Understanding Gastrocnemius Tendinopathy
The gastrocnemius muscle is located on the back of the calf. The upper end of the muscle attaches on the back of the knee, while the lower end inserts onto the back of the heel via the Achilles’ Tendon. The gastrocnemius is a important ankle and knee muscle, and plays an important role in maintaining proper mechanics at the knee with weight bearing activites such as walking, running, and climbing stairs. If the gastrocnemius becomes strained or overloaded pain can occur in the back of the knee and/or back of the calf.
In our experience almost every case of gastrocnemius tendinopathy is related to 1) a biomechanical problem as the hip of foot that is creating excessive strain on thegastrocnemius, or 2) a sciatic nerve problem. These issues must be addressed to fully resolve the gastrocnemius problem (see discussion below).
Signs and Symptoms of Gastrocnemius Tendinopathy
- Gradual onset of pain and/or tightness on the back knee or calf
- pain may be more towards the inside or outside of the knee depending on whether the medial or lateral head of the gastrocnemius is involved
- Stiffness or tightness on the back of the calf
- ankle stiffness/reduced range of motion
- In the early stages pain symptoms usually improve with warm-up or exercise
- In later stages pain may worsen and be present during activity
What Causes Gastrocnemius Tendinopathy?
Gastrocnemius Tendinopathy is an example of a repetitive strain injury. Unlike a traumatic injury which is caused abruptly following a trauma or accident, repetitive strain injuries (referred to as a RSI for short) are associated with very small amounts of tissue stress and damage that, if not addressed, can accumulate slowly over time and lead to pain.
Here’s how this works….
As the gastrocnemius is stressed and over-used it can lead to small scale damage in the muscle. This damage is referred to as ‘micro-trauma. Although only small this damage still needs to be repaired. The body does this by forming new tissue in and around the injured tissue. This new tissue, often referred to as scar tissue or soft tissue adhesions, is very sticky and acts to ‘glue’ the damaged tissues back together. For an analogy, think of a big rubber band with a pin prick in it. This pin-prick does not affect the rubber band much, but we still want to repair it so we put a little dab of glue over the area.
If the overload at the gastrocnenius continues (this is almost always associated with biomechanical problems at the hip or a restriction in the sciatic nerve, see below) there will be ongoing micro-trauma and subsequent repair of this micro-trauma. Overtime, this scar tissue will build up and will start to interfere with the normal strength and flexibility of the gastrocnenius. Going back to our analogy, think of this as more and more pin pricks in that rubber band, followed by a big build up of glue around the area. This will in turn make the rubber band stiffer and weaker. As scar tissue builds-up in the gastrocnemius it cannot stretch or contract as well. At this point pain and in the back of the knee, or calf will develop.
Why the hip and pelvis are important with gastrocnemius tendinopathy
It is important to realize that many cases of gastrocnemius tendinopathy are actually caused by a problem at the hip or pelvis. If the muscles around the these segments are not working properly it will force the gastrocnemius to contract harder than normal during during such as walking, running, climbing stairs, or with exercises at the gym. The gastrocnemius is essentially forced to compensate for these problematic muscles. (“Do you want to know if your knee pain is linked to a problem at your hip or pelvis? Try squat test, 1 leg squat test, or lunge test). If these issues are not resolved the gastrocnemius tendinopathy will not fully resolve, and will likely come back in the future.
Is your gastrocnemius tendonopathy caused by a sciatic nerve problem?
In addition to muscle problems at the hip and pelvis, a restriction in the sciatic nerve is also a common cause of gastrocnemius overload. The sciatic nerve is the major nerve that supplies the muscles, joints, and skin of the leg. As the nerve travels down the leg is passes between, underneath, or in some cases through many key muscles of the leg (including the piriforms, hamstring, and calf muscles). Under normal circumstances this nerve must be able to move and slide along these muscles. However, if any of these muscles develop scar tissue adhesions (which occurs with repetitive overload, see above) the sciatic nerve can become stuck or glued to these muscles. This is turn prevents the nerve from sliding along the muscles, and instead the nerve is over-stretched with leg movements. This can damage the nerve, so when the nerve becomes restricted the body must find a way to protect it. It is common for the body to increase the tension in the muscles on the back of the (especially the hamstings and calf) as a protective mechanism. This prevents the nerve from over-stretching). Although this solves one problem it creates another as over time the over-activity of the gastrocnemius can lead to a pain and injury. (To see is a restricted sciatic nerve restriction may be causing your hamstring pain try a Sciatic Nerve Tension Test).
Treatment – Resolving Gastrocnemius Tendinopathy
The proper treatment of gastrocnemius tendinopathy must not only address pain and tissue damage at the gastrocnemius itself, but MUST correct any biomechanical problems at the hip or pelvis, or any restriction in the sciatic nerve if either of these factors are present.
For treatment to be effective we have found that there are certain steps that must be followed, and these steps must be performed in the right order if we are to expect the right results. Here is our approach when treating gastrocnemius tendinopathy in our clinic….
Step 1 – Resolve scar tissue adhesions and facilitate healing
Perhaps the most critical most critical step is to treat the scar tissue adhesions. These adhesions are a sign that the gastrocnemius (or other surrounding muscles or sciatic nerve) is not healthy, and unhealthy tissue will not respond as well to traditional stretches and exercises – think of trying to stretch out that rubber band caked with glue. Resolving scar tissue adhesions is a critical step in resolving gastrocnemius tendinopathy, but it is often a missed or underappreciated step as many practitioners do not have the clinical skills to address this problem.
Scar tissue adhesions do not resolve with stretching or traditional massage or soft tissue methods, but instead must be treated with specialized techniques. One of the most effective methods is to use a technique known as Active Release Techniques (ART). For those who are unfamiliar with this treatment method, ART is a new and highly successful hands-on treatment method that was specifically designed to identify and address scar tissue adhesions that are interfering with the normal movement of the body.
During an ART treatment the practitioner will first shorten the muscle, tendon, ligament, or joint capsule and then apply a very specific tension with their hands as they stretch and lengthen the tissues. As the tissue lengthens the practitioner is able to assess the texture and tension of the tissue to determine if the tissue is healthy or contains scar tissue that needs further treatment. When scar tissue adhesions are felt the amount and direction of tension can be modified to treat the problematic area. There are ART protocols to treat specific muscles and tendons, as well as restrction in the sciatic nerve.
Step 2 – Correct strength and flexibility
Simply treating the scar tissue adhesions will make the damaged tissue healthier, and will often result in a significant reduction in pain. In fact, it is not uncommon to see a significant improvement in just a few visits. However, although addressing the scar tissue makes the muscles healthier, they may still be somewhat tight or weak. When this is the case specific stretches or exercises can be incorporated into a home exercise/rehabilitation routine to help support in office care. Initially the focus is on correcting local muscle deficiencies (i.e., at the knee, hip, or foot).
Step 3 – Re-Train Functional Movement Patterns
The final stage with treatment is to ensure proper alignment and movement coordination of the foot, knee, hip, and trunk with functional movement patterns. This ensures movement of the hip, knee, and foot are coordinated and working together as a unit. This is what is required during real life activities such as running, walking, cycling, and climbing stairs (the key functional movement patterns with respect to gastrocnemius tendinopathy include the squat, 1 leg squat, and lunge).