How do I tell a calf strain apart from an Achilles rupture?

Achilles rupture is usually a clinical diagnosis: absent plantarflexion on the Simmonds-Thompson test, a positive Matles test, a palpable gap above the heel and no single-leg heel raise. A calf strain preserves these findings, with tenderness higher in the muscle or at the musculotendinous junction. Ultrasound helps when examination is equivocal.

How long does a calf strain take to recover?

Timelines vary widely: in one cohort of elite athletes graded on MRI, mean return was about 8 days for grade 0, 17 for grade 1, 25 for grade 2 and 48 for grade 3, and injuries involving tendon or aponeurosis take longer. Return should be based on criteria rather than a date.

Should I take anti-inflammatories after a calf strain?

NICE CKS advises paracetamol or a topical NSAID first, with an oral NSAID considered after 48 hours if needed. The PEACE and LOVE framework raises a concern about very early anti-inflammatories, but this is a consensus position rather than a NICE prohibition.

Why should DVT always be considered with a calf injury?

The symptoms overlap, DVT can occur alongside a calf muscle injury, and lower-limb immobilisation raises VTE risk. A large tear can also raise the Wells score. If DVT is possible, follow the NICE pathway with the 2-level Wells score, proximal leg vein ultrasound and D-dimer.

Calf Muscle Injury

Lower Leg

Lens

Overview

Calf muscle injury is a strain or tear of gastrocnemius, soleus or plantaris, ranging from a low-grade strain to a complete tear, most often of the medial head of gastrocnemius (tennis leg).

It typically affects middle-aged recreational athletes as sudden posterior leg pain during explosive push-off. The main clinical hazard is missing 2 mimics with the same picture: deep vein thrombosis (DVT) and acute Achilles tendon rupture. Check for both at every calf injury consultation.

Anatomy & Pathophysiology

The superficial posterior compartment contains gastrocnemius, soleus and plantaris, which join to form the Achilles tendon.

Posterior view of the lower leg showing gastrocnemius medial and lateral heads, soleus, and plantaris with the medial gastrocnemius musculotendinous junction highlighted as the most common calf injury site — Posterior calf anatomy. The medial gastrocnemius musculotendinous junction is the most common calf injury site (tennis leg). Soleus injuries are more common in running athletes.

Gastrocnemius crosses the knee and ankle and is predominantly fast-twitch. The medial head is the most common injury site, the lateral head less so
Soleus crosses the ankle only and is predominantly slow-twitch. Its injuries, particularly those involving its central tendon, may take longer to recover
Plantaris is small; its rupture can mimic a medial gastrocnemius tear but rarely changes management

Gastrocnemius tears follow ballistic loading with the knee extended and the ankle dorsiflexed, such as a lunge or push-off, often with a sudden pop. Soleus injuries can be gradual with overuse or acute during steady running, especially uphill, usually without a pop.

The best-supported risk factors are increasing age and a previous calf strain. Fluoroquinolone antibiotics raise the risk of tendon injury and rupture, especially of the Achilles: the MHRA warns this can occur within 48 hours of starting treatment or be delayed several months after stopping.

Clinical Pearl

•Medial gastrocnemius (tennis leg) is the most common calf injury
•Gastrocnemius fails with the knee extended in ballistic loading
•Soleus fails during steady running, usually without a pop
•Test soleus with resisted plantarflexion with the knee bent

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Calf Muscle Injury

Overview

Anatomy & Pathophysiology

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Frequently asked questions

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