Calf strains are a burden on elite athletes, casual runners, walkers and everyday active people. Injuries to the calf lead to significant time spent on the sidelines doing rehab, so it’s important to understand how to best manage the injury. This article will provide you with insight into different aspects of calf strain management.
What is the calf? What muscles make it up?
The calf complex consists of many different muscles that are at risk of potential injury. For this blog, we are going to stick to the two main areas of injury which are the gastrocnemius muscle and the soleus. These two are the most commonly injured muscles in the calf and are more likely to be injured when undergoing physical activity (1).
The calf muscles play the biggest role in plantarflexing the foot, which is when we point our foot down. There are two key differences in the soleus and the gastroc muscle in their muscle function. The soleus is more of a slow twitch muscle, and is more dominant in our slower movements like jogging or walking. It also is more dominant in plantarflexion when our knee is bent. The gastroc is the opposite and is more a fast twitch muscle, and is more dominant when our knee is straighter with things like sprinting, jumping and hopping (2).
The gastroc muscle is the most commonly injured muscle in the calf, and is more likely to be injured on the inner part of the calf. Soleus injuries are less common, but can still happen. Overloading activities with the knee bent and requiring repetitive plantarflexion will be more likely to cause soleus strains, with uphill running being a common example.
Risk Factors for Calf Strain Injuries
There are a number of risk factors for calf injuries which are important to understand. Some of which are modifiable while others are not. The following are found to increase risk of calf strain on our sports injury screening.
Increasing Age: Studies have shown that reaching higher speeds as we get older increases the likelihood of suffering a calf strain as our muscle function and quality declines with age (2).
Body Mass Index: Those with higher BMI’s are at a greater likelihood of calf injuries as it is theorised that greater demand is placed upon the calf to load into plantarflexion (3). The evidence is more limited in this space however and requires more research.
Overload/Muscle Fatigue: Overloading in activity without proper rest periods can lead to increased fatigue of the calf complex, and increase risk of re-injury (4).
Previous history of calf & soft tissue injury: Those that have suffered a calf injury in the past, have been shown to be twice as likely to suffer another one compared to those that haven’t had a calf injury (5).
Age is what we call an unmodifiable risk factor in that we can’t change, as much as some of us would like to! BMI can be modified, but BMI is becoming used less and less within the health community due to its limitations, so data around its link to calf injuries is limited. Previous injury is also unmodifiable as we can’t change what has happened in the past. Overload/muscle fatigue can be modified to a certain extent. The most important thing to takeaway from these risk factors is what we can do to mitigate their risk? Well injury prevention and exercise rehab advice provided by a trained health professional can help in all these areas. This will be discussed in more detail throughout the blog.
Clinical Examination and Symptoms of Calf Injuries
An examination for calf strains by a physiotherapist or osteopath can rule in or rule out a calf strain. It’s important to also rule out any peripheral vascular or neurological conditions which may be masking itself as calf pain. Another serious presentation to rule out is an achilles rupture or tendinopathy. Both these injuries, especially rupture, can take months of rehabilitation before getting right. A well trained osteo or physio can help identify these more complicated potential causes.
If the above are ruled out as a cause for your calf pain, then it is unfortunately an option that you may have suffered a calf strain. What is typically the main scenario in calf strains is going from dorsiflexion (neutral foot position) into plantarflexion quickly (foot pointing down) with high load, and if the load is too much, as the foot goes back to neutral (dorsiflexion) is where the strain is likely to happen (6). Think sprinting, hopping, skipping, stepping, jumping, etc. These are the more common scenarios we see where someone has strained their calf. Typically patients report feeling like they’ve been kicked in the back of the leg, and this can sometimes be difficult to diagnose in contact sports where this a potential diagnosis, known as a contusion or “corky.”
It’s typically from this point where you will come to see us. We can examine your calf pain and determine what the injury is. Through our clinical examination, we can provide insight into the muscle/muscles that you have likely injured, whether it be gastroc, soleus or potentially both. We can also rule in or rule out those other more deep muscles of the calf too that could potentially be injured.
The basics for examination of a calf strain consists of assessing strength, range of motion and palpation/observation. We will assess the ability for you to load the leg and place weight through the foot while doing everyday activities like walking, stairs and going up on your toes. Then it’s important to look at the range of motion of the ankle, foot and lower leg. Can these things move freely with or without pain is an important factor to look at here. Observation and palpation are another must for calf injury assessment. Observation should look for asymmetry or obvious differences between the calf muscles. For example, if somebody has suffered a serious calf injury like a rupture to one of the gastroc heads, this will be evident in observation. Feeling through the calf is important too, so we can localise the area that is injured and help narrow down the muscle that needs to be the focus in rehabilitation.
