Calf strains and pains

The sneaky calf strain can be likened to the unwelcome guest who turns up unannounced, interrupting our training schedule, imposing on our plans and often returning weeks later when we thought we were finally rid of them...

In this blog, we delve into the different types of calf strains and how to manage them, so they don’t return unexpectedly.

The calf complex or Triceps Surae, which is Latin for ‘three headed calf,’ consists of three muscles; the medial and lateral gastrocnemius, soleus and plantaris, which all unite to form the Achilles tendon. In the thick of sports season, we tend to see calf injuries coming through our doors at Back to Bounce on a weekly basis. They present unexpectedly as an unwelcomed guest when people are in the middle of a training session, doing a box jump at Crossfit, changing direction at a social netball game, or running after a toddler. Often people report a sudden feeling of being ‘pain or weakness in the back of the calf’, with these with the inability to walk and weight bear. And other times they sneak up, first warning us with a feeling of ‘tightness’ in the calf which then progresses to a bigger problem when ignored. Accurate diagnosis, management and a progressive rehabilitation plan are extremely important when returning from a calf injury to reduce the risk of the injury recurring and returning weeks later.

So, let’s go through the phases of rehabilitation and how you can prevent the recurrence of calf strains and pain…

Types of strains

There are various types of calf muscle strains. Some occur as a gradual progression of tightening after a long run, and others come on much quicker and sharper, for example when sprinting at a sporting field or pushing off one leg on the netball court if we have returned after having some time off. Typically, the soleus muscle usually is the type of strain which occurs with endurance sports with prolonged running. After an active person has experienced a tightening sensation whilst doing a slow run, then notice the next day pain with walking or doing a calf raise. These usually are much easier to settle as long as the person doesn’t then go and make the strain worse. In the case that they do in fact continue to run and this progresses to a higher-grade strain, which can then sometimes take months to rehabilitate.

The gastrocnemius is typically injured when the knee is fully extended and there is a rapid or explosive movement taking place at the ankle. These higher degree strains occur with fast movements involving propulsion, ballistic movement or rapid plyometric movement changing direction such as doing a box jump at gym or jumping for a shot at basketball. Someone who is able to continue to run after the feeling of tightness or a pulling sensation experienced during a long run usually has a different recovery program compared to someone who has a severe pull in the calf and has to stop instantly. The plantaris muscle is typically strange with a knee injury. And the instance of an Achilles tendon rupture, this is reported as the feeling of being ‘kicked in the calf’ or ‘shot in the back of the leg.’ This last one is a much more serious injury with longer healing timeframes, sometimes requiring surgery in certain cases.

So what do we do if we think we have a calf strain?

First of all it is important to assess the degree of the tear by having an individual assessment by a health professional and further scans if required. All calf injury recovery programs are individual and vary from person to person so it is imperative to have a thorough assessment to determine a healing time frame prognosis, analyse predisposing factors that led to the injury and develop an individualised, progressive rehabilitation plan.

Acute inflammation phase

With calf muscle strains, the best thing to do is to treat it earlier rather than later. The aims of early rehabilitation are to regain normal ankle and knee range of motion and walking pain-free as soon as possible. If possible, it is advisable to get your injury assessed within the first 48-72 hours. The tried and tested RICER protocol works well for the initial inflammatory phase. It is important to not take anti-inflammatory medication in this phase and work on restoring pain free range of motion of the knee and ankle. In some instances, the use of crutches is warranted if walking or weight bearing is painful. The use of heel raises or supportive shoes is also useful to help regain normal gait pattern. The earlier you can start strengthening the calf, the better. It is advisable to begin a strength program by day one to two post injury to initiate early tissue remodeling. It is important to try and reduce any muscle loss of the affected limb in this phase by keeping active and exercising within the limits of the calf strain.

Rebuilding and rehabilitation

The next phase is to focus on tissue remodeling and rebuilding the capacity of the calf musculature and tendon. Your physiotherapist will guide you with the correct protocol for the type of tear you have. It is important to differentiate which muscle is injured in order to tailor your rehabilitation program to you. Here is where we work on recovering strength, range of motion, decrease swelling, pain and increase functional capacity of the calf complex. In the early phase, some exercises may involve exercises such as straight leg or bent knee calf raises, ankle exercises, balance retraining, followed by kinetic chain exercises involving the hamstrings glutes and foot muscles. In this phase it is important to rebuild the muscle fibres to help the muscle regain its normal strength, equal to the unaffected side. Single leg balance exercises are important to regain stability and proprioception of the calf, particularly for sports such as tennis, netball and basketball. This is a good time to begin addressing predisposing factors and strength deficits.

