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Calf Tightness

What Is Calf Tightness?

Calf tightness is tightness in the gastrocnemius and soleus muscles. These muscles form the bulk of the calf.

You may wish to read about the anatomy of the calf muscles here.

Calf tightness can lead to a number of problems in the lower leg and foot. As the gastrocnemius and soleus are large and powerful muscles, contraction of these muscles creates considerable force across the foot and ankle. Abnormally tight calf muscles can either cause or exacerbate a foot and ankle problem.

Calf tightness can be associated with the following conditions:

What Can Cause It?

Calf tightness can be caused by or be associated with the following:

  • Failure of adequate stretching following exercise such as running
  • Footwear contributing to chronic calf shortening ie high heels
  • Sedentary lifestyle with lack of regular exercise
  • Neuromuscular conditions
  • After a period of immobilisation for example in a plaster cast
  • Hamstring tightness
  • Chronic low back pain
  • Hindfoot deformity
  • Flat foot deformity (pes planus)
  • High arched foot (Pes cavus)

What Are The Symptoms?

The most common symptom felt in the calf in patients with calf tightness is muscle spasm and cramping pain.

It is not uncommon, however, for patients to have tightness in the calf muscle and actually have no or little pain and discomfort in the calf itself. Instead, these patients often complain of pain resulting from problems caused or exacerbated by the calf tightness as described above such as plantar fasciitis and Achilles tendon problems.

Tightness in the calf, increases the forces going across the forefoot (ball of the foot). When the forces are greater than normally encountered in the foot, a diagnosis of increased forefoot loading is made.

Increased forefoot loading exacerbates any problem a patient may have in the forefoot such as:

For information regarding symptoms in conditions associated with calf tightness please read the relevant condition page below:


Not all calf cramps are caused by calf tightness, the following may also be underlying causes and will be investigated as part of the initial work up:

  • Over exertion of muscles
  • Dehydration
  • Conditions that result in electrolyte imbalance
  • Medications such as  diuretics
  • Patients with kidney failure
  • Pregnancy
  • Underactive thyroid
  • Peripheral vascular disease
  • Idiopathic calf cramps (no known cause)

What Investigations May Be Required?

There currently does not exist any readily available and reliable investigation to measure calf tightness.

The best way of assessing calf tightness is by clinical examination.

Your surgeon will look for the following:

  • Positive Silfverskiöld test – Improved ankle dorsiflexion as the knee is bent indicates gastrocnemius tightness
  • Calf muscle tenderness on palpation of the muscle belly
  • Diffuse plantar forefoot callosity (increased thickening of the skin on the sole of the foot as a result of increased load going through the tissues)
  • Decreased forefoot clearance on heel walking
Clinical picture demonstrating the Silfverskiold test

Clinical picture demonstrating the Silfverskiold test

Clinical picture demonstrating diffuse plantar callosity of the forefoot

Clinical picture demonstrating diffuse plantar callosity of the forefoot

Decreased forefoot clearance on heel walking

Decreased forefoot clearance on heel walking

 

Can The Problem Get Worse?

Left untreated, calf tightness can lead to various problems as already discussed above.

If you develop increasing pain and spasms in your calf muscle this needs to be investigated and treated.

Non-Operative Treatment Options

Non-operative management for calf tightness aims at relieving pain and return to full activity, including sports whenever possible.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. New training regime and exercise program.


Soft tissue massage

Massaging the affected muscle can alleviate cramps.


Physiotherapy

Calf stretches (particularly eccentric) as part of a comprehensive physiotherapy program can be very successful in stretching out the calf muscles.

The following exercises are recommended as part of any physiotherapy program:

  • Gastrocnemius (calf muscle) stretches
  • Soleus (calf muscle) stretches
  • Gastrocnemius Eccentric loading
  • Hamstring stretches
  • Gluteal muscle strengthening
  • Core stability

Please read here for more details about the exercises.

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

Releasing the calf tightness may be done as a sole procedure or in conjunction with another operation. It may be done at the same time as the foot operation or as a staged procedure depending on the condition being treated.


Proximal medial gastrocnemius release

This operation involves making a small 2cm incision at the back of the knee and releasing the medial head of the gastrocnemius muscle. It lengthens the calf muscle and relieves the tension across the Achilles tendon. It is very effective in reducing pain and improving function. It has a 85-90% success rate.

The operation is carried out under local anaesthetic and a short sedation. It is a day case procedure so you can expect to go home the same day. As the wound itself is small and the operation involves cutting fascia and not muscle most patients are able to walk out of hospital without crutches and are able to drive within 4 to 5 days. Calf stretching exercises are recommended for 2 weeks post surgery to help maintain the increased length obtained by surgery.

Expect to feel the benefit of the operation 6 to 8 weeks post surgery.

A typical wound following a proximal medal gastrocnemius release

A typical wound following a proximal medal gastrocnemius release

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Worsening pain
  • Calf muscle tear
  • Achilles tendon rupture
  • Exacerbate co-existing foot condition

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • Need for further surgery
  • Complex regional pain syndrome
  • Wound healing problems
  • Painful scar
  • Persistent pain

Potential specific complications of proximal medial gastrocnemius release include:

  • Saphenous nerve injury
  • Persistent tightness

Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

The operation will be done as a day case procedure.

Following a proximal medial gastrocnemius release –

You will have a small waterproof dressing applied to the back of the knee. It is advised not to remove this until seen at clinic by Mr Malik at the 2 week follow up.

For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.

Most patients are able to walk comfortably without any aids after the operation. If both legs have been operated on then crutches maybe necessary. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence calf stretching exercises as soon as possible after the operation. Activities can be gradually increased as pain allows.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.


Six weeks post operatively

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably and most patients can sense an improvement in their symptoms and improvement in the calf tightness.


Three months post operatively

Final clinical examination. Discharge if satisfactory.

FAQs

How long does the operation take?

This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.

The time given below is only a guide to the actual surgical time.

For a proximal medial gastrocnemius release 

15 minutes


When can I drive?

Following a proximal medial gastrocnemius release – 

Most patients are able to drive within a week or two. Please see guidance below.


When can I return to work?

Following a proximal medial gastrocnemius release – 

Most patients are able to return to work within 3 to 5 days.


What should the final outcome be?

Following a proximal medial gastrocnemius release – 

Excellent pain relief and return to sports by 3 to 6 months in approximately 90% of patients.

When can I drive?

As soon as you feel safe to do so and can do an emergency brake.

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