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Calf strains are a common acute soft tissue injury seen by sport doctors. Most calf strains occur in the inside of the large calf muscle called the medial gastrocnemius. We see calf muscle tears usually in middle-aged active patients in sports such as running, football and tennis. In fact, calf muscle tears are so common in tennis players that we refer to these calf injuries as ‘tennis leg’.

How do calf strains present?

Most patients report sudden pain in their calf with activity. More commonly, the pain is located on the inside of the calf. Patients may limp or have difficulty walking. Also, swelling or bruising of the calf may be present.

Assessment of the injury reveals tenderness at the inside of the calf. Swelling and bruising of the calf is often present. Patients may have problems standing on their toes because of pain and weakness in the calf.

It is important to exclude other injuries such as Achilles tendon ruptures, soleus muscle tears or bone injury.

Does your torn calf muscle need investigation?

Previously, we thought that most torn calf muscles did not require investigations. However, a new study published this week (and co-authored by me) suggests otherwise. This study examined hundreds of patients with calf strains. All patients had an ultrasound scan of the calf. Interestingly, the study found that the location of the tear influences the time to return to activity. For example, if the tear is only in the calf muscle, then the injury is short-lived. However, if the tear involves the muscle and the connective tissue or surrounding Achilles tendon, then the injury time is almost three times as long. Also, cases with bleeding in the calf muscle led to longer injury. It seems that ultrasound is useful at grading these calf strains.

How do we mange a torn calf muscle?

At the beginning, it is important to rest the calf. Compression with a bandage or sock is important to reduce further bleeding. A heel raise in a shoe will help with walking. Occasionally, in larger tears with bleeding in muscle, it may be necessary to remove the blood to help healing. This procedure of removing the blood is done with a needle under ultrasound-guidance’. Also, crutches or a walking boot may be necessary.

As pain reduces and walking becomes easier, patients start a slow and gradual exercise programme supervised by an expert such as a physiotherapist.

In summary, calf strains are a common injury in runners and other sports such as tennis. Seeing a sport doctor is important to grade the tear and rule out other injuries. A recent study shows that ultrasound helps with deciding on return to activity. These injuries are treated with exercise in most cases.

Dr Masci is a Sports and Exercise Medicine doctor with an expertise in the management of general musculoskeletal injuries including muscle injuries. An expert in MSK ultrasound with a specialisation in ultrasound-guided injections for joints and tendons, he has written 20 peer-reviewed papers. He has presented at international conferences including Arsenal football conference. Dr Masci consults at OneWelbeck. For enquiries, please contact info@sportdoctorlondon.com or visit his website www.sportdoctorlondon.com

Injections for tendonitis?

I see many patients with tendonitis – tennis elbow, golfer’s elbow, Achilles tendonitis, patellar tendonitis, hip tendonitis, foot tendonitis and wrist and hand tendonitis. Managing tendonitis is always difficult, partly because we don’t completely understand tendonitis. Partly, also, because our treatments are not great. I wrote a blog explaining how to manage tendonitis. Exercise is the best medicine for patients with tendonitis, but some cases are resistant to exercise and require other treatments.

One option for patients with difficult tendonitis is an injection. We have used cortisone injections for tendonitis since the discovery of cortisone over 70 years ago. Today, doctors perform over 500000 steroid injections for arthritis or tendonitis. Cortisone is a good pain reliever for arthritis and tendonitis, but it has some nasty side effects such weakening of tendons. Recently, other injections such as platelet-rich plasma (PRP) or hyaluronic acid are used to inject into or around tendons to help with pain.

What is the evidence for injections in tendonitis?

According to a recent paper, we are a bit clearer on the positives and negatives of an injection.

First, it is becoming clear that cortisone injections produce short term pain relief but little long term benefit. Also, there are some tendons (tennis elbow) where an injection of cortisone can cause harm. While the evidence for harm is not definite for other tendons, the balance is certainly favouring a negative effect.

Second, platelet-rich plasma (PRP) injections, which shows promising results in arthritis, seem to be less effective in tendonitis. There are a few studies that show a positive effect of platelet-rich plasma (PRP) injections for tennis elbow and plantar fasciitis. However, there is no evidence for benefit in Achilles tendonitis or patellar tendonitis. I outline the evidence for PRP in this recent blog.

A specific type of injection called high-volume injection for Achilles and Patellar tendonitis showed some promise in early studies. However, recent work suggests that the effect is probably short term and limited.

Other injections such needle tenotomy have some evidence for use in tennis elbow. But there is little evidence for other tendons. Recently, a new procedure pioneered by me called tendon scraping is used for some cases of Achilles and Patellar tendonitis with good results.

Finally, injections of tendons are better under direct vision using ultrasound to improve accuracy.

To conclude:

In summary, injections form a small part of the treatment of tendonitis. Exercise treatment should always be the first treatment. I only use an injection in difficult cases. More importantly, I try to avoid injections that cause harm such as cortisone injection.

Dr Masci is a Sports and Exercise Medicine doctor with an expertise in the management of general musculoskeletal injuries including tendonitis. An expert in MSK ultrasound with a specialisation in ultrasound-guided injections for joints and tendons, he has written 20 peer-reviewed papers on tendonitis. He is a recognised tendon specialist and has presented on tendonitis at international conferences including Arsenal football conference. Dr Masci consults at OneWelbeck. For enquiries, please contact info@sportdoctorlondon.com or visit his website www.sportdoctorlondon.com

What is tendonitis?

