Evaluation of Calf Pain

Differential Diagnosis

Common

1. Muscle strain of the Gastrocnemius or Soleus

2. Muscle Contusion of the Gastrocnemius

3. Muscle Cramps

4. Referred Pain from the Lumbar Spine

5. Delayed onset of Muscle Soreness

Less Common

1. Superficial Posterior Compartment Syndrome

2. Deep Posterior Compartment Syndrome

3. Referred Pain: Superior Tibiofibular Jlint or Knee

4. Entrapment of Popliteal Artery or Endofibrosis of external iliac artery

5. Stress fracture of the Fibula

6. Stress fracture of the Posterior Cortex of the Tibia

7. Varicose Veins

Not to be Missed

1. Deep Venous Thrombosis

2. Arterial Insufficiency

History

• Description of the onset of pain

• Previous Injury

• Low back pain

Physical Examination

Remember that a complete examination should include the joint above and below. Always examine the knee to rule out knee injury or ligamentous disruption. Also examine the ankle, and Lumbar Spine (for referred pain)

Inspection

1. Assess for swelling

2. View ankle from behind: loss of definition of acchilles tendon indicates significant swelling

3. Check condition of skin

Palpation

1. Tibia

2. Fibula

3. Gastrocnemius

4. Soleus Muscle Body

5. Soleus Aponeurosis

6. Deep Posterior Compartment

7. Anterior Compartment

Motion

Muscular Strength

Muscular strength is graded on the MRC Scale

1. Plantarflexion; Gastrocnemius and Soleus,

2. Dorsiflexion; Tibialis anterior, extensor digitorum longus, extensor hallicis longus, peroneus tertius

3. Inversion; Tibialis anterior,

4. Eversion; peroneus longus, peroneus brevis

Neurovascular

1. Check the Heel Jerk Reflex (S1 S2) and grade

2. Check Distal Sensation

Special Tests

1. Thomson's Test for intact acchilles unit (also known as the Simmond's Calf Squeeze Test)

Investigations

1. Plain Films: Rarely Useful

2. Ultrasound: May help differentate between a muscle strain and a contusion.

3. MRI: Also helpful in questions of Strain versus Contusion

4. Doppler Ultrasound: If DVT is suspected.

Appendix

Muscular Movers of the Ankle

Index

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