Calf Strains - A Guide to Getting Back on you Feet
Katie Breeze: Posted on 09 March 2018 04:11
When writing blog posts, I like to be guided by topics that I am either frequently asked about, or conditions that I seem to be seeing more of at a particular time.
Calf pain and strains appear to be topic of the moment right now, and so today, I've put together some information on common forms of calf injuries, their causes, common symptoms and recommended treatments .
For runners, they are frustratingly common and in their many forms, are often sudden in onset and initially stop you instantly in your tracks.
Having suffered a gastroc strain myself last year, I can whole-hearted sympathise with you if you are reading this for advice on how to help yourself, so I hope you find this useful.
In the fitness industry calf tears often occur in typical training activities such as shuttle runs (requiring rapid acceleration and change of direction), split jumps (where one leg is thrust backwards on landing), incline running and sprinting.
Similarly, injuries to the calf and/or achilles are extremely common in boxing sessions where participants are jumping and hopping on their toes, and regularly during running on uneven surfaces or during hill training, when the explosive extension of the knee combined with dorsi-flexion at the ankle when running intensely uphill, suddenly over stretches at the gastrocnemius musculotendinous junction.
Depending on their severity, you may feel a little sore but able to walk with a slight limp for a few days but return to activity within 1-4 weeks; you may be able to weight bear but not without the aid of crutches; or in severe circumstances, you may be completely incapable of weight bearing, and need the help of crutches to get around for a 2-3 weeks, with a very gradual return to mobility.
In more severe cases, where there is a full rupture of the gastroc, soleus or even the Achilles tendon, a much longer and very specific rehabilitation programme should be followed and closely guided by a professional therapist.
The good news is, that following the careful rehab plan outlined here, and most importantly, looking after the injured site in the very early stages after injury with the PRICE protocol (protection, rest, ice and elevation for the initial 24-48hrs), will put you on the front foot back to recovery.
Of course every individual responds to rehab differently, and so I would urge you to seek advice from a Sports Therapist or Physiotherapist who will fully assess your injury, and help guide you back to fitness.
As a rough guide, your therapist will:
Take a health history and details of the mode of injury or of what you were or had been doing when you first felt it
Ask what you have done to treat it so far
Examine the area to determine if there is any swelling or bruising present and will palpate your calf to find out which area is most sore
Check if there are any unusual bumps or dips in the calf area, (usually the result of a section of torn muscle fibres and would indicate a more severe strain
Examine the appearance of your Achilles tendon and how it moves as they squeeze your muscle. It is important to rule out tearing of the Achilles tendon, which can appear very similar to a calf strain in the initial stages.
Ask you to contract your muscle and move your knee and ankle joints in order to determine how much range of motion you have and whether or not moving your foot causes calf pain.
Further tests will be performed actively, passively and resisted, in order to help determine the location, severity and nature of the strain. It is likely that these tests will be performed in any subsequent treatment sessions to assess the stage of rehab and determine the how best to progress exercises.
So to help you have a clearer picture of what structures the therapist will be assessing, lets look at the calf and what it is made up of.
WHAT MUSCLES MAKE UP THE CALF?
The calf muscles are in the lower leg, at the back of the shin bone, and are primarily made up of:
1) the large and powerful GASTROCNEMIUS muscle which spans from just above the back of the knee to the base of the heel bone
2) the SOLEUS which sits beneath the gastrocnemius, and
3) the PLANTARIS muscle and tendon (not shown) is long and thin, and joins the soleus and gastrocnemius muscles to insert onto the calcaneus (or heel bone) via a common tendon – the Achilles tendon
Interestingly, although not shown in the figure above, the plantaris muscle is composed of a thin muscle belly and a long thin tendon.
It is 2-4 inches long and is actually absent in 7-10% of the population.
It performs a weak part in moving the knee and ankle, but is largely considered redundant, and is therefore often used as a source for tendon grafts
It is quite commonly overlooked as a cause of pain, when assessing the lower leg and especially Achilles tendon. It can sometimes be the primary source of pain however, and thus it is necessary to diagnose and manage a plantaris tendinopathy in order to perform at your physical best and make a complete recovery.
MOVEMENTS OF THE CALF MUSCLES
Due to the large gastrocnemius muscle crossing over both the knee and the ankle, it functions to bend the knee and point the foot/raise the heel. These two key movements of everyday life allow the foot to push off during walking and running and also with the assistance of the soleus, to provide balance and stability when landing from a jump.
When the leg is straight, the gastrocnemius is responsible for raising the heel
The soleus is responsible for the same movement (i.e. raising the heel or plantar flexion), but when the knee is bent.
PAIN IN THE CALF - HOW IS THE CALF INJURED?
Causes of calf pain can include muscle cramp, delayed onset muscle soreness (DOMS) and referred pain from the lumbar spine. However, by far the most common cause of pain in the lower leg, is a strain to the musculotendinous complex of the gastrocnemius and/or soleus.