Return to jumping, hopping and plyometrics

The next phase is plyometric training which involves hopping, jumping, bounding, acceleration, deceleration and changing direction, all specific to the sport you are returning to. This phase is about building the load capacity of the calf complex in the context of the load, volume, endurance and type of movements required by your sport. The gastrocnemius is responsible for taking 2-3 times bodyweight of force when running and the soleus muscle takes 6.5-8 times body weight. Therefore, to replicate the force needed when running we need to train with an additional 60-80% of body weight repeatedly and with speed. That’s quite a lot! This is where loading the calf at a higher rate than what we need when running such as drop jumps, hopping and jumping for length and height are critical elements of rehabilitation.

Common mistakes made in calf rehabilitation; and how to not make them

Some common areas not to be ignored are to; firstly, look at the predisposing factors as to why the calf strain occurred in the first place. This may be because of the calf doing more than it was capable of, or prepared to do, for example if you completed in a 10km trail run when you have only ever done a 2km road run previously. Or playing a full game of basketball involving running, landing, pushing off and accelerating when you have only ever done some basic shooting. Increasing training load gradually and progressively is important to reduce the risk of not only calf strains but other injuries also. Sometimes we think doing lots of repetitions of calf raises at the gym equips us to then return to run, however when we miss integral components of the rehabilitation plan, we can wind up right back where we started; often limping, icing and nursing a new calf strain. “Just a few calf raises at gym” is NOT enough to prepare the calf for a game of soccer or social run with friends when you are only three weeks post injury. So you need to be calculated, progressive and precise with calf rehabilitation programming.

Ensuring that all the phases of rehabilitation or completed appropriately is being comprehensive with your rehab and reducing the risk of re-injury. Hopping fast, landing, changing direction and pushing off at speed are all important elements to include in rehabilitation prior to returning to running and sport. It is essential to gradually progress your program and continue to consistently challenge the calf right through from the acute phase through to the plyometric jumping, running and return to sport phase and beyond. Once you have had a calf strain you will be predisposed to having it happen again so if you rush the return to sport or if you don’t rehab it appropriately, you may increase the load on other areas of your body which can lead to further injury.

Once you return to running and sport, it is essential to continue good rehabilitation exercises to continue rebuilding. Also ensure you don’t overload the calf complex by taking 1-2 days off in between runs. Don’t just assume you will be able to pick up from where you left off with your running distance as it takes time to rebuild endurance of the calf.

“...when we miss integral components of the rehabilitation plan, we can wind up right back where we started; often limping, icing and nursing a new calf strain. ‘Just a few calf raises at gym’ is NOT enough to prepare the calf for a game of soccer or social run with friends when you are only three weeks post injury.”

Recurrent calf strains; WHY does this unwelcome guest return?

In the instance of a recurring calf muscle strain, where pain, tightness, weakness or dysfunction consistently return following your return to exercise, it is worthwhile to have a thorough assessment of your running/jumping/bounding biomechanics and muscle patterning by a physiotherapist or exercise professional. It is also important to thoroughly assess your loading history and previous injuries and imbalances to determine if one side is working harder and if so, why. There may be an underlying biomechanical reason for someone relying more on their calf complex for forward propulsion so may need some more help from their other extensors such as glutes and hamstrings to generate power. This is where the assessment by a health professional is important to determine strength deficits and map out a plan of how to best address them.

Shoes are another important aspect to also consider if recurrent calf strains are interrupting your sport season. In particular, looking at the heel lift your shoe can play a part. If you train in shoe with a slight heel lift and then compete in track shoes or football boots, this is something to consider looking at.

We hope this information has been helpful to you, or perhaps someone you know may benefit from you sharing this with them. Remember to seek individual advice regarding your injury as the information in this article is not intended to be medical advice for your injury but is instead general in nature. If you follow a specific program of calf rehabilitation from the acute phase right through to your return to sport with guidance, consistency and progressive programming, you will achieve success and hopefully ward off the unwelcomed calf pain once and for all. Remember that it takes time and patience to return from a calf injury back to your sport, along with precise programming tailored for you.

At Back to Bounce, our mission is to help people get moving, achieve their goals, and BOUNCE BACK to their BEST

We are a passionate team of physiotherapists who love supporting our community on every step of their rehabilitation journey with expert knowledge, care, guidance, and support. If you would like further information about our clinic, physiotherapy team and services we offer to help get you back on track after a calf injury, you can check out all our info here. If you need further information, you can call our clinic on (07) 5378 1571 or book online for an appointment here.