muscle-related diagnoses, there are some potentially serious ones, like a blood clot or claudication (when arteries in your legs are blocked). This is why it's always important to see your doctor for an evaluation of your calf pain.

Muscle-Related Causes

Here is an overview of calf pain diagnoses that are muscular in origin, ranging from a calf muscle strain (when the muscle is overstretched or torn) to a muscle cramp or bruise.

Calf Muscle Cramp

A calf muscle spasm or cramp—also referred to as a "charley horse"—refers to an involuntary contraction of one or more calf muscles. Muscle cramps in the calf are often reported as intensely painful, and may be associated with stiffness and a visible knot. Although this uncontrollable tightening of the muscle is generally short-lived, calf muscle soreness may persist for days.

Calf Muscle Strain

Calf muscle strain, and more specifically a medial gastrocnemius strain, is the most common cause of acute onset calf pain. Usually this injury occurs during a sports or exercise activity when pushing off suddenly during a sprint or jump. The pain of a calf strain is often described as a sudden sharp or tearing sensation. If severe, swelling and bruising may also occur.

A medial head calf muscle strain is sometimes referred to as "tennis leg," because it commonly occurs when tennis players quickly change directions to return a shot.

Calf Muscle Contusion

A calf muscle contusion or bruise often occurs after a direct blow to the calf or a series of repetitive blows to the lower leg. In addition to swelling, bruising (torn blood vessels), and severe, sharp pain, a hematoma (a collection of blood) may form.

Soleus Muscle Strain

The soleus muscle is located below the gastrocnemius muscle in the calf. Straining of the soleus muscle is commonly a chronic injury that occurs in long-distance runners. The pain is often reported as a deep soreness or tightness in the calf that can be reproduced when bending the knee and dorsi-flexing the ankle (pulling your toes back toward your shin) at the same time.

Plantaris Muscle Rupture

The plantaris muscle is a thin muscle that runs along the gastrocnemius muscle but is only a fraction of the size. When the plantaris muscle tears (ruptures), often as a result of lunging forward, a sudden, snapping pain in the back of the leg is felt. Swelling and bruising in the back of the leg may occur, along with cramping of the calf muscle.

Non-Calf-Muscle Related Causes

While muscle injuries are the most common cause of calf pain, there are others that may stem from nerve problems, knee joint problems, or foot and ankle conditions.

Achilles Tendonitis/Rupture

The Achilles tendon is the largest tendon in the body, and it connects the calf muscles to your heel bone. When the tendon becomes irritated, usually as a result of overuse, a burning pain may develop in the back of the leg, usually just above the heel. Calf pain and stiffness may also be present.

If the Achilles tendon tears ("ruptures"), a person usually experiences severe, sudden pain in the back of the leg, along with difficulty bearing any weight on the affected leg. In addition, some people report hearing a "pop" when the tendon ruptures.

Blood Clot

Blood clots can form in the deep veins of the leg (called a deep vein thrombosis) and cause the classic symptoms of swelling, redness, warmth, and a tender, cramping pain in the calf.

Certain conditions increase a person's risk of developing a blood clot such as:

  • Increasing age
  • Pregnancy
  • Obesity
  • Immobilization
  • Cancer
  • Smoking
  • Undergoing a recent surgical procedure

A blood clot is a very serious cause of calf pain because, without treatment, the clot can travel to the lungs (called a pulmonary embolism) and cause difficulty breathing.

Baker's Cyst

A Baker's cyst is not a true cyst but rather a collection of knee-joint fluid that pools in the back of the knee, most commonly as a result of arthritis. If a Baker's cyst ruptures, the fluid may leak down into the calf region causing an aching pain in the calf, along with swelling.

Nerve Entrapment

An enlarged or swollen calf can place pressure on nerves, causing symptoms like numbness, tingling, and/or sharp pain. The two nerve entrapments that most commonly cause calf pain are sural nerve and peroneal nerve entrapment. Rarely, a severe peroneal nerve entrapment leads to muscle weakness and foot drop.

