Friday, March 13, 2009

Calf Pain- is it my Achilles Tendon?

Achilles was a mythical Greek warrior, most famous for his role in the Trojan war. A mighty fighter, Achilles killed the Trojan Hector, as reenacted in this scene from the movie "Troy".

Achilles was the son of the nymph Thetis and Peleus, the king of the Myrmidons. When Achilles was born, his mother tried to make him immortal by dipping him in the river Styx. However, he was left vulnerable at the part of the body she held him by, his heel

The Achilles tendon is aptly named- a complete tear of this structure is a devastating injury, often career ending for many athletes.

The Achilles tendon (also known as the triceps surae), is formed by the confluence of the medial gastrocnemius, lateral gastrocnemius, and soleus muscles. Achilles tendinopathy and strains are a common problem, and can be
clinically difficult to distinguish from tears of the distal gastrocnemius muscle, particularly the medial head of the gastrocnemius muscle.

Another tendon that is in close proximity to the Achilles is a thin, rope-like tendon known as the plantaris. This tendon typically tears in the upper leg, and the examiner can be hard-pressed to distinguish between a tear of the medial head of the gastrocnemius muscle, a high Achilles strain/tear, and a plantaris tear.

In this case 36 year old male felt calf pain. His physician sent him for an MRI, with a prescription stating, "MRI right distal leg, possible Achilles tear".

The MRI technologist read the prescription, and (appropriately) imaged the distal leg:

Note that the Achilles tendon is absolutely pristine on this T1-weighted image.

It is at this point that the MRI technologist proved himself a master of his craft. He had interviewed the patient, and noted that the pain was actually in the mid calf, more than the distal calf. The technologist then slid the patient out of the MRI magnet and switched coils (a coil is a device used to pick up the MRI signal), and reimaged the patient. All this takes extra thought, extra time and extra care, but this is what separates the good MRI technologist from the excellent technologist.

This coronal STIR was then obtained, showing fluid in the upper calf, in a location and morphology highly characteristic of a tear of the plantaris tendon (Helms et. al, radiology 195:201-203, 1995):

The patient's fear of an Achilles tendon tear was assuaged, and the much more sanguine diagnosis of a plantaris tear was given.

The plantaris muscle originates from the lateral aspect of the distal femur, courses down the calf, and then inserts on to the calcaneus bone of the foot. Plantaris tendon tears are treated conservatively, and have an excellent prognosis, unlike Achilles tears, which have a much more prolonged recovery, and may need to be addressed surgically.

Vic David MD


Keshav Kulkarni said...

Yet another good one.
- Dr K Kulkarni (

Dan Bodor, MD said...

You have a fantastic blog site with excellent case reports. Regarding this case, although we have classically attributed hemorrhage at this location to plantaris tendon tears, an excellent study performed at UCSD in 2002 points out that only a very small minority of these are from plantaris tendon tear and the vast majority are actually from gastrocnemius injury. In nearly every case I have seen since reading this paper, I have found a partial medial gastrocnemius tear, typically at the distal myotendinous junction, that accounts for the hemorrhage. Conservative treatment remains the same.

Vic David MD said...

Thx for your comments.

I tend to agree with you, the vast majority of "tennis leg" cases are medial head of gastrocnemius tears.

For me, when I see the hemorrhage concentrated near the myotendinous junction of the medial head of the gastrocnemius, I will call it a gastrocnemius tear. When there is a paucity of fluid at the gastrocnemius myotendinous junction, and the hemorrhage tracks along the course of the plantaris tendon, I will call it a plantaris rupture.

As you pointed out, both conditions are treated in the same fashion. One of those lucky cases in medicine where you don't have to be completely correct to help the clinician manage the patient!

Anonymous said...

I'm 40 years old, who had a complete tear of the medialhead of the gastrocnemius muscle at the distal myotendinous juntion. I must see the orthopedi expert in a couple days to see what treatment to follow. My physician is saying is not a case for surgery.
I would like to know a couple things. When and why surgery wouldn't be so effective as conservative treatment. Is my injury case for surgery? How many months I would need for full recovery? thanks.
excellent website!

Anonymous said...

Dear Anonymous...I'm 36 years old & did the same thing! I did it stepping down from the step in step aerobics & it's been 5 weeks since I did it. I've already been in a cast for 2 weeks to reduce the swelling & my movement. Now I'm in a boot. I am not seeing any results even with therapy. I have begun therapy, but see no improvement. First, I have the same questions as you do. No one seems to have a clear cut answer for me & they seem to shy away from talking about surgery. I'm a runner & they are telling me at least a year before I will run again. Everything I read says even walking again my be as much as 6 months. But, again, my actual orthopedic surgeon & therapists don't seem to want to answer me definitively, making me even more nervous. I hope someone can answer this who has experience in this exact type of tear & can offer us both insight.
Signed, Nervous Runner!

