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[Expert Physio Q&A] Calf injuries unraveled: shoes, surfaces, and syndromes with Craig Purdam

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This episode with Craig Purdam is a snippet taken from our Practicals live Q&A sessions. Held monthly, these sessions give Practicals members the chance to ask their pressing questions and get direct answers from our expert presenters. In this episode Craig discusses:

  • Medial tibial stress syndrome 
  • Rocker bottom shoes 
  • Surfaces and distances and their roles in relation to calf injuries
  • Popliteal artery entrapment syndrome


👉🏻 Learn more about Physio Network’s Practicals here - physio.network/practicals-purdam

Craig Purdam was the Head of Physical Therapies at the Australian Institute of Sport for 35 years and the Deputy Director of Athlete Services for 3 years. He has worked as a clinician for elite sport for over 40 years and has been a physiotherapist to five Olympic Games (1984-2000) and a longstanding physiotherapist to the Australian National Men’s Basketball team over that period. He has worked with the Australia national track and field, rowing and swimming teams along with AFL football.

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UNKNOWN:

you

SPEAKER_03:

The classic feature with this girl I was talking about is to run her on a treadmill and bare feet and her feet would turn white, which is really cool. Of course, the other things are reduced or absent pulses, discoloration of the foot, variable numbness, but that's certainly going to be more the nerve and also coolness of the lower leg and foot. So when you've got a collection of these, that's when you'd start to suspect this.

SPEAKER_01:

Welcome to another Insightful Expert Q&A episode. We're excited to share with you a snippet from a recent Q&A session with Craig Purdom. Craig is a renowned physiotherapist who served as the head of physical therapies at the Australian Institute of Sport over an impressive 35-year tenure. Craig brings a wealth of experience in managing elite athletes and a profound understanding of lower limb injuries. In this episode, Craig dives into the topic of calf injuries as part of his practical series with Physio Network. we'll be exploring key management strategies and uncovering some fascinating differential diagnoses related to the lower limb. Practical subscribers enjoy exclusive live access to these Q&As, where they can connect with leading experts and have their questions answered directly. We hope you enjoy the chat.

SPEAKER_02:

Craig, thanks for joining us. I'll let you introduce yourself and then we'll get into the many questions we have planned for tonight.

SPEAKER_03:

Craig Purdom, physio of a long time, worked at the Institute of Sport for 35 years, exposed to a number of sports, basketball, track and field, a lot to do also over the years with my out-of-work job now with different football codes and that sort of thing. So I've seen a lot of these challenges. Our knowledge has grown in all of these and calf injuries certainly has been another one of those challenges we're looking to meet.

SPEAKER_02:

First question, you mentioned that slow running selectively loads the calf and the proximal musculature isn't involved until faster speed. Does this mean on a return to run program that speed is not an important variable to control compared to other variables such as distance or terrain?

SPEAKER_03:

Yeah. Speed is important because if we go, and I think I mentioned this and Carlos Padret and others are very much of the same view, that running just at a slow plod really is a dominant calf exercise. And so we prefer And he prefers actually that people start running up around four or five meters a second. So it's no plot. It's actually more like a tempo type run. Here we're sharing between those proximal muscles and distal muscles. So it's not that speed is unimportant, but the question also raised the other variables we might consider such as distance, which we absolutely do, and also terrain. I'll get to terrain in a minute. But with the distance, as we're introducing them to running, we prefer that they just run through. A lot depends on the sport. Is it a basketballer and 30 meter run throughs or is it a footballer who might be doing sort of 60 or 80 meter run throughs? And then it's more about the volume of those repetitions you might be doing and you're quantifying the distance. You also quantify the velocity as you go up. The terrain or the actual surface you're running on is also a variable. You don't want the surface too soft or too slippery because we can get unanticipated loads on the calf and firmer surfaces are generally better because they're more predictable. So I'll just stop there. There's another question a bit on terrain a bit later, so I'll revisit that.

SPEAKER_02:

Moving on to the next question. Do you ever address footwear? If so, any recommendations, especially for returning to running following a strain?

SPEAKER_03:

Yeah, nice question. So obviously footwear in the early stages is very much about heel raises and other things to try and length protect. that particular lesion but later I think there's a good case and like I'm late to this and it was well after I ever did any running but the new shoes with the big lifts that actually do unload the Achilles and do unload the calf there's probably a pretty good case for returning to some sort of running in the higher stack shoes but by and large yeah I think they make a lot of sense in this case.

SPEAKER_02:

And again another follow-up is what is your view on like a rocker bottom shoe does that make it any easier for the calf, in your opinion?

