Calf Strain Rehab: From Research to Practice

9 min read. Posted in Lower leg
Written by Ashish Dev Gera info

Ever had your calves decide to go rogue, leaving you limping and wondering what on earth just happened? When it comes to muscle injuries of the lower limb, calf strains often take a backseat compared to the more commonly discussed hamstrings and quadriceps injuries. However, calf strains are quite prevalent across various sports, particularly among running and ball sports, yet they don’t often receive adequate attention in terms of understanding and management. It is crucial to understand the significance of proper rehabilitation to enable athletes to safely return to their sport (and stay there!). Athletes and physiotherapists should be aware of the signs and symptoms of calf strains, as well as the importance of keeping up with research for effective rehabilitation. By shedding light on this often overlooked aspect of sports injuries, we can better equip individuals to prevent, manage, and recover from calf strains successfully.

Well, get ready to decode the mystery because we’re diving into the world of calf strains! How does research play into kicking those painful setbacks to the curb? Let’s find out together! In this blog, I’m going to highlight how Physio Network’s Research Reviews helped me successfully rehabilitate my runner back to sport.

With our Research Reviews you get access to expert summaries of the latest and most clinically relevant papers – so you can easily keep up to date, and become more confident and effective in your clinical practice. Learn more HERE.



The case

The patient, Mr. J.D., is a 28-year-old male who is an avid runner and preparing for a marathon. He presented with complaints of acute pain in his right calf during an interval training session. He described a sudden onset of pain while sprinting, accompanied by a popping sensation in the calf. There was no history of direct trauma or previous calf injuries. However, he did complain of soreness and progressively increasing tightness in the calves after his runs for the past one month. He also mentioned a recent increase in training intensity leading up to the incident. There was a history of a right ankle sprain a year ago while playing basketball. Mr. J.D. reported difficulty bearing weight on the affected leg and expressed concerns about his ability to participate in the upcoming marathon. A detailed subjective history was taken regarding the training loads, lifestyle factors and understanding the beliefs of the patient.

Upon examination, Mr. J.D. exhibited tenderness, discolouration and swelling in the right calf region, localised to the gastrocnemius muscle. Active plantarflexion and dorsiflexion of the ankle elicited pain, particularly during resisted plantarflexion. There was a noticeable decrease in strength during push-off, and Mr. J.D. demonstrated a limp while walking. No palpable defect was detected in the right calf muscle. Right Active Range of Motion (AROM) of the ankle was lesser compared to the left, and Passive Range Of Motion (PROM) was restricted as well. Magnetic Resonance Imaging (MRI) was not completed as the patient opted out and was happy with the assessment and diagnosis.

The diagnostic process was made easy for me by this brilliant Review by Tom Goom for Physio Network. Given the mechanism of injury and clinical findings, a calf muscle strain, particularly involving the gastrocnemius muscle, was the primary differential diagnosis. Achilles tendon rupture was ruled out due to the intact ankle plantarflexion strength and negative Thompson test. Neural conditions and entrapment syndromes were ruled out. Red flags including Deep Vein Thrombosis (DVT),claudication conditions and bone sarcomas were ruled out.

The primary outcome measure for monitoring Mr. J.D. ‘s progress was the Visual Analog Scale (VAS) for pain, assessing the severity of pain experienced during functional activities such as walking, running, and jumping. Additionally, the Lower Extremity Functional Scale (LEFS) was utilised to evaluate Mr. J.D.’s functional limitations and monitor changes in his ability to perform activities of daily living and sports-related tasks.

To assess psychological distress and frustration due to the sudden interruption of his training and competition schedule, the Tampa scale of kinesiophobia was utilised. Addressing the patient’s concerns about the impact of the injury on his running performance and goals was crucial for maintaining motivation and adherence to the rehabilitation program.


Assessing capacity and prognosis

The standing heel rise test was performed to check the load tolerating capacity of the calf muscles when the patient was able (one week after the initial visit). He was able to perform 34 repetitions on the non-involved side with good form, compared to 23 on the right. The rehabilitation plan was started and a 6-12 weeks timeline was given to the patient for return to running.


