Calf pain in runners is quite common and can become a persistent nuisance. Fortunately it usually responds well to treatment and there are a lot of simple exercises you can do to help it recover. This is the first of a series of pieces on calf injury and will guide you through early management of a calf tear. Later pieces will examine non-traumatic calf pain and rehab of strength and flexibility.
The calf is made up of 2 large muscles – gastrocnemius and soleus and a smaller muscle called plantaris. Gastrocnemius is the more superficial of the muscles with soleus sitting beneath it. Gastroc. has two heads to it and crosses both the ankle and knee joints – this makes it somewhat vulnerable to injury. Injuries to soleus are far more rare. In one study of 141 cases referred for ultrasound after calf strain just 1 had a soleus tear while 94 had gastroc injuries.
Traumatic calf injury
The calf is usually injured with sudden movements that dorsiflex the ankle (bend it up) while weightbearing. With the gastroc this often happens with the knee straight as the muscle is then stretched over 2 joints. Activities like rapid lunges (common during racquet sports) or acceleration to sprint when running are common causes of calf injury. It may also occur when the muscle is fatigued after distance running.
During a calf injury many people describe a sudden sensation of being struck on the back of the leg. Swelling is common and it can be difficult to walk initially. In more minor calf injuries people can sometimes continue with their sport at the time of the injury but the pain becomes more severe after. Of the two heads of the muscle the medial head (on the inside of the calf) is more commonly injured than the lateral head (on the outside).
Management of acute calf injury involves POLICE (formerly RICE). With muscle injuries anti-inflammatory medications are not currently recommended, especially in the first 48 hours as they are thought to delay healing. As with all injuries RunningPhysio recommends seeing an appropriate health professional. In the case of calf injuries this is especially important as there is a risk of Deep Vein Thrombosis (DVT).
Symptoms of DVT include pain, swelling and tenderness in the calf often accompanied by warmth and redness of the skin. Unfortunately these are often common symptoms after a calf injury even without DVT. In many cases people sent for investigation of suspected DVT are found not to have one, however if in doubt get it checked out as a DVT is a serious condition and can lead to pulmonary embolism which is potentially life threatening.
Treatment of a calf injury depends largely on severity (timescales detailed below are approximate and may vary considerably between individuals) but I follow these principles of treatment for calf injuries;
- Respect the healing process
- Allow a period of relative rest
- Maintain calf flexibility and strength where possible but exercise within pain limits
- Gradually re-introduce activity that involves stretching or loading the calf muscle
- Rehab any deficits that exist after the healing process (this might include calf strength, power, endurance or bulk, reduced calf flexibility, altered movement control etc etc.)
With a minor calf injury symptoms will be mild with minimal swelling, you will be able to walk unaided with slight discomfort but sudden movements that stretch or work the calf may cause an increase in pain. Initial treatment involves rest for 2-3 days after which you can often resume gentle cross training, providing it's pain free. This might include swimming, or cycling (with low resistance) but should avoid impact, heavy resistance or sudden movements. Once symptoms settle you can start some light jogging on a treadmill and see how it feels before gradually returning to training. The timeframe for this varies from around 1-4 weeks depending on the injury and the individual. When you do return to running avoid hill training and speed work initially as this places a greater stress on the calf muscle.
Moderately severe calf injuries need to be treated with a little more caution. In the early stages there will be noticeable swelling and discomfort. You will be able to walk unaided but with some difficulty and pain. Any movements that place even a small stress or load on the calf are likely to be painful. This might include going up or down stairs, moving the ankle or pressure on the calf area.
The first 2-3 days are likely to involve bleeding within the muscle and significant swelling. In these acute stages you'll need to be more attentive to rest, elevation and ice and I wouldn't recommend cross training. You may benefit from offloading the calf a little. This can be done by putting a heel wedge in your shoe, strapping the calf or even wearing shoes with a heel (although probably something stable rather than stilettos!). This should be a short term strategy and you should aim to walk in normal shoes or barefoot as soon as comfortable to do so.
By days 4-7 you may find you're comfortable enough to start very gentle exercises for the calf. Simply move the foot up and down, first with the knee bent, then with it straight. Move only as far as comfortable – don't push through pain. Little and often is usually best – around 10-15 reps 3 times per day. The aim is to encourage the muscle to contract and relax, this should help clear swelling and maintain flexibility.
After day 7 you're usually in the sub-acute phase of injury. The muscle is still healing and that new tissue will be vulnerable so you want to avoid excessive stress on it. The body is amazing when it comes to healing and it's worth respecting that. We often aim to accelerate things but perhaps, in truth, our aim is more to promote the best environment to allow things to heal at their normal rate. It's important to maintain flexibility and strength in the calf muscle as things heal, but this shouldn't come at the expense of the healing process.
From approximately day 7 to 21 post injury scar tissue is still developing but isn't usually strength enough to handle large loads. As a result I would avoid static stretches during this period, instead use the 2 traditional calf stretches (pictured below) but do them dynamically. Rather than moving until you feel a stretch and holding it, just focus on controlled, gentle movement in pain free range. Alternatively a minisquat is a simple way to maintain ankle mobility. You can also start some supported calf raises if able – do on both feet (rather than just 1) – push up onto your toes and slowly lower. You can usually resume cross training from 2-3 weeks post injury but keep it pain free and avoid impact and resistance work.
From 3-4 weeks after calf injury the scar tissue will usually have developed enough to handle a little more load, at this stage you may benefit from starting static calf stretches if comfortable. In which case stretch both the gastroc and soleus muscles, using the techniques above and holding for around 30 seconds for 3-5 reps. You can often progress strength work at this point, if comfortable try single leg calf raises on your weaker side. Do as many as comfortable and gradually increase until you can do the same on both legs. Stop if painful!
Severe calf injuries can result in a complete tear of the gastrocnemius muscle. There will be significant swelling and pain and a haematoma may develop. You may be unable to walk without help from crutches, even then it will be difficult to weight bear and many people choose to hop instead! Management of these injuries varies considerably and will be guided by your consultant or physiotherapist.
Final thoughts: calf injuries can be painful and potentially debilitating and should be assessed by a health care professional to rule out serious complications such as DVT. As ever on RunningPhysio if in doubt, get it checked out. Most calf tears respond well to treatment but the healing process must be respected and it's important not to do too much too soon.