While working with the South Simcoe & Dufferin Track & Field Club I assess and treat a lot of “tight calves”. Most athletes are instructed to stretch and roll out their calves when they are sore from the previous workout. If the cause of their pain is myofascial (muscular) in nature then I would generally agree with this advice. However, I was surprised how many of these athletes have a tibial nerve irritation which presented itself as tight and tender calves. For the athlete, it is important to know that this is a different type of injury and requires a different style of treatment than a calf strain. In fact, stretching and foam rolling may continue to irritate the nerve and worsen the injury.
As a chiropractor my most important tools are my hands and my understanding of human anatomy. The knowledge of human anatomy and the nervous system is vital to the proper examination and treatment for each athlete. My hands are also important because they provide me with a lot of information during both the physical examination and treatment. It’s the combination of these two things that allows me to “find the sore spots”.
When assessing someone with “tight calves” I rely on palpation to identify muscular tightness. The calf has a lot more muscles than most people realize. Use the image below while reading through the next paragraph so you don't get lost.
The outermost compartment is made up of the plantaris, gastrocnemius and soleus. The calf on the left-hand side is showing the gastrocnemius and solues. Deep to the soleus is an intermuscular septum that divides the superficial compartment from the deep compartment which houses the flexor hallucis longus, flexor digitorum longus and tibialis posterior. These muscles can be seen in the calf on the right because the superficial muscles have been removed. Flexor digitorum longus is farthest to the left, tibialis posterior is in the middle and flexor hallucis longus is farthest to the right. Understanding the location and depth of each of these muscles allows me to identify which ones are the cause of the pain.
Because of the different attachments of these muscles we can preferentially stretch each muscle to identify which ones are limiting motion. The gastrocnemius crosses both the knee and the ankle so it is tensioned most with ankle dorsiflexion and knee extension. The soleus only crosses the ankle and can therefore be tensioned with just ankle dorsiflexion. A good test for muscle length of the superficial compartment is the knee-to-wall test (seen in the image below). In this test you should be able to hold your foot about 10cm away from the wall and then bring your knee to the wall without pain or your heel coming off the ground.
The flexor hallucis longus and flexor digitorum longus run deep to the gastrocnemius and soleus in the calf and then run along the inside of the ankle behind the medial malleolus and then along the bottom of the foot to the toes. A good test for these muscles is the toes elevated knee-to-wall test (seen in the image below). It is quite common for runners to have limitations with this test and it is important to address because not having a full range of motion will alter their gait pattern by forcing them to have a shorter stride or turn their foot out.
Ok, now let’s get back to the tibial nerve irritation. The tibial nerve can be seen on the image of the calf muscles, as the yellow wire running along the center of the right calf. The tibial nerve is a branch of the sciatic nerve that runs through the popliteal fossa (back of the knee), and then dives through the proximal attachment of the soleus (calf muscle). It runs along the inside of the ankle deep to the flexor retinaculum with the tendons of the tibialis posterior, flexor hallucis longus and flexor digitorum longus. It then branches out to provide innervation to the bottom of the foot. Palpation at the possible areas of entrapment and along the length of the nerve provides me with information that may lead me to the diagnosis of a tibial nerve irritation. The other test is to have the athlete lay on their back and dorsiflex their ankle then monitor the symptoms they experience in their calf. Next, the patients leg is brought into a straight leg raise while maintaining ankle dorsiflexion. If they experience increased symptoms in the calf with hip flexion then they are showing signs of increased tension and irritation along the tibial and/or sciatic nerve.
As I mentioned previously, the treatment for a tibial nerve irritation is different than a calf strain or myofascial pain of the calf musculature. Some of the treatments I use include nerve mobilization with soft tissue therapy and/or local vibration and acupuncture. The goal of nerve mobilization is to move the nerve through its area of entrapment with the goal of increasing nerve motion and decreasing nerve tension. If the nerve is tensioned it can be painful and increase the symptoms the patient is experiencing. This is why stretching is not indicated for this diagnosis!!!
If you have been experiencing calf tightness, book an appointment for a complete assessment and proper diagnosis. Knowing the cause of your symptoms will help to guide an individualized treatment plan to get you back to do what you love as soon as possible.