Member Case Study: Soleus Pain

author : AMSSM
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Question from Tri14kix
I am new to triathlon training as my background has been mostly bodybuilding and strength training with some running many years ago. Most of my aerobic training has been spinning, so when I began running for my first sprint I began having issues with my left soleus. At about the 1/2 mile mark my left soleus becomes extremely tight and painful. The pain then progresses into my left arch and then into my left knee.

 

My left knee does feel swollen behind the patella (a sensation that I need to pop my knee), and I attribute this to my soleus. I also feel as if my knee catches or will give out during my stride. My left tibia is also extremely tender to touch about six inches above my ankle medially. I have only run a total of about four miles since the beginning of July because my stride is affected by my soleus, so I cannot imagine this is from overtraining. My running volume was zero prior to July for over 10 months. I also do not believe it is shin splints as my tibialis anterior is without pain. The pain is on the tibia medially and my soleus both medially and laterally.

I also have some right knee pain medial to my patella which radiates down to my tibia. This has improved with rest and ice. I do have a nagging tibia patellar tendonitis as a result of heavy squats and lunges last year. The condition did heal through the winter with decreased intensity but returned with my first run.

I am also running in some new shoes. I have a low arch with mild to moderate overpronation so I am running in Brooks Addiction 8, which are motion control shoes designed for my foot fall. I cannot completely blame the shoes as I had issues last summer (but to a lesser degree) with my left soleus while running warm up laps prior to softball games in different shoes.

I appreciate any thoughts you may have regarding this complaint.

By David Kelly MD
Member AMSSM

The question you pose is a challenging one due to the numerous symptoms you are experiencing. I do not have the space to discuss all of your issues so I will deal with your main complaint – the soleus muscle. It is possible that all of your symptoms stem from the soleus issue and we can resolve them all anyway.

With that said, let’s talk about the soleus muscle. The soleus is a long, wide, thin muscle that runs from its origin at the proximal tibia to its attachment at the heel as part of the Achilles tendon. It lies just deep to the gastrocnemius (calf) muscle. While the calf muscle is short and thick and the tendon long, the soleus is long and the tendon is short.

Differentiating between gastrocnemius and soleus pain is typically done via location. Calf pain is usually felt high up on the back of the leg, often radiating into the posterior knee. Soleus pain is typically felt at the midpoint of the back of the leg. As the soleus lies fairly close to the back of the tibia, the tibia pain being experienced may be related to the soleus problem. (That said, I would not completely disregard the notion of shin splints or stress fracture.) More likely, though, is that your calf and/or soleus are tight. This tightness will cause strain on the soleus, thereby causing pain during running. It also accentuates plantar flexion (pointing of the toes downward) which puts strain on the tibialis anterior, leading to shin pain (even though the muscle itself may not seem sore).

To see if your calf or soleus is tight, do this little test:

  • Stand with one leg on a small step stool facing sideways toward a mirror.

  • With the other leg straight and the ankle at 90 degrees (neutral), dorsiflex the foot (pull the foot up towards your head) as much as possible.

See figure 1.A.

 

  

 

You should be able to dorsiflex about 20 degrees from neutral. If you can’t, then the calf muscle is tight. Now repeat the whole process but with the knee bent to 45 degrees as well.

 

See figure 1.B.

 

 

 

With the knee bent, you are isolating the soleus muscle. If you can’t dorsiflex to 20 degrees from neutral then the soleus is tight.

A tight soleus muscle could potentially contribute to the arch pain, shin pain, and knee pain you are experiencing (assuming you don’t have multiple problems occurring simultaneously). The above test should offer some insight into how to stretch the soleus and calf in isolation.

 

There are many variations of position (i.e. leaning against a wall or standing on a step) when stretching the calf region, but in principle they are all the same. Actively dorsiflex the foot with the knee straight and you stretch the calf. Do the same with the knee bent to about 45 degrees and you will isolate the soleus.

 

See figure 2.A and 2.B.

 

 

 

 

 

A distinct difference is felt between the two stretches with the soleus stretch being felt only in the lower half of the leg along the Achilles tendon and not in the calf muscle.

Increasing flexibility in the gastrocnemius and soleus should help resolve these symptoms, but it will take time. Additional measures include local massage and body weight resistance exercises. I suggest one- or two-legged toe raises with high reps (25-30). This should be done with knees straight and also with knees bent. You may continue to run during this rehab process. Do not stretch prior to running. Instead, just do a five-minute warmup, your run (even if it’s only a mile), then stretch and cool down afterwards. You may also wish to alternate between walking and running during your training sessions until your symptoms start to improve.

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date: October 15, 2008

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AMSSM

The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

FIND A SPORTS MEDICINE DOCTOR

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