Popliteal Tendonitis

The popliteal tendon wraps around the knee joint, connecting the thighbone to the popliteal muscle—a triangular-shaped muscle that works with the tendon to control forward motion and rotation of the knee. The pain of popliteal tendonitis is felt above the calf, in the back and side of the knee, and worsens when walking or running downhill. In addition to pain, if the injury to the popliteal tendon is acute, bleeding into the knee joint may occur.

Rarely, the popliteal tendon tears, but this may occur with trauma, such as with a direct blow to the inside of the knee.

Popliteal Artery Entrapment

Popliteal artery entrapment—a rare condition seen mostly in young male athletes—is believed to stem from a developmental defect in which a person's gastrocnemius muscle compresses the popliteal artery (located in the knee and back of the legs) when the knee is flexed.

The symptoms of popliteal artery entrapment include a deep pain in the calf that occurs after a vigorous lower leg workout, such as cycling or running.

Lower-Leg Peripheral Arterial Disease and Claudication

Claudication from lower-leg peripheral artery disease—when there is reduced blood flow in the arteries of the lower legs—causes pain in the buttock, hip, thigh, calf, and/or foot upon walking a certain distance. The pain resolves with rest within 10 minutes.

Claudication pain in the calf is usually described as cramping and results from narrowing of the artery in the mid-thigh (superficial femoral) or the knee (popliteal artery).

Fracture of Lower Leg Bone

A bone break or fracture in one of the lower leg bones (the tibia or fibula) may cause calf pain, often reported as constant. Leg deformity and swelling may also be present.

Bone Infection

Rarely, a bone infection in the lower leg may cause calf pain, usually described as dull and constant. In addition to pain, warmth, redness, and swelling may be present.

When to See a Doctor

If you are unsure of the cause of your symptoms, or if you do not know the specific treatment recommendations for your condition, you should seek medical attention. Treatment of calf pain must be directed at the specific cause of your problem.

Some signs that you should be seen by a doctor include:

  • Inability to walk comfortably on the affected side
  • Injury that causes deformity of the lower leg
  • Calf pain that occurs at night or while resting
  • Calf pain that persists beyond a few days
  • Swelling of the calf or ankle joint area
  • Signs of an infection, including fever, redness, warmth
  • Any other unusual symptoms

Diagnosis

In many cases, the diagnosis of calf pain is made clinically, meaning with a detailed medical history and physical exam alone. However, sometimes imaging tests, like an ultrasound, or blood tests, like a D-dimer, are needed.

Medical History

Prior to your doctor's visit, it's a good idea to jot down a couple notes about your calf pain, such as when it started, what it feels like, and whether you have experienced any other symptoms like numbness or swelling. In addition to inquiring about the specifics of your calf pain, your doctor will want to know whether you have any health problems and if you experienced a recent injury or trauma.

Physical Examination

During the physical exam, your doctor will inspect and press on (palpate) your lower leg in order to look for signs of swelling, tenderness, warmth, and discoloration or redness. He may also check your reflexes and leg/ankle/foot pulses.

Lastly, he will maneuver your foot, ankle, and knee, potentially performing specialized tests if a certain diagnosis is suspected.

Two examples of special tests sometimes used to evaluate calf pain include:

  • Thompson test: The Thompson test accesses for Achilles tendon rupture and entails a doctor squeezing the calf muscle while the person lays flat on an exam table with his or her foot hanging over the edge. The test is positive (suspicious for an Achilles tendon rupture) if the toes do not flex downward when the calf is squeezed.
  • Garrick test: The Garrick test may be useful for evaluating popliteal tendonitis. In this test, a person lies flat on their back on an exam table with the knees and hips flexed to 90 degrees. The test is positive if rotating the knee (your doctor will do this) causes pain at the site of the popliteal tendon.

Blood Tests

In most instances, blood tests are not warranted for diagnosing calf pain. That said, a D-dimer may be ordered to aid in the diagnosis of a blood clot. The inflammatory markers, erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP), may be helpful in making the diagnosis of a bone infection.

