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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 or visit his website

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 or visit his website

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.


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 or visit his website

ITB Friction Syndrome (or ITBFS for short) is one of the most common conditions a Sports Medicine Doctor will see, particularly during the Spring/Summer months as people become more active and ramp up their training for events such as triathlons or obstacle course races.


But what is it, why does it happen and more importantly what can we do about it?


In my first year as a junior doctor I was a keen 5-10km runner, running 3-4 times per week around central London. I then managed to gain a place in the London Marathon and so I slowly began to build up my training.

I thought I was doing everything right; following a programme to the letter, buying my trainers from a running shop (with a gait assessment) and everything felt good during each training session. That was until injury struck with just 3 weeks to go after running around the beautiful Somerset countryside.

Unfortunately, the knee pain was so intense that I was unable to run the marathon that year – even walking was a struggle, so 26.2 miles was never going to be an option.

I spoke to my GP who referred me to a physiotherapist, and it was at that point that I was diagnosed for the first time with ITBFS.

After four months of physiotherapy, having worked hard on my strength, control and flexibility, I was pain free and back running 10-12 miles at a time with no symptoms. I was ready to restart my training for my deferred marathon place, but this time I was going to take things slower.

Everything felt great until 3 weeks to go (again) when the pain returned with a vengeance. My ITBFS was back.


Why me? How can I make it go away? These were the questions I needed to answer at this point.

Many years later, a sports and exercise medicine diploma and a masters looking at ITB, I might not have all the answers, but I now know where I went wrong.


What is the ITB?

The ITB is a piece of fibrous connective tissue, which is an extension of the Tensa Fascia Lata (TFL) located at the top of your hip.

The band tracts down the outside of the thigh and inserts on a bony bump known as Gerdy’s Tubercle (on the outside of the knee), along with the patella and the femur.


How does the band cause pain?

This is open to some debate. It is generally thought that that band flicks over the lateral femoral condyle as the knee bends and straightens as you run, cycle or walk.

This then leads to inflammation at the area of friction and the patient experiences pain on the outside of their knee.


What factors can trigger ITBFS?

Generally, there are usually 2 or more factors that lead to someone developing ITBFS. These can include:

  • Over-pronation (rolling in of the foot) leading to the knee losing control as it bends. This increases the tension on the band. This could be due to the wrong type of trainers, or because the trainers are reaching the end of their life.
  • Incorrect bike set up resulting in the cyclist having suboptimal positioning on the bike. This affects both the knee position, the tension on the band and the number of times the knee hits the angle of most friction.
  • Hill training – this requires a higher level of strength control required to cope with the increased fatigue that results. Running downhill also increases the number of times the band flicks across the friction point
  • Running regularly on a camber – this affects the position of the knee as the heel strikes the ground which in turn leads to a higher tension on the band and an increased prominence of the lateral femoral condyle
  • Training beyond your body’s current physical capabilities – increasing training should be matched by an appropriate strength and conditioning program to reduce the fatigue effects that occur as the mileage or intensity is increased.
  • Poor flexibility
  • Changes in training program


How is it diagnosed?

This is usually done relatively easily based on the symptoms someone has and what is found during the examination.

An ultrasound scan may be performed to demonstrate if the band is thickened or is there is any fluid surrounding it.

An MRI is commonly performed if the diagnosis is in doubt, or if there is a failure to respond to standard treatments.


How is it treated?

The vast majority of patients improve after a period of rehabilitation.  It is however important to identify the key factors that lead to ITBFS developing in the first place so that these can be addressed and hopefully prevent it reoccurring.

For some people, additional interventions maybe required.

  • A short period of anti-inflammatory medications (very common)
  • Ultrasound guided steroid injection into the point of pain (common)
  • A review by podiatry to perform a gait assessment and to consider orthotics to help with foot positioning (moderately common)
  • Botox injections into the TFL (rare)
  • Surgical lengthening on the ITB (very rare)


So, what went wrong with me, why did my pain return? As with all ITB related pain, my symptoms came as a result of a number of factors. I had the right trainers; the right training program and I had been through physio but that wasn’t the whole picture.

I made 2 key “errors” that lead to the perfect storm as I increased my mileage.

  • For 4 months I worked hard on my strength and control with the physio. However, I made the schoolboy error of stopping the exercises when I was discharged given, I felt better. All the hard work was wasted as I slowly deconditioned and returned to my old habits. Elite athletes spend almost as much time in the gym as they do in their chosen sport, making them faster and stronger but also importantly to reduce their injury risk.
  • On both occasions I made 1 key change to my training late on. Being based in London the vast majority of my runs were on the flat, but the final runs were on the hills of Somerset – something my body was not conditioned to cope with over a 18-20-mile distance.


I eventually completed the marathon that year with the help of a steroid injection to try and calm my symptoms. I wasn’t pain free, but I finished, and I now know what it feels like to struggle with an overuse injury while trying to achieve a goal. I also know the importance of getting to the route cause of why an injury occurs.


With my Sports Medicine Consultant head on, what advice would I give to anyone who suffers from any injury to help them get on top of their symptoms?

  • If you are a runner, get an up to date gait assessment and the right pair of trainers for you. Feet change over time so what was right for you 2 years ago may not be right now.
  • Don’t make major changes towards the end of your training – e.g. don’t start hill training with 3 weeks to go (I learnt that the hard way)
  • Strength and conditioning is important. While you might not have as much time as an elite athlete, at the very least try and do 1-2 sessions per week.
  • Don’t ignore your symptoms, the longer you leave it the harder it is to sort out.
  • If you are struggling and a big day is approaching, consider a steroid injection. This won’t fix the underlying issue but might get you through the event.