Complete calf injury rehab – your step-by-step guide

7 min read. Posted in Lower leg
Written by Dr Jahan Shiekhy info

Calf rehab has advanced significantly as our understanding of injuries to the calf complex has developed. It’s no longer enough to simply ensure the patient meets strength-endurance standards before sending them back to sport – we now understand that we need to rebuild the calf’s capacity to handle high magnitude loads, high rates of loading, and off-axis loading (e.g. frontal and transverse plane motion). Further, deficits in the calf and side-to-side imbalances can persist for months after return to sport, so management also needs to address this period.

The phases of calf strain rehab include:

  • Protection/early loading phase
  • Tensile loading phase
  • Rate of loading training/return to run phase
  • Return to sport phase
  • Maintenance phase

In this blog, we’ll walk through these phases of calf injury rehab based on expert physio Craig Purdam’s Practical.

If you’d like to see exactly how expert physio Craig Purdam treats calf injuries, watch his full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

 

Protection/early loading phase

The protection phase consists of light loading of the calf muscles in length-protected positions (i.e. avoiding end-range). Generally, it’s better to be conservative and move through this phase slowly, rather than speed through and risk re-injury during later phases.

During this acute phase, limit heavy loading and ensure all exercises are performed in length-protected positions. Start exercises approximately 10-days post-injury for intramuscular tendon injuries, and 3-5 days post-injury for myotendinous injuries. Using heel-elevating footwear for up to three weeks may also be helpful.

The patient should avoid alcohol and anti-inflammatory medications, as they can interfere with the normal healing process. To support healthy tissue remodeling, consider using compression garments during exercise, cyclical compression, and/or massage.

Start with resistance band plantarflexion exercises in length-protected positions. Perform these with low loads, aiming for 4-6 sessions per day, with 20-30 repetitions each session. As recovery progresses, introduce upper extremity-supported bilateral heel raise isometrics, holding for 6-8 seconds. You can then move on to isotonic bilateral heel raises as the patient improves. For myotendinous injuries, start these exercises 7-10 days post-injury; for intramuscular tendon injuries, wait around three weeks. For gastrocnemius injuries, the leg press machine can be used early in the rehab process to improve whole kinetic chain strength.

 

Tensile loading phase

Loading of the calf muscles can start to increase in the tensile loading phase, with the aim of developing strength-endurance and then maximal strength.

Introduce strength training with 3-4 sets of 12-20 repetitions to build strength-endurance. Start with bilateral exercises and gradually advance to single-leg variations. Use a metronome set at 60 beats per minute (bpm) to maintain a consistent pace. Resistance exercises should include three types of calf loading:

  1. Vertically-oriented knee-extended heel raises, to bias the gastrocnemius
  2. Vertically-oriented knee-flexed heel raises, to bias the soleus
  3. Horizontally-oriented loading such as sled pushes or heel raises with a 45-degree lean

In the below excerpt from his Practical, Craig demonstrates the sled push, which can be introduced in a length-protected manner:

As strength improves, introduce heavier loads with lower repetitions (4-6 reps) to enhance strength. Progress towards a full range of motion and introduce heel raise “pulses”, performed at rates up to 132 bpm for strength-endurance exercises. Note, that while we introduce “pulses” at 132 bpm, we still need to include slower speed, maximal strength exercises to build the tensile loading capacity of the calf. Increasing the speed of the sled pushes is also a great progression. The patient is ready to progress to the next phase when they are able to perform 5 repetitions of a single-leg heel raise with at least 80% of their body weight. Strength progressions should continue until the patient meets their sport-or-activity-specific benchmarks.

 

Rate of loading training/return to running phase

This phase begins to introduce higher rates of calf loading and initiates the process of returning to running. Initially, this can involve progressing the intensity, volume and/or range of the heel raise “pulses”, and the speed of sled pushes. These exercises should be performed 2-3x per week.

As the patient improves, introduce double-leg skipping, gradually shifting more bodyweight towards the affected side for vertically-oriented loading. Athletes should also initiate bilateral box jumps, eventually progressing to unilateral box jumps. For horizontally-oriented loading, incorporate band-resisted wall switches, which Craig shows us in the below video taken from his Practical:

Once the patient displays adequate performance in these vertically and horizontally loaded exercises, introduce higher level drills such as “A-skips,” “B-skips,” and bounding exercises.

To return to running, start replacing some drill days with running sessions (e.g. two drill-days, one run-day in the first week). The exact volume and speed of running the patient builds toward will depend on the demands of their sport or activity.

To advance to the return to sport phase, athletes should be able to perform 5 reps of a bilateral box jump onto a 30cm step and 5 unilateral box jumps onto a 15-20 cm step, with no significant asymmetry between sides. Submaximal hop tests should show less than a 10% difference between legs and no major subjective asymmetries.

 

Return to sport phase

This phase introduces off-axis loading of calf muscles, acceleration and deceleration, and rapid loading in lengthened positions. The athlete also builds up the volume of loading needed to match the chronic workload demands of their sport.

Sport-specific training

Gradually increase the volume of running at various speeds needed for the sport. Incorporate acceleration and deceleration drills along with sport-specific exercises to tailor training to the demands of the game.

Off-axis loading

Include this by performing heel raises with internal and external hip rotation to target the lateral and medial calf musculature, respectively. See Craig demonstrate this in the video below from his Practical:

For a full return to sport, ensure that strength benchmarks, such as for heel raises and leg presses, meet sport-specific norms. The athlete should also meet the acceleration, deceleration, and agility standards required for their sport and be able to handle the running volume at the various speeds needed.

 

Maintenance phase

This phase may continue for several months after the athlete returns to play. During this phase, the athlete continues training with high rates and magnitudes of loading, but at a lower volume, to adjust for the volume of loading added by their sport.

Deficits in calf strength often persist for four-to-six months after returning to sport, highlighting the need for ongoing calf-specific training. As the athlete increases sport participation, reduce the volume of training but maintain high exercise intensity. Ensure the athlete develops and sustains an appropriate chronic workload for their sport.

Training should also address the whole kinetic chain, because proximal muscles contribute about 30% to plantarflexion force production. Further, calf strains may be linked to chronic overloading of a single side (e.g. chronic overloading of the right lower extremity leading to strain in the right soleus).

 

Wrapping up

Calf injury rehab is no longer just about meeting basic strength-endurance standards before returning to sport. We need to rebuild the calf’s capacity for a range of requirements such as rapid and off-axis loading. Remember that deficits and imbalances can persist for months after athletes return to play, so we also need a maintenance plan to ensure they can handle the demands of their sport. By using this comprehensive, graduated approach to calf rehab, you can be confident about getting your athletes back to playing in a fitter, more resilient state.

Want to know more about how expert physio Craig Purdam effectively manages calf injuries? Watch his full Practical HERE.

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