Imaging

Sometimes when diagnosing calf pain, doctors utilize various imaging tests. For example, an ultrasound may be used to evaluate calf tendon injuries, tears or, more seriously, a blood clot. If your doctor suspects a fracture of the lower leg, ankle, or knee, an X-ray may be ordered.

Less commonly, a magnetic resonance imaging (MRI) scan is ordered, most often to access multiple muscles in the calf at once, to diagnosis a nerve entrapment, or to diagnose popliteal or Achilles tendon injuries.

If your doctor is concerned about popliteal artery entrapment, a magnetic resonance angiography (MRA) is required to confirm the diagnosis. An ankle-brachial index (a vascular study) is used to diagnose claudication from peripheral artery disease.

Treatment

Treatment of calf pain depends entirely on the cause of the problem. Therefore, it is of utmost importance that you understand the cause of your symptoms before embarking on a treatment program. There are, however, some common treatments that are likely to be suggested.

Rest

The first treatment, in most cases, is to rest the muscles and allow the acute inflammation to subside. Often this is the only step needed to relieve calf pain. If the symptoms are severe, a walking boot and crutches may be helpful.

Ice and Heat Application

Ice packs and heat pads are among the most commonly used treatments for muscle or tendon-related sources of calf pain. Depending on your situation, one may be better to use than the other. For example, in the case of calf strains, it's best to apply ice four times daily (for 15- to 20-minute sessions) until the swelling subsides.

Stretching

Stretching the muscles and tendons of the calf can help with some causes of calf pain. A good routine should be established.

Physical Therapy

Physical Therapy is an important aspect of treatment of almost all orthopedic conditions. Physical therapists use different techniques to increase strength, regain mobility, and help return patients to their pre-injury level of activity—or as close to it as possible.

Medications

Nonsteroidal anti-inflammatory medications, commonly referred to as NSAIDs, are some of the most commonly prescribed medications, especially for patients with calf pain caused by tendonitis or a muscle strain, contusion, or cramp.

Less commonly, a steroid injection—called cortisone—may be used to treat certain sources of calf pain, like a persistent Baker's cysts or nerve entrapment.

If you are diagnosed with a blood clot, you will likely be placed on a blood thinner, also referred to as an anticoagulant, such as Coumadin (warfarin) or Xarelto (rivaroxaban). These medications prevent your current blood clot from getting bigger, and they also prevent new clots from forming.

Surgery

Rarely, surgery is needed to treat calf pain. One classic exception is an Achilles tendon rupture, which requires surgery within a day or two after the injury. In addition, a vascular surgery consult is required for a popliteal artery entrapment.

Prevention

There are some lifestyle habits you can adopt to prevent many calf-pain diagnoses, especially the muscle-related ones.

For instance, in order to prevent muscle cramps and strains in your calf, it's important to warm-up (for example, gently jogging in place) followed by stretching your calf muscle prior to exercising. Be sure to cool down after you exercise, as well. This means slowing down your activity for at least 10 minutes before stopping completely.

In addition, especially for muscle cramp prevention, it's important to stay hydrated and avoid overexercising, especially in very hot weather or rooms. Drinking an electrolyte drink or taking an electrolyte tablet—which contains potassium, magnesium, and calcium—and limiting alcohol and caffeine intake may also help stave off muscle cramps.

Lastly, while many non-muscle related sources of calf pain, like blood clots and claudication from peripheral artery disease, are not as straightforward when it comes to prevention, there are things you can do to minimize your chances of developing them, such as:

  • Stopping smoking
  • Maintaining a healthy weight
  • Taking your medications as prescribed
  • Seeing your primary care doctor for regular check-ups and screening tests (e.g., diabetes and cholesterol)

A Word From Verywell

You may be tempted to self-diagnose or try to treat calf pain on your own, instead of visiting the doctor. However, the problem with that is that some conditions are serious, like a blood clot, and require urgent management. With that, be good to your body and see your doctor. In most instances, some rest, ice, and a pain reliever will be all you need to get back to your normal routine.

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Article Sources

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