Let us begin with a brief overview of tendon function and structure. Tendons are the fibrous connective tissues which attach a muscle to the bone. The primary function of a tendon is to transmit the force from the muscle which permits movement. Close inspection of tendons reveals the presence of rope-like collagen proteins. These proteins bundle together to form fibrils.

Essentially, tendonitis is a breakdown of the collagen proteins within the tendon.  Many times, this breakdown occurs rapidly as the result of sudden stress or movement. However, it can also occur over a period of time, as in the case of gradual tendon overload. Finally, ageing and certain medical diseases such as diabetes or obesity can also contribute to the development of tendinopathy. Overall, the condition is common in the general population, even more so than osteoarthritis.

Diagnosing tendonitis

For the most part, patients with tendonitis complain of pain arising from their tendon. The pain often occurs after an activity that stresses the tendon. Common activity/tendon correlations include running and the Achilles tendon, jumping for the patellar tendon or playing tennis or golf for the tendons of the elbow. Finally, tendonitis pain is usually inflammatory, which means it warms up with the activity and often gets worse during cool down.

With these points in mind, most cases of tendonitis are easily identified through accurate description of the pain. Nevertheless, an examination is always useful to exclude other causes of pain arising from structures such as muscle, ligaments or joints. For example, some causes of knee pain in runners is due to cartilage injury of the knee joint rather than the tendon.

Likewise, imaging can be helpful to identify the more complex cases.  MSK ultrasound shows typical changes of tendonitis with tendon swelling, collagen breakdown and large blood vessels. The advantages of MSK ultrasound are that it is inexpensive and readily available, often at the first consultation. However, some cases require a more detailed MRI scan to get a clearer picture of the changes in the tendon. MRI is particularly useful in hamstring or hip tendons, for example.

Tendonitis treatment

Previously, doctors thought that tendonitis simply produced active inflammation.  Accordingly, they would suggest taking anti-inflammatory tablets such as ibuprofen or diclofenac. Remember, they believed that the acute inflammation played a key role in the development of tendinopathy.

However, we now know that in tendonitis, tendons swell with water and then undergo a gradual breakdown of their collagen proteins. This relatively new understanding of the progression of tendonitis has led to a change in common treatment approaches. More recent studies suggest that anti-inflammatory medications delay or even slow down healing.

Considering these discoveries, physical therapy and exercise are now the most useful and effective treatments for tendonitis. Physical therapy must be supervised by an experienced physiotherapist. An important rehab principle for tendonitis is that the load placed on the tendon should be relatively heavier but less frequent for lower limb tendons (such as Achilles tendon). Conversely, load should be light and frequent for upper limb tendons (such as tennis elbow or shoulder rotator cuff). Another important principle in treatment is to find the critical factor that caused the tendonitis, such as an error in training or a weakness in the locomotive chain.

Patient outlook

Essentially, pain often improves with exercise therapy, but the how and why is unknown. It could be due to the direct stimulating effect of exercise on collagen fibres. Alternatively, it could an indirect effect of increased muscle strength and reduced load on the tendon.  In fact, improvements in tendon pain and function occur regardless of the type exercise done. For example, in Achilles pain, concentric exercise which forces muscle to shorten while contracting has a similar positive effect to eccentric exercise where the muscle lengthens with contraction.

In addition to exercise therapy, doctors or physiotherapists may use other techniques to improve the results of exercise. One such treatment is shockwave therapy, where sound waves produced by pressurised air are delivered directly to the diseased tendon. The sound waves initiate an inflammation, which stimulates the body’s own healing capacity. Another treatment is Nitric Oxide patches, which are applied to skin over the tendonitis and work to improve tendon healing and reduce pain.

In addition to shockwave, various types of injection therapy are used in more difficult cases. Dr Masci has performed research on the effects of different injections in tendonitis. A recent review co-authored by Dr Masci suggests that there are no clear favourites.  However, there is increasing evidence that cortisone can cause harm when used for some tendons such as tennis elbow.  It should be noted that surgery has little role to play in the treatment of many types of tendinopathy. A recent review of surgery found that outcomes are no different to physiotherapy despite risks such as infection or poor wound healing.

Summary

In conclusion, tendonitis involves the breakdown of collagen proteins in the tendon. The condition is quite common in active people.  Pain in the tendon post-activity is a common presentation. Imaging such MSK ultrasound can confirm swelling and collagen breakdown. Exercise is effective for most cases. Occasionally other treatments such as shockwave or injections can help patients recover.

Dr Masci is a Sports and Exercise Medicine doctor with an expertise in the management of general musculoskeletal injuries including tendonitis. An expert in MSK ultrasound with a specialisation in ultrasound-guided injections for joints and tendons, he has written 20 peer-reviewed papers on tendonitis. He is a recognised tendon specialist and has presented on tendonitis at international conferences including Arsenal football conference. Dr Masci consults at OneWelbeck. For enquiries, please contact info@sportdoctorlondon.com or visit his website www.sportdoctorlondon.com