A calf strain is a tear of the muscle fibres of the muscles at the back of the lower leg and can range from mild to very severe. Here we explain the symptoms, treatment, and exercises to return you back to full fitness in the shortest possible time.
Treatment includes rest, ice and compression during the acute stage followed by a full rehabilitation program consisting of stretching and strengthening exercises.
Symptoms of a calf strain can vary significantly but usually involve a sudden sharp pain at the back of the lower leg. The calf muscle will often be tender to touch at the point of injury and swelling and bruising may appear within hours or days.
Depending on how bad the calf injury is, the athlete may be able to continue exercising although he/she will often have some discomfort/tightness during or after the session. When injuries are more severe the athlete can recall when the injury occurred and or they may be unable to walk due to severe pain.
A calf muscle tear is graded from 1 to 3, with grade 3 being the most severe. A grade 1 will not normally need professional treatment whereas grade 2 or 3 injuries, depending on their severity, may require more specialist treatment and rehabilitation advice from a sports injury professional.
Grade 1 symptoms - A Grade 1 calf strain is a minor tear with less 25% of the muscle fibres affected. The athlete may feel either a twinge of pain in the back of the lower leg or a feeling of tightness. They may be able to carry on playing or competing without pain or with only mild discomfort in the calf. However, after exercises, there is likely to be tension or aching in the calf muscle which can take up to 24 hours to develop.
Grade 2 symptoms - Symptoms of a Grade 2 strain will be more severe than a grade one, with anything up to 90% of the muscle fibres torn. There will be a sharp pain at the back of the lower leg and usually significant pain when attempting to walk. There is likely to be swelling in the calf muscle with mild to moderate bruising, however, this may take hours or days to be visible. Pain will be felt on resisted plantar flexion (pushing up onto the toes). Tightness and aching may be present in the muscle for a week or more before subsiding.
Grade 3 symptoms - Grade 3 injuries involve 90-100% of the muscle fibres and are often referred to as ruptures. The athlete will definitely know exactly when the injury occurred because of severe and immediate pain at the back of the lower leg. The athlete will be unable to continue exercising and will often be unable to walk due to weakness and pain. Considerable bruising and swelling will develop, although this may take hours to be visible. The athlete will be unable to even contract the calf muscle at all and in the case of a full rupture, a gap in the muscle can usually be felt where the muscle is torn bunches up towards the top of the leg.
Read more on calf strain assessment and diagnosis.
Anatomy & causes
Calf muscle tears usually occur as a result of a sudden pushing off movement or from excessive over-stretching of the calf muscles as demonstrated in jumping activities or during quick changes of direction. If muscles are particularly tight then they may be more susceptible to strains. Gradual overuse can cause tension in the muscles which in turn causes knots or potential weak points. A good massage therapist can often identify these weak points in a muscle before they progress into a strain.
Shortened muscles are also susceptible to injury and this is most commonly seen in women who wear high heels a lot of the time. Over a period of time, the calf muscles adapt and shorten due to the raised heel. Then when flat running shoes are worn, the muscles are stretched excessively and at higher risk of injury. Wearing high heels can also weaken the calf muscles, also increasing the risk of injury.
The calf muscles are actually two muscles, the Gastrocnemius and Soleus, which together are known as the calf muscles. The Gastrocnemius is the big muscle at the back of the lower leg. The Soleus is a smaller muscle lower down in the leg and lies underneath the gastrocnemius.
Both muscles contract to produce 'plantar flexion' at the ankle joint which is the same movement as standing up onto your tip-toes. The Gastrocnemius is the powerful muscle which produces propulsion during dynamic movement such as sprinting and jumping. A tear to the medial part (head) of the gastrocnemius muscle is often referred to as 'Tennis Leg' and is the most common type of calf strain. If you want to sound clever then say you have a 'grade 2 lesion at the MTJ of the medial head of the gastrocnemius'! The MTJ is the muscular tendonous junction where the muscle joins the Achilles tendon.
If the soleus muscle is injured the pain is usually lower down the leg but is not painful when attempting to bend the knee (unlike gastrocnemius). The soleus muscle is the main calf muscle that facilitates running for long periods.
Calf strain treatment
Treatment involves immediate first aid followed by rest then a gradual stretching and strengthening program.
