Understanding the Causes and Symptoms of Calf Muscle Strain (Education is key)

Let’s get the boring part out the way first before I tell you how to fix your calf so it never comes back.

Your calf muscles primarily consist of the gastrocnemius and soleus. The gastrocnemius has medial and lateral heads that attach to your femur, while the soleus originates lower down on your tibia and fibula. Both insert on your calcaneus, or heel bone, via the Achilles tendon.

Their primary action is to plantar flex your foot, however, the gastrocnemius also helps flex the knee since it crosses this joint.

Calf Muscle Strain? Which muscle is to blame? 🤔

Ever felt like you got pain in your calf while making a quick move in football or increasing your speed in running? That could be your gastrocnemius muscle saying, “Hey, slow down!”

But wait, there’s another culprit too! Ever experienced that sneaky, gradual tightness or cramping in your calf after a long run? Ah, that might just be your soleus muscle whispering, “Hey, calm the F**k down!"

Both are very annoying, frustrating and very common.

In either scenario, most calf strains occur from doing too much too soon without the right amount of strength in the calves.

Maybe you decided to start running or playing football 3 days a week after being relatively inactive for the last 3-5 years. Or did you suddenly increase your running mileage in preparation for an upcoming race?

I want to make this clear, IT IS NOT USUALLY BECAUSE YOU HAVE TIGHT CALF MUSCLES. If you do a google search this is the first thing that it will say.

The tightness comes from muscle weakness and fatigue. It's a symptom, not a root cause. If you have been stretching your calves, STOP.

This can make it more painful, prolong your recovery time and further increase your injury risk.

Think of it like trying to carry a mountain of books when you’ve only ever lifted a few. Your muscles need time to catch up, or they protest!

How do you know which muscle in the calves is to blame?

Soleus Strain Sports Injury

A soleus injury typically has a slow onset with poorly localised symptoms that you might describe as “tightness” or “cramping”. 

If you've pulled or torn your calf muscles, there was likely a discrepancy between the load you placed through them and your capacity to tolerate and recover from that given load. 

See below 

FYI: Capacity also includes factors like sleep, nutrition, stress, injury history, change of footwear, equipment and training history.

The goal of exercise rehab is to increase your capacity to the point where it is greater than the loads you put through your body when running, playing football or doing your preferred sports.

Identifying the Signs of a Severely Strained Calf Muscle

There are different grades to a torn calf muscle and a clear diagnosis is important to differentiate and deal with calf symptoms. read the link below for more information.

Pulled Calf Muscle: Causes, Symptoms & Treatment - Knee Pain Explained (knee-pain-explained.com)

If you're in severe pain with excessive bruising then get this checked out by your GP, or a local physio or feel free to send me a message/ email on social media (hello@functionalmovementphysio.co.uk) or visit me in my Liverpool city centre clinic. 

If you have a grade 1/2 tear and your pain is under control then you can commence the rehab process below whilst gradually monitoring your symptoms. 

Any concerns please contact your GP before starting. 

Rehabilitation Exercises for Calf Muscle Strain

Tailored Loading Exercises for the Calves

Let's delve into specific exercises designed for knee-straight and knee-bent heel raises.

Isometric Calf Exercises - Stage 1

Examples of exercises you will see in my rehab program (see above)

Isometrics are some of the best exercises to build strength in the calves quickly and reduce pain. That's why I include these first in my client's rehab before doing more dynamic calf raises which I'll explain later. 

Balance/ Stability Exercises - Stage 1

Concentric Strengthening Exercises - Stage 2

Knee Straight Heel Raises We have a multi-level progression for knee-straight heel raises:

• Level 1 – Double Leg Heel Raises: Aim for 3 sets of 25 reps, full range, no pain.

• Level 2 – Single Leg Heel Raises (Floor): Target 3 sets of 15 reps per leg, full range, no pain. Move to level 3 upon success.

• Level 3 – Deficit Single Leg Heel Raises: Aim for 3 sets of 15 reps per leg.

• Level 4 – Weighted Deficit Single Leg Heel Raises: Aim for 3-4 sets of 6-10 challenging reps per leg.

Effective Treatment Options for Soleus Strain - Stage 3

Seated Heel Raises

• Option #1: Seated Progression

  • Level 1 – Seated Heel Raise: Aim for 3 sets of 6-12 reps with added weight.

  • Level 2 – Deficit Seated Heel Raise: Increase range with 3-4 sets of 6-12 reps.

Option #2: Standing Progression

• Level 1 – Double Leg (Floor): Aim for 3 sets of 25 reps before progressing.

• Level 2 – Single Leg Heel Raises (Floor): Target 3 sets of 15 reps per leg.