A strain of the gastrocnemius muscle is commonly referred to as tennis leg, and most frequently occurs in sports like running, tennis and skiing, however there a many risk factors that may cause a calf
COMMON MODES OF INJURY
It is commonly injured in middle aged athletes, and/or those who might have taken up activities that they haven’t performed before or for a while
Performing activities with tight calf muscles or with an insufficient warm up prior to activity are common factors affecting the likelihood of a strained calf
Explosive jumping sports such as netball and basketball
Group exercise classes such as step classes (usually on stepping down and pushing the rear leg down to the floor and then pushing off to complete the next step) as well as during high impact classes. These injuries often occur towards the end of the class due to muscle fatigue or a loss of technique.
Simply being unlucky performing every day activities however, can cause this type of injury, such as falling off a curb, climbing stairs or suddenly running for a bus.
Poor footwear choices; not only inappropriate trainers for running in but something that I see more and more regularly, is the damage caused by the regular wearing of high heels.
Over time, with consistent daily wearing of high heels, the gastrocnemius and soleus become shortened and weakened. As and when the foot is placed in flat shoes and asked to function dynamically, it is biomechanically compromised and prone to injury.
Even a gentle calf stretch can become painful with prolonged wearing of high heels, so give yourself a break every now and then to avoid this becoming a problem.
SO, take heed ladies (and gentlemen), don't fall victim to those "killer heels"!
These injuries are all sustained when the the gastrocnemius muscle is forcibly lengthened and overstretched suddenly against its own contraction. Most frequently, but not always, this strains the medial head (the inside) of the gastroc, and half way down the calf, where the muscle fibres of gastrocnemius meet the Achilles tendon and fail to withstand the tension created by the movement.
N.B. Differentiating strains in the gastrocnemius, soleus, plantaris and Achilles tendon is particularly important for an accurate prognosis, appropriate treatment, and successful prevention of recurrent injury.
SYMPTOMS
A sudden pain at the back of the leg, often reported to feel as though someone has struck you hard from behind
Occasionally people report hearing a pop or cracking sound
Difficulty in contracting the muscle or standing on tip toe, or weight bare at all
Pain and swelling or bruising in the calf muscle
If the rupture is very bad you may feel a gap in the muscle
TREATMENT
It is important to get an assessment of the exact nature and severity of the calf pain being experienced, so that the correct treatment can be offered.
While the initial stages of treatment of all grades of these injuries is very much the same for the Acute phase (the first 24-to 48hrs), care should be taken when deciding on the pace and progression of rehabilitation, in order to prevent secondary inflammation, and/or further tissue damage by progressing too quickly.
The information below offers a breakdown of:
the types and grades of gastroc/soleus strain and Achilles tendon injury
the symptoms you might experience, and
some advice on how best to treat them.
Of course all individuals are different and respond in varying ways to rehab, and so guidance through a qualified physical therapist is always advised when embarking on any rehab programme.
THE DEGREE OF STRAIN
This is commonly graded by a physical therapist from 1 to 3.
1 = A mild strain where only a few of the muscle fibres are strained. This can take approximately up to 4 weeks for recovery
2 = A moderate strain with more muscle fibres torn but not a complete rupture. This can take approximately between 4 and 8 weeks for recovery
3 = A severe tear where most of the muscle fibres are torn and can cause a complete rupture of the muscle belly. This can take approximately between 8 and 12 weeks.
SIGNS AND SYMPTOMS OF CALF TEARS
➢ Quite often it is reported to feel like someone has kicked you hard from behind, sometimes accompanied, but not always, by a loud popping or snapping sound.
➢ Difficulty contracting the muscle, standing on tip toe, or weight baring at all
➢ Pain and swelling or bruising in the calf, and after a couple of days near the ankle and foot, (where the blood and tissue fluid pool as a result of gravity
➢ If the rupture is bad, a gap or dip in the muscle may be felt
MINOR CALF INJURIES
➢ Pain will be present initially accompanied by mild swelling
➢ Walking will be possible unaided but mild discomfort when the calf is either stretched or contracted against resistance
MODERATE CALF INJURIES
➢ Swelling, redness, heat, bruising and possibly a dip in the muscle at the point where the fibres have bunched may be evident on contraction of the muscle
➢ Pain on resisted contraction may be severe
SEVERE CALF INJURIES
➢ Pain will be present initially accompanied by mild swelling
➢ Walking will be possible unaided but mild discomfort when the calf is either stretched or contracted against resistance
TREATMENT
MINOR CALF INJURIES
➢ PRICE protocol (Protect, Rest, Ice and Elevate) for 2-3 days
➢ Providing it is pain free, gentle stretching of the calf muscles and light not impact aerobic activity may commence, such as swimming or cycling (with low resistance, avoiding sudden movements
➢ Gentle calf raises, ideally in a swimming pool may be attempted after 3 days of pain subsiding – 3 sets or 16 raises
➢ If symptoms settle by the 3rd week, light jogging may be attempted The timeframe varies between 1 to 4 weeks depending on the injury and the individual When running is possible, avoid hill running and speed work for 2-3 weeks, as this places more stress on the structures that have been injured.