Facey Poo said...
This comment has been removed by the author.
Gamlin said...

Hey there, i'm up in arms over my calf pain.

I have led a sedentary lifestyle on and off for the last couple years and approximately 4 months ago I developed a pain in my left calf.

Seemed to only be there in the mornings and only when I was sitting, if I ran or biked, it would go away for a few hours.

Then it progressed to the right leg...

It usually is in the back of the calf sometimes in the front.

Usually gets worse at night.

Seems to be like a dull squeezing sensation thats always there in both legs.

In the morning it seems to almost be in my ankles.

I'm a non-smoker, was a heavy alcoholic for a couple years, but have been sober for almost a month.

I had a ddimer (negative) and venous ultrasound. Negative.

Full physical.. everything came back good, except slightly elevated high cholesterol and slightly low good cholesterol.

WBC slightly low too, but i'm sure it's not related.

blood glucose good.. so im pretty sure not diabetes.

What would be the next step in diagnosis treatment??

Would really appreciate some insight.


Anonymous said...

Hi i am a fit 33 year old woman who has increased my exercise classes from one a week to two and also play netball once a week. Last night went out to recieve centre pass and BANG felt like someone shot me right in middle of my left calf or kicked me. Felt like constant cramp in calf, cant walk with foot straight can only apply weight on toes with crutches for five paces b/fore pain increase. Did not sleep even after icing,elevation & compression still painful. Pain is mostly in calf and soleus muscle, achilles sore if pressed pain runs up leg. Trying to work out whether calf or achilles? Will go to physician tomorrow request MRI, would like to have more of an idea as to what i am suffering from!
Thanks nurse mich

Facey Poo said...

Hello folks above, I too have recently injured my calf (last night). I had a full tear of two quad muscles last December while playing softball and managed to finish out the game, and play the doubleheader. However, last night as I was standing still ready to return a serve playing tennis and POW, I thought I had been shot in the back of the leg. It hurt so much that I initially believed that I was hit by a rubber bullet (I was shot with one from a shotgun during training in the USMC a few years back), and it was/is 10X more painful than the quad tear. Fearing the worse (full rupture), I went to the emergency room. Not only did the Dr. admit that she had no training in soft tissue injuries, she said the hospital prohibits MRI's for soft tissue. WHAT? She also thought I was going to be ok because I wasn't in pain, but I had to explain that my pain level while at a 3 when not moving, was a BIG 10 when she squeezed or flex/extended my calf. So here is my dilemma, I am 33, full time Grad Student, no health care (Disabled Vet), and scared as hell after reading these posts. Do I go to get the MRI, or is the treatment for all of these injuries the same with varying recovery times? It seems like no one can get repairatory (made that word up) surgery unless we are in Pro Sports (not really fair). Some info about the injury, my calf muscles are very well defined, but at the moment one is flat like I had implants and someone popped it. I can not straighten my leg while placing my ankle @ a 90 degree angle, but I can do both independently. I can place weight (30%) on the ball of my foot while both my ankle and knee are bent, but 0% in any other position. What do you think/can you advise? Any help would be much appreciated.



Much of the pain has subsided, and I have regained the ability to stand flat on the foot. However, I am still fully incapable of walking forward or pushing off with the injured foot. My calf is still flat compared to the other, or itself prior to the injury. I have friend who was a Wimbledon finalist about 10 years ago. He says he knows two people with a similar injury,. One he says started out like mine, but hasn't been able to push off with his injured leg for over 8 months and he is still limping around. The other he says, arrived at the same point in the healing process as the other, and and was back playing tennis about 3 weeks later. I am curious, are there any signs (other than MRI) that hint as to the extent of the injury (one that are visible now), that can give me a clue as to what I am in for? What degrees of separation exist between the medial head tear, and the plantaris rupture? Is one less damaging than the other? Thank you for the help.

Anonymous said...

I had suffered a "pluck" when stretching forward to retrieve a drip shot from the opponent with my left leg trailing behind and was about to recover to upright position I had this injury. My left calf swelled to enormous size and sign of blood seen onthe surface of the lower leg. It was excruciating painful. How long will that heal?

Denise Williams, LMT said...

Thanks for the post. A new patient of mine presents with many of the symptoms in this post.

Best regards from Much Kneaded Massage of NYC

Denise Williams, LMT said...

Follow-up. I've made some progress with my sports massage client as a result of reading the info in this post.

Thanks again

ateel7 said...

i came upon your blog here as i await confirmation of my own achilles question...did you have a thompson test done?? would like to know if it you had no movement and it still turned out to be your calf?

ateel7 said...

i came upon your blog here as i await confirmation of my own achilles question...did you have a thompson test done first?? would like to know if it you had no movement and it still turned out to be your plantaris?