Rehab and return to play

Tom Goom’s Review sets the stage for successful and optimal rehab by exploring six phases of the process:

1- Early loading stage

The focus was on settling the early irritation and pain down, but not with complete rest. Isometrics were used within a limited range, for lower repetitions and load. Taping was used as an adjunct, and a walking aid was prescribed to avoid excessive load at this stage.

2- Loaded strengthening phase

Strengthening was progressed after week one by increasing the range, and mainly targeting the soleus. Tom’s Review gave me confidence in the clinical reasoning behind loading the calf early, and setting the foundation for successful rehab. This prevented deconditioning and also helped combat pain-avoidance beliefs. Loading through range and movement direction training was started as pain subsided. Some exercises and their variations used in this phase were double leg calf raises (3 sets of 12), progressed to single leg calf raises in standing (3 sets of 12), wall sits with a heel raise (3 sets of 20 second holds) and toe walking (3 sets of 15 second walks). These exercises were progressed by adding more weight, manipulating the tempo, adapting ranges, and moving to unilateral work. The patient was compliant with the exercises at home and regular with the physio appointments which were two times a week initially during the painful phase, and three times a week in the following phases.


3- Plyometrics stage

As outlined in Tom’s Review, plyometrics were added to the program in the form of pogo jumps (3×15 seconds, progressing to 3x1min pain free) and double leg forward hops progressing to single leg hops (3 sets of 8). The patient was familiar with skipping and two minutes of pain-free skips were performed.

4- Preparation for running phase

Drills like brisk walking, stairs and lunges were added to prepare the patient for running demands, all while monitoring symptoms and assessing progress. Progression of strengthening exercises continued by adding more weights and introducing heavy, slow resistance training to improve calf resilience and capacity. The patient’s calf strengthening program included eccentric double leg calf raises on a stepper with weights (1.5x bodyweight;4 sets of 8), double to single leg calf press holds (1.5x bodyweight; 4 sets of 20 sec holds), toe walking with weights, and challenging plyometrics to develop more power.

Reassessment of the calf musculature load bearing capacity was completed by performing pain free standing single leg heel raises with weights equal to 0.4 times the patient’s bodyweight for 3 sets of 10.

5- Return to running stage

The response to running-specific training was noted and exposure to training was implemented according to the patient’s response, as per Tom’s Review. This stage also included an in-depth discussion and patient education regarding all the risks involved in returning to running too soon. Prognosis was given according to the severity of the injury and realistic timelines were set. The return to running phase was started only after there were no adverse reactions to any of the previous activities completed; for example, single leg hops were painless and there was no increase in the feeling of tightness in the calf muscles. Initially, for the first three weeks, a walk/jog program was implemented, slowly reducing the walk time and phasing off walking by week ten. Once the patient was able to achieve pain free continuous running, care was taken to build up distance and capacity before introducing explosive speedwork and downhill running.

6- Athlete monitoring

The patient was discharged from care at week 12 with an progressive strength training program targeting the lower limbs and running program to gradually increase the training load and prevent recurrence. It is recommended that the patient be monitored for at least two months after return to activity due to the high rate of recurrence in calf strains – the running program required the patient to monitor VAS and general tightness at the end of each week and contained rules to adapt the running program accordingly, with guidance to check in with the physio as needed.



Injury prevention

According to this Review by Dr Teddy Willsey, considering the method of injury and injury history can aid clinicians in accurately predicting return-to-play timelines following calf muscle strains. Taking a thorough history from the patient is imperative in deciding the severity of the injury, the strengthening plan and eventually mapping out a return to running program. As Shruti Nambiar points out in her Review there is limited literature present on effective ways to prevent recurrences of calf strains. However, calf strengthening exercises have shown promise in this area.


Wrapping Up

In the realm of calf strain rehabilitation, success isn’t just about ticking boxes on a generic protocol – it’s about crafting a personalised journey tailored to the individual’s needs and aspirations. By prioritising thorough assessments, early implementation of strengthening exercises, and a progressive approach targeting range, strength, control, and power, we pave the way for a resilient return to play. Remember, it’s not just about getting back on the field; it’s about staying there. Patient education, setting realistic timelines, and aligning expectations are our compasses in this voyage. And in navigating these waters, the insights gleaned from Physio Network’s Research Reviews have been my guiding star.

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