Acute Management for Calf Injuries
If you injure your calf on a saturday football game or maybe you’ve injured it late at night on a run, you might be wondering, what do I do in the meantime until I can see my osteo/physio? Well we advise our patients to follow a process called PEACE and LOVE. There are 3 key things you should follow to best manage a calf injury in the time before you see a health clinician.
Rest/De-Load
Calf injuries require a big emphasis on de-loading/resting the area for 3-4 days. Crutches might be an option if you are unable to weight bear properly without severe pain
Compression
Compressing the site of injury can help with controlling swelling and inflammation in the area. This can help aid the recovery in the first few days.
Don’t stretch!
Stretching acutely torn tissue is not helpful and will likely just be sore and make things feel worse.
If you follow PEACE and LOVE and those 3 key tips for acute management, you’re already setting yourself up for a better recovery.
Exercise Rehab & Return to running for Calf Injuries
Rehabilitation exercise should be started as soon as possible, ideally a few days post injury (7). Gentle loading is best in early days with seated raising as an option if patients can’t tolerate standing raises. Standing raises are the goal and the aim is to get back to doing this as soon as possible. Some experts recommend going straight to single leg raising as soon as the injured person can perform just a few reps (7). Light resistance band exercises for foot movements are also likely to be suitable for patients in the early stages of management.
When we start to get towards the middle and end stages of rehabilitation and are looking at return to play/performance, bigger strength goals are required to meet the demands of sport. This means loaded calf raises with weight, working through the full range of the foot and ankle. This can be done in a variety of ways but it would be best to speak to your health clinician to best determine what method would be best for you. Plyometrics are also an important aspect of preparing the calf for sport & performance. Plyometrics can be achieved in a variety of ways to rebuild power back into the calf. Some of the different ways include skipping, hopping & jumps to name a few (7). Some experts recommend doing jumps on inclines to better challenge the foot and ankle through more range (7).
Return to running post calf injury needs to be graded and cautious to avoid re-injury. There are a few different sets of criteria from different protocols for return to running. Calves don’t respond as well to early running like other soft tissues such as the hamstrings or quads. An early return to running post calf injury potentially increases risk for recurrence (7). The general consensus for return to running and return to play looks at relief from symptoms, strength and range of motion compared to the non-injured side (8). How this is measured will be different between clinicians but each will have a set criteria as to what determines readiness to run and return to sport.
Conclusion….
In summary, calf injuries are a burden and can lead to significant activity time missed. What is essential is getting onto the road to recovery early. The phases of de-load, load and return to sport should be guided by a trained clinician (which we have at Peak MSK Physio). This way, the clinician and you can work out suitable exercises and progress accordingly. As well as exercise, determining the safest and quickest timeline for a return to your sport can be tricky, and going back too soon will potentially increase injury risk. Make sure you are guided through this final phase by your osteo or physio to give you the best chance to play out your season.
Section: FAQ
- What Causes Calf Strains and Who is Most at Risk?
Calf strains can be caused by factors such as aging, higher body mass index (BMI), muscle overload, and a history of previous calf injuries. As we age, muscle function declines, increasing the risk of strain, especially with high-intensity activity. Those with higher BMI may place more stress on their calves, while overuse or fatigue from insufficient rest can lead to injury. People who have had prior calf injuries are also at a higher risk of re-injury.
- What Are the Key Differences Between the Gastrocnemius and Soleus Muscles?
Gastrocnemius is the larger, more visible muscle and is used for powerful movements like running and jumping. It crosses both the knee and ankle. The soleus is located underneath, used for endurance activities like walking, and only crosses the ankle. The gastrocnemius has fast-twitch fibers for quick movements, while the soleus has slow-twitch fibers for sustained activity.
- How do I know if I have a calf strain versus another type of injury?
A calf strain causes sudden pain or tightness in the lower leg, often after physical activity. Achilles tendinopathy leads to pain above the heel that worsens with movement. Vascular issues, like a blood vessel clot (DVT), cause swelling, redness, and tenderness. A physio or osteo can help differentiate between these conditions and others that may appear similar through a thorough assessment, ensuring the correct diagnosis and treatment.
- How long will it take to recover from a calf strain, and when can I return to running or sports?
Depending on the severity of the injury, most people are back to full capacity within 4-6 weeks with minor to moderate strains. More severe tears and ruptures are closer to a 12-16 week recovery time.
- How can I prevent calf injuries in the future?
To minimise risk of future calf injuries, following prevention style exercise programs are likely to be most effective. Strength training regularly, plyometrics, stretching and keeping active are the best ways to build resilience. If you’re unsure where to start, make sure to see one of our clinical team members who help guide you through this process.
- What should I do immediately after a calf strain?
As mentioned in the blog, follow PEACE and LOVE protocols. Avoid stretching as you can risk tearing more muscle fibres that are already vulnerable. Speak to your physio or osteo to get the all clear before starting rehabilitation exercises.
