Calf Injuries

What is the calf and what does it do? 

When we are talking about the “calf”, we are talking about the posterior, so back, of the lower leg. In this compartment there are a variety of muscles, including the lateral and medial gastrocnemius heads, the soleus, and deeper muscles such as plantaris, flexor hallucis longus and tibialis posterior. 

Now it is important to consider the attachment sites of the two gastrocnemius heads, as they cross over both the knee joint and insert onto the medial and lateral femoral condyle, and then attach to the calcaneus via the achilles tendon. The gastrocnemius primarily performs plantarflexion at the ankle joint (the movement of pointing your toes to the ground) and flexion at the knee joint (bringing heel to your glutes). The soleus sits slightly deeper than the gastrocnemius and also acts as a strong plantar flexor, making this muscle very important to the forward propulsion in running. Deeper muscles such as flexor digitorum longus, flexor hallucis longer and tibialis posterior, control ankle inversion (the turning in of foot) and flexion of our toes. 

Hi Harry, I have had a few calf injuries in the past, that tend to get better for a few months and then get sore again. Why is this?

There may be a variety of reasons why someone might injure a muscle in their calf region and continue to have recurring calf muscle strains. For starters, it is important to consider what rehabilitation was completed. A really high percentage of injuries re-occur in the return to running phase of management. So managing this aspect carefully is vital. 

What this means is that the calf tissue, or damaged site, has not had sufficient time to a) heal, and b) return to its pre-injury level of strength and function. Therefore, over time, and over a number of runs, the tissue capacity will continue to decondition – which may result in another acute injury or consistent calf awareness. 

Whilst yes, we understand that the muscle tissue has been compromised to a level where an injury may arise, we need to consider in finer detail why the muscle remains in this fatigued state and is susceptible to reinjury. This may include contributing factors such as running biomechanics, footwear, injury hx, running load, or fatigue/cumulative running load.

For example, are we running in a manner that places more load through our calves rather than other components of our lower body? Or, are we spiking too quickly in running load and volume? 

These are just a few of the questions that we would consider when assessing a recurrent calf injury presentation! 

What can I do to minimise my risk of calf injury? 

When we talk about how we can minimise the risk of a calf injury, we want to consider training aspects of strength, power, and endurance. We recommend to most runner’s that a specific and tailored strengthening program will be extremely effective in mitigating risk of injuries, but we do have to be really careful with how we implement these in runners as there will be a fair bit of calf load coming from running already. So it requires thought and planning. By completing a variety of exercises targeted at the calf complex, we can gradually increase the tissue capacity of this region. This means that the muscular tissue has a greater ability to withstand the stresses of running, and thus, will be less prone to fatigue and therefore, injury. Typically, for recreational runners, clinical research suggests that obtaining 25 single leg calf raises without stopping as a good indicator for having adequate calf strength where the risk of a strain is reduced. For more advanced to elite runners, the evidence suggests that individuals should be able to complete 30 single leg calf raises with great control. 

Further, are we programming our run training in a manner that effectively allows appropriate time-frames for tissue healing between runs? This may look like: rather than running on 3 days consecutively, we might look to break up our run days throughout the week. What this means is that we can adequately allow the tissue site to heal and experience adaptations. This ultimately will mean that we can maintain the calf tissue capacity and significantly reduce the risk of an acute or subacute calf strain. 

Other considerations might include: footwear, not just running footwear, but casual footwear as well, load through your calf away from running i.e., steps per day (too little and spiking your load with running isn’t helpful, and massive days can also be problematic if your running load is high). And the general injury considerations i.e: nutrition, sleep, stress etc. 

I think I have tweaked my calf a few days ago, what should I do: 

If suspecting a calf strain of some degree, the immediate goal is to optimize the healing process by providing PEACE and LOVE. PEACE and LOVE is an abbreviation we use in the clinic. The first step after an acute calf strain is to protect the damaged site – this means avoiding activities that may increase pain for the first few days after injury. We also want to provide elevation to the limb at times, and avoid taking any anti-inflammatories for 48 to 72 hours post injury. And seek education, you know your body best! Avoid unnecessary passive treatments and medical interventions and let nature play its role. Essentially rest is best.

Once we have let the damaged site have a period of healing, we can then look to begin to load the tissue. Initial loading will be very much dependent on symptoms, and we would look to avoid any aggravation of pain throughout this initial loading period. The next phase of rehabilitation will include considerations of: optimism – conditioning your brain for optimal recovery by being confident and positive; vascularisation – choosing pain-free cardiovascular activities to increase blood flow to repairing tissues; exercise- starting to restore mobility, strength and proprioception by adopting an active approach to recovery. 

Is it true that you’re more likely to get a calf injury as you get older? 

Unfortunately, yes. From a variety of studies we know there is strong evidence that increased chronological age is a risk factor for future calf strain injury.

But why is this the case? 

We know that calf muscles are some of the quickest tissues to lose muscle mass with a removal of stimulus, this means losing some of that force generating qualities. Also, must consider that with an increased age, we might lose some of the stiffness property of the calf muscle-tendon unit, which is needed for optimal action for quick pushing off of the foot during activities like running. But we also need to remember that each of the mal-adaptations I mentioned are modifiable, which gives us some of the key areas to target with exercise interventions for injury prevention or risk reduction strategies in older athletes. 

I have strained my calf, what are exercises can I be doing to strengthen my muscles to prevent it happening again:

No rehabilitation process is the same! 

If we are working with a compromised calf, so a calf that may have recently had a tissue strain, we do not want to load it too quickly, and want to look to avoid symptom production. However, here are some super easy and basic exercises we can do in the initial phases after a calf strain that are centered around gradually improving muscle function. 

• Double leg calf raise isometric holds at wall
• Double leg calf raise at wall 

• Progress to single leg holds with weight shift 

Now once we are able to effectively complete these body weight exercises in the early stages of rehab, if accessible and safe to do so, we can then look to gradually increase the tissue load through the calf with heavier gym exercises. 

For example: 

• Seated double leg calf iso 3 x 30- 40 sec 
• Seated double leg calf raises 3 x 8
• Smith machine standing single leg isometric holds and single leg calf raise

Finally, once safe to do so, we also would want to implement a level of plyometric and power training. These exercises are targeted towards improving the elasticity of the calf complex, in a movement similar to the motion of running. 

• Double leg pogos 
• Single leg pogos
• Wall A march with hold 3 sec. 

That being said, whilst all these exercises are great at gradually loading the calf tissue and restoring function over a period of time, each individual calf strain is not the same. Rehabilitation of a muscle injury must be tailored to the individual. Why? So that we can not only optimise tissue healing and function alongside a gradual return to running or sport, but also, significantly decrease the risk of re-injury.