SPEAKER_03:

It seems to, again, but this is more anecdotal talking from the running physigos who have tried all these out and they'll, Kevin Leavithall will tell me that his Achilles is a whole lot better and he can recover from one session to the next much better in these rocker bottom shoes. We did have an issue though with them in some of our elite athletes. If they did all their training in these, a couple of them just lost their soleus. It they just fell off a cliff because they've worked out a way of actually propelling themselves along with not having to use it so much. And so with those highest level athletes, we generally try and recommend a mixture of shoes because then they'll go from that and go to the track in spikes. And it's not like the spikes have got big lifts, so I had to try and find some happy medium. But better people to answer this would be people like Kevin and all those guys, Brent Kirkbride and others.

SPEAKER_02:

Brilliant. Thank you. Next question. Can you discuss the calf muscles involved in MTSS? Does the calf muscle or attachment cause MTSS?

SPEAKER_03:

Look, this is some work Ben Ray Smith, Scott Epsley and myself were playing around with maybe 10, 15 years ago or so, and it really hasn't advanced as much as we would like. But our understanding of medial tibial stress syndrome really dates back to a guy called Don Detmer, who did a lot of work on compartment syndrome. So this was back in the 70s and 80s. He typified three different types of periostitis. The first one was like a medial stress fracture type thing, which you see in some people, but actually not a lot. This type two, which we're going to talk about, which is really an invaginate of the muscle that peels up the periosteum. And type three, which is actually more your compartment type syndrome, we're not going to talk about that. So it's this concept of it peeling up the periosteum. But the really interesting thing is where we get our medial tibial stress syndrome is where we haven't got any muscles originating. All we have is the posterior crural fascia enveloping those muscles and then coming into here and melding with the periosteum of the actual tibia. There's articles back in there that talk about a traction-induced thing, but it's not longitudinal traction. It's actually this transverse traction. And then this later work by Boucher and others, and they're the closest, they talk about this tenting effect, which in effect is sort of lifting the periosteum away from the bone. So a long-winded answer, but coming back to the questions So are the calf muscles involved? Yes, they are, but it seems to be much more about the FTL really lifting up the periosteum rather than the muscle tractioning off the tibia as we had been led to believe. Soleus lies outside that as just more superficially, and that may or may not be involved too. So I hope that answers that question.

UNKNOWN:

Music

SPEAKER_00:

We'll be right back.

SPEAKER_02:

Brilliant. Separate to MTSS, another question on popliteal artery entrapment syndrome. Have you had any experience with this in terms of diagnostics and treatment? I'd love to hear your thoughts.

SPEAKER_03:

Yeah, I've had some very unfortunate experiences with these. So the popliteal artery, our gastrocs actually start off in our legs somewhat laterally and then they migrate medially in our development. But there are eras within this and some are left still hanging on to lateral So we end up with tight bands around the popliteus. Some people have a third head of gastroc, which sits just here and also jams up the popliteal artery. Sometimes it's confused with the tibial nerve as it comes down here, but the tibial nerve is more affected by the plantaris muscle here. And so this can be part of the presentation as well. Similarly, when we're talking about gastrocs, we do see these people with hypertrophic gastrocs and In fact, almost without fail, the ones we see who've got this popliteal artery entrapment have huge, really dominant gastrocs. And I think we're seeing these a bit more in some of the girls. Nominally, males are 85% of the population, but we're now thinking with the advent of high-level sport for a lot of the girls that we're seeing a lot more popliteal artery entrapments. So I'm now just going to talk a bit about the presentation. So as we've said, male dominant. but most of the figures probably need to be revisited. The reason for the artery occlusion is generally about medial gastroc. And the classic feature with this girl I was talking about is to run her on a treadmill and bare feet and her feet would turn white, which is really cool. Because most people, when they examine people on a treadmill, they've got the shoes on, so you can't see it. That's a bit like trying to pick up RSD or something, you know, with someone's shoes on. So it's the same sort of deal. So this seems to be almost pathognomic of this condition. Of course, the other things are reduced or absent pulses, discoloration of the foot, variable numbness, but that's certainly going to be more the nerve, and also coolness of the lower leg and foot. So when you've got a collection of these, that's when you'd start to suspect this, and particularly if you've got fairly dominant gastrocs. So the artery entrapment syndrome, the initial management through the medicos is generally to try and Botox of the medial head of gastroc. Now, they don't Botox the entire belly. It's generally only about 5% or 10%. And then what they can do is retest with whatever the claudicant provocation was, and then they can determine whether that worked or not. Or sometimes they'll do an arteriogram, then Botox them and see if they can get, you know, and a certain number of people actually do very well just with that. If not, then it's pretty much surgery. I don't think as physios we've got a whole lot to offer, you know, apart from you know you can try the soft tissue stuff but without much success

SPEAKER_02:

we'll probably call it there for tonight and we'll see you all later

SPEAKER_03:

yeah

SPEAKER_01:

thank you we hope you found Craig's insights both valuable and inspiring keep in mind this was just a brief snippet from a comprehensive 60 minute Q&A session as a practical subscriber you'll gain exclusive access to live sessions with top experts like Craig where you can join in real time and even submit your questions in advance want to be Thanks for listening and see you next time.