N.B. WARM UP WELL, with gentle dynamic stretching such as inch worms, lunge walking, knee and heel raises
MODERATE CALF INJURIES
➢ PRICE protocol (Protect, Rest, Ice and Elevate) for 2-3 days during the acute phase post injury.
➢ Pain will be quite severe initially and weight baring might be difficult
➢ Going up and downstairs and other movements at the ankle may be extremely painful
➢ Avoid weight baring in the acute stage of repair (initial 2-3 days)
➢ Slightly offloading the muscle, with strapping and/or by placing a wedge in the shoe to raise the affected heel, or even wearing a low-heeled shoe, may reduce pain
➢ 4-7 days – gentle movement of the calf; first with the knee bent, draw the toes up towards your body and point the toes; then try the same movement with the knee straight. 3 sets of 16 exercises should be sufficient.
Be guided by pain. DO NOT PUSH THROUGH IT.
There should be no swelling or bruising after the exercises. These exercises are aimed at mobilising, flexibility and reducing swelling, not strength
➢ DAY 7 = Sub-acute phase
➢ Do not attempt to push it. The newly healing tissue will be vulnerable to excessive stress. Scar tissue will be developing but will not withstand excessive force. Movements should continue to be aimed at flexibility and mobility, so avoid static stretching. Favour GENTLE DYNAMIC instead
➢ EXERCISES TO COMMENCE:
1. Move in and out of a calf stretch, supporting your body weight against a wall.
2. MINISQUAT – for ankle mobility Stand with feet hip width and feet pointing forward. Sit back into a mini/half squat, maintaining a straight back, and achieving pain free flexion of the ankle. (3 sets of 12)
3. Supported heel raises – start on two feet, push up on to toes, and slowly lower (3 sets of 12)
➢ Resume cross training 2-3 weeks post injury, pain permitting, but avoid impact or anything with sudden movements. Swimming and cycling are ideal.
➢ When running is possible, avoid hill running and speed work as this places more stress on the structures that have been injured.
SEVERE CALF AND ACHILLES TENDON INJURIES
These can result in a complete tear of the gastrocnemius, soleus muscles or in extreme cases a ruptured Achilles tendon. There will be significant pain and swelling and a haematoma may develop. You will probably be unable to weight bear without the help of crutches, or at all. Management of these will vary greatly between individuals and professional help should be sought from, and guided by your Sports therapist or physiotherapist.
IMMEDIATE PRICE PROTOCOL SHOULD BE FOLLOWED AND MAINTAINED OVER AT LEAST THE INITIAL 24 HRS.
TREATMENT
The most important thing to bear in mind while reading this, is that every individual is different, and each person’s injury and recovery will therefore be different. Your previous fitness, your anatomical features and posture and gait prior to injury will play a part in how you recover, adapt and rehab. So always be guided by your body, and listen to pain but try not to be scared by it. If after you have performed some exercises you are unable to weight bear, and experience swelling, redness and sever pain, it is likely that you have taken it a little too far. In this case, rest, ice, elevation and compression are necessary, and it is worth returning to the previous stage in rehab until those movements/exercises can be performed pain free. Only then, move on to the next stage. If, however, after exercising, you feel a mild ache, it is likely that the soft tissues have been moved in ways that they perhaps haven’t been used to for some time. Allow time for rest and elevation afterwards, but don’t be alarmed.
N.B. Some Achilles Tendon injuries are full ruptures. In these cases, your consultant will decide whether or not surgery is the preferred initial treatment.
Returning to full fitness
In order to start the functional rehabilitation phase (activity and sports specific training), it is important the athlete has full range of motion and 80 to 90% of pre-injury strength. When you can comfortably manage that and perform all of the exercises above, then you are ready to return to activity.
Cardiovascular exercise is important and should begin as soon as possible after injury depending on what pain will allow.
· Stationary cycling, hand cycle ergometer, running in water and swimming are all possibilities depending on severity of injury and what pain will allow.
· When running is commenced, it should be done as much as possible on a clear flat surface such as a running track. Grass or bumpy surfaces will increase the risk of re-injury. Jog the straights and walk the curves. Speed should be gradually increased over time to a sprint.
· Sports specific drills using cones can be introduced. Changing direction, running in a figure of 8 pattern and zig zagging between cones.
· Ankle taping can be very beneficial when starting running training particularly during early sessions until confidence, proprioception, strength and balance are all returned to pre-injury normality.