The most common origin of calf pain is from the calf muscles, which are located between the heel and the knee joint. It consists of three muscles: the gastrocnemius, soleus and plantaris muscles. Calf pain is any feeling of discomfort in the fleshy tissue on the back side of the lower leg, from below the knee to above the ankle. Your calves are made up of muscles, tendons, ligaments, nerves and blood vessels, all of which are subject to injury, infection or other conditions that can be painful.

Calf pain may last briefly or be constant. It may affect your entire calf or only a localized area. Your pain may feel dull and achy, throbbing, piercing, or tingling. Pain-like sensations that are often described as pins-and-needles, prickling, or burning are called paresthesias. Calf pain may be simply irritating and uncomfortable or so debilitating that you can’t put weight on your leg or walk.

Sign and Symptoms

• Pain in the calf (at rest, during or after physical exertion or at night)
• Limited mobility in the ankle
• Reduced muscle strength to loss of strength while extending the foot
• Numbness or tingling along the lower leg
• Swelling, fluid retention
• unusual coolness or pale color in the calf
• redness, warmth, and tenderness of the calf

Muscle-Related Causes

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 a 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, and severe, sharp pain, a hematoma (a collection of blood) may sometimes form.

Soleus Muscle Strain

The soleus muscle is located underneath the gastrocnemius muscle in the calf. Straining of the soleus muscle is commonly a chronic injury that occurs in long-distance runners.² 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.² Swelling and bruising in the back of the leg may occur, along with cramping of the calf muscle.

Non-Calf-Muscle Related Causes

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. Without treatment, the clot can sometimes travel to the lungs (called a pulmonary embolism) and cause severe 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.⁵ 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

Pressure on nerves can cause symptoms like numbness, tingling, and/or sharp pain.⁶ The two nerve entrapments that most commonly cause calf pain are sural nerve and peroneal nerve entrapment. Rarely, a severe peroneal nerve entrapment can lead 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 flexion 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.⁷ 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). The symptoms of popliteal artery entrapment can 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—can cause 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 severe calf pain. 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.

Diagnosis

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. They may also check your reflexes and leg/ankle/foot pulses. Lastly, they will maneuver your foot, ankle, and knee, potentially performing specialized tests if a certain diagnosis is suspected.

An example of a special test sometimes used to evaluate calf pain includes:

Thompson test: The Thompson test assesses for Achilles tendon rupture and entails a doctor squeezing the calf muscle while the person lays flat on an exam table with their 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.

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.12 The inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), may be helpful in diagnosing or ruling out a bone infection.

Imaging

When diagnosing calf pain, doctors may utilize various imaging tests. X-rays can assess for many types of abnormalities of the lower leg, ankle, or knee. Additional tests, such as an ultrasound or MRI, may be used to evaluate calf tendon injuries, tears or, in other cases, blood clots. In some cases, more specialized tests such as vascular studies may be required to confirm the diagnosis.

Treatment

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 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.

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 leg or calf pain.

Degenerative causes: Doctors typically prescribe physical therapy for spinal or nerve entrapment causes of calf pain. In some cases, strengthening the muscles around the spine can correct body alignment and relieve pressure (compression) on the nerve or nerve root. For acute pain, your doctor may prescribe a short-term course of pain relievers. Steroid injections can calm inflammation.

Deep vein thrombosis: For blood clots, doctors prescribe “clot-busting” drugs (thrombolytics), blood thinners (anticoagulants), and compression stockings. Surgery may be necessary to remove the clot.

Infections: Doctors prescribe antibiotics to clear bacterial infections, such as cellulitis.

Peripheral artery disease: Medications are a common treatment for PAD with leg pain. These include drugs to lower cholesterol and blood pressure, blood thinners to improve blood flow and prevent clots, and pain relievers. Lifestyle changes, including a heart-healthy diet, more physical activity, and not smoking can help PAD from getting worse.

Varicose veins: The first-line treatment is self-care, such as compression stockings and more physical activity. Your doctor may recommend removing painful varicose veins with nonsurgical treatments.

Prevention and Self Care

• Stop the activity that is causing pain and rest your leg.

• Apply an ice bag on your calf for 15 to 20 minutes, several times a day. This will help reduce inflammation and swelling.

• Elevate your leg above the level of your heart (over the back of the couch, for example) when you are resting.

• Wrap an elastic bandage around your calf; loosen the bandage if it hurts. Compression will help limit swelling and provide support to the calf.

• Massage your calf gently to generate heat and relax the muscles and other soft tissues. You can also apply moist heat or soak in a warm bath.

• Take a magnesium supplement to help prevent cramps.
• Stop smoking and drinking alcohol, Maintain healthy weight

• Drink plenty of water to stay hydrated. This will help prevent muscle cramps.

Calf stretches

Perform gentle calf stretches for muscles cramps and for minor calf injuries after 1 to 2 days of RICE (rest, ice, compression, elevation):

• Sitting calf stretch: Sit on the floor with the affected leg extended and the other leg bent towards you. Wrap an exercise band or towel around your foot, placing the ball of your foot at the center of the cloth/band. Pull the two ends towards you until you feel a little tension in your muscles and tendons. Hold for 5 seconds, then release. Repeat a few times on each leg, at least once a day until the area heals.

• Standing calf stretch: Put your hands on a chair or palms against a wall, about an arm’s length away. Keep one leg back, with your forward leg slightly bent. Both feet are flat on the floor. Slowly bend your forward knee and elbows, moving your hips towards the chair/wall until you feel a stretch in the rear calf. Hold for 30 to 60 seconds. Repeat a few times with each leg.

• Small (baby) steps: Take a step very slowly—one step should take a minute. Start from a slightly staggered position. Slowly, lift your back foot off the ground all at once, rather than pushing off with your toes as you normally would. Only lift it 2 to 3 inches. Slowly bring it forward and place it gently next to your other foot. Now repeat with the other foot. Repeat a few times on each side, a few times a day if possible.

References :

https://www.verywellhealth.com/causes-of-calf-pain-and-treatment-options-2549387

https://www.healthline.com/health/calf-pain#prevention

https://www.healthgrades.com/right-care/bones-joints-and-muscles/calf-pain

https://www.mayoclinic.org/symptoms/leg-pain/basics/definition/sym-20050784

https://www.blackroll.com/pain/calf-pain

https://www.health.harvard.edu/pain/when-walking-makes-your-legs-hurt