• Level 3 – Deficit Single Leg Heel Raises: Perform 3 sets of 15 reps per leg.

• Level 4 – Weighted Deficit Single Leg Heel Raises: Aim for 3-4 sets of 6-10 challenging reps per leg.

Common training errors

Mistakes to Avoid in Heel Raises Executing heel raises optimally is crucial for maximum benefit. Common mistakes include rolling off the big toe, clawing toes into the ground, and poor control on the descent. Remember, maintain straight-toe alignment, squeeze the calf muscles at the top, and move deliberately through each repetition.

These are things to think about whilst doing the exercises.

Lower Body Multi-joint Strengthening - Stage 4

Plyometrics - Stage 5

Only commence these exercises until all other exercises are pain-free and you can hop a single leg on the floor pain-free during and after. 

Is Imaging (X-ray, MRI, CAT, Ultrasound) Necessary?

Usually not. If you have done a grade 3 tear to your calf then you might be sent for an ultrasound or MRI to determine the level of the tear. If you have ruled this out then conservative management is usually the go-to management with great success. If you go through this program and follow it without resolution of any symptoms you are either progressing too quickly or you need to speak to a local physiotherapist to rule out anything more sinister.

Returning to Physical Activity Safely After a Calf Muscle Strain 

Green et al. 2022 suggest meeting these 3 criteria before running:

1. Adequate calf strength as demonstrated by a single leg heel raise 

2. Tolerance to repeated hopping on a single leg

3. The absence of clinical signs and symptoms.

There is not one accepted benchmark for calf strength and repeated hopping, but generally, you should be able to perform about 25-30 single-leg heel raises through your full range of motion and demonstrate 10-20 single-leg hops in place without pain.

Once you can achieve these milestones, you can initiate running. As of now, there is no set protocol for returning to running following a calf strain, but here are six “rules of thumb” from Green et al. 2022:

1. Run on alternate days to start.

2. Avoid prolonged, slow continuous running early, especially for soleus injuries.

3. Do not progress volume and intensity on consecutive days.

4. Schedule off-field exercises (i.e. loaded calf strengthening) after running.

5. Running progressions should meet the demands of your sport. For example, don’t run excessive mileage if you don’t need it.

6. Avoid sudden changes in conditions, such as the surface and footwear.

These authors also outlined a return to play checklist. A lot of the criteria will be similar for all calf strains, however, some are specific to the muscle injured.

For example, since gastrocnemius injuries usually occur from high-intensity activities, drills focusing on accelerations, cutting, jumping, maximal velocity, etc, should be a focal point before returning to sport. In contrast, soleus injuries will focus on total running volume, since these usually occur from cumulative overload during long-distance running.

How to Prevent Calf Muscle Injuries during Exercise

Change: For programming, at the very minimum, you should perform the heel raises 2-3 times a week, progressing through the levels based on performance and pain tolerance. For example, you might perform a knee straight variation on Monday and Friday, and a knee bent variation on Wednesday.

Once tolerated, include hopping and jumping exercises and perform these before the heel raises. You can do the hopping progression Monday and Friday and the jumping progression on Wednesday.

Other optional exercises can be included if time allows. For example, after the hopping and jumping, you can perform squats, deadlifts, and split squats as your main compound lift. Then you can perform the other ankle and foot strengthening exercises, and single leg balance to end your workout.

When you meet the criteria to begin running, ideally, you will run on the days you do not perform the strength exercises. If you have to perform them on the same day, complete the running first. Also, it is important to continue performing the previous strength exercises even after you return to running to help reduce the risk of re-injury.

Calf Strain Muscle Injury Summary 

The calf muscle strain is a common injury that can cause discomfort and difficulty in daily activities. This blog provides a thorough summary of the causes, symptoms, and treatment options for individuals dealing with this injury. One important point to note is that stretching should be avoided initially, as it can further aggravate the already strained muscle. Instead, a focus on progressive strengthening and rehabilitation exercises is recommended to aid in the healing process. 

It is crucial to seek guidance from a healthcare professional, such as a general practitioner or physiotherapist, before beginning any exercise regimen for a calf muscle strain.

By following the advice and guidance provided in this blog, individuals can start their journey towards regaining strength and function in their calf muscles. If you need anything during this process then please let me know via social media, email me (hello@functionalmovementphysio.co.uk) or if you live locally in Liverpool UK then come and visit me in the clinic HERE.

Let me reassure you!

You can get back to pain-free running, sport and performance but most of the clients I see are usually given the wrong advice and exercises. If you don't believe me have a read of my growing list of reviews. 

Much Love

Stuart Goldfinch (Specialist Physio & Rehab Expert)