Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia
Pearl: Don't confuse a soleus muscle strain with an Achilles tendon or gastrocnemius muscle injury.
Presentation: "What's the deal with the soleus?" I asked myself after seeing a series of patients over a period of months with apparent injuries isolated to this muscle. Typically these were older "athletes" who presented with pain in the lower medial calf with running and walking. They also reported marked pain with palpation or inadvertent contact of the posterior lower leg. Consistently there were no known traumatic events that caused the pain. Typically, these individual admitted to having recently increased the amount of running they were doing.
On examination the patients demonstrated marked pain to palpation of the posterior lower leg inferior to the muscle bellies of the gastrocnemius muscle. Interestingly, tightening the gastrocnemius muscle with mild plantar flexion against resistance (and thereby protecting the soleus by the tightened gastrocnemius tendon) shielded the underlying soleus from a painful examination. However, when the gastrocnemius was relaxed, palpation of the lower posterior leg resulted in my patients nearly jumping off the examination table. These patients also tended to have pain when they stood on the tips of their toes.
Discussion: The name of the soleus muscle is derived from the sole fish whose shape it resembles. (See figure 1.) It is a powerful muscle in the lower posterior leg that runs from just below the knee to the heel. (See figure 2.) Some anatomists consider it and the gastrocnemius muscles to be a single muscle, the triceps surae. The action of the calf muscles, including the soleus, is to plantar flex the foot.1 They are vital in walking, running, and dancing and the soleus specifically plays an important role in standing (i.e. if not for its constant pull, the body would fall forward). The muscles of older athletes have undergone significant changes and more prone to injury and slower to heal.2
Treatment of this injury is rest, ice, NSAIDS and gentle stretching.3 Stretching of the soleus is demonstrated in figure 3 and is similar to one recommended for the gastrocnemius muscle. The different stretches can be differentiated by remembering that knee bent exercises work the soleus muscle and stretches that straighten the knee focus on the gastrocnemius muscle. Wearing a heel pad will shorten the calf muscles and reduce dynamic tension on the muscle. Other possible and probably unproven modalities are ultrasound and massage. Finally, muscle strengthening exercises are generally part of muscle injury rehabilitation.
References:
- http://www.wheelessonline.com/ortho/soleus
- Goodpaster BH, Park SW, Harris TB, Kritchevsky SB, Nevitt M, Schwartz AV, Simonsick EM, Tylavsky FA, Visser M, Newman AB. The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. J Gerontol A Biol Sci Med Sci. 2006 Oct;61(10):1059-64.
- http://www.topendsports.com/medicine/stretch-calfsoleus.htm
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