Self Help Treatment
Apply the P.R.I.C.E. principles of protection rest, ice, compression and elevation as soon as possible. A cold therapy and compression wrap will help stop any internal bleeding, reduce pain and swelling. Cold therapy can be applied for 10 to 15 minutes every hour initially reducing the frequency of pain and swelling go down. Do not apply ice directly to the skin as it can cause ice burns. Read more about P.R.I.C.E.
Rest! This is especially important and often difficult to do. The more you use the muscle when it is trying to heal the longer it will take to heal. Wear a compression bandage or calf support. This will protect the muscle and help reduce swelling in the early acute stages and support the muscle and improve blood flow later in later rehabilitation stages where running and exercises are introduced.
Wearing a heel pad will raise the heel a little and slightly shorten the calf muscle, hence taking some of the strain off the muscle. Put heel pads in both shoes because otherwise one leg will become longer than the other causing other problems.
When pain allows begin gentle stretching and strengthening exercises. Stretching exercises can begin once the initial acute phase has passed and pain allows. This may be a couple of days or longer depending on the injury.
In the later stages use a foam roller to help stretch the fascia or connective tissue which surrounds the muscle. Self-myofascial release is a way of stretching the fascia yourself, similar to sports massage. It is also excellent for helping prevent calf strains in the future. The leg is rolled over the roller along the full length of the muscles from the ankle to just below the knee and back again.
See a professional therapist who can make an accurate diagnosis and advise on further treatment and rehabilitation, particularly if you suspect a grade two or three injuries.
Read more detail with our calf strain rehabilitation program.
What can a professional do?
A doctor or medical professional may prescribe anti-inflammatory medication e.g. ibuprofen which is beneficial in the first few days after the injury. Do not take ibuprofen if you have asthma and always speak to a pharmacist or doctor before taking medications. There is some evidence that anti-inflammatories can impair healing so do not take them for more than a few days at the beginning of the injury. Also, taking medication can sometimes mask pain and may, therefore, be detrimental to the healing process.
An on-field first aider or physio may apply a compression bandage immediately following injury to stop bleeding and prevent swelling, but this should only be applied for 10 minutes at a time as restricting blood flow completely to the tissues could cause more damage. A normal calf support or sleeve can be worn longer.
Electrotherapy such as ultrasound may be applied. This transmits high-frequency sound waves into the tissues, which can help in the early stages with pain relief and swelling and in the later stages of rehabilitation, will have a micro-massage effect and stimulate blood flow into the muscle.
Sports massage can be applied after the initial acute phase has finished. Do not massage in the first 5 days post-injury as this may increase bleeding. After the acute stage massage will stimulate blood flow, stretch the muscle and release areas of spasm and knots in the muscle. The other major benefit of massage in the latter stages of a calf strain recovery is to soften the newly formed scar tissue and help to align the newly laid fibres in order to encourage more effective muscle healing and prevent re-injury. Finally, a skilled masseur may also be able to identify areas of the muscle that is at risk of injury so regular massage can be beneficial even when fully fit.
A sports injury professional will carry out a full assessment of your injury and hopefully make an accurate diagnosis. Then, if required, they will then treat the injury and prescribe and progress a full calf strain rehabilitation program consisting of a number of stretching and strengthening exercises.
Both stretching and strengthening exercises are important and should only begin after the acute stage and always be done pain-free.
Active calf stretch is used in the early stages as it applies only a gentle stretch to the muscle. The athlete simply pulls the toes upwards inducing a stretch at the back of the leg. Hold for a couple of seconds and relax. Repeat this 10-20 times. To stretch the soleus muscle, sit with the knees bent and perform the exercise the same way with the feet on the floor.
To stretch the big gastrocnemius muscle the back leg must be kept straight and is done either leaning against a wall or if flexibility is good on a step. Ease into it until you feel a stretch, hold for 20 seconds. If the stretch eases then increase it, but do not push too far in the early stages. Perform 3 repetitions and repeat this 3-5 times a day.
The deeper soleus muscle must be stretched with the knee bent. This takes the larger gastrocnemius muscles out of the exercise (because it attaches above the knee). Lean against a wall with the leg to be stretched at the back. Bend the knee keeping the heel in contact with the ground until a stretch is felt. Hold for 15 to 20 seconds and repeat three times. If a stretch is not felt then another method is to place the ball of the foot against the wall and bend the front knee until a stretch is felt.
Read more and watch video demonstrations of calf exercises.
Plantar flexion with a resistance band is a gentle exercise to start with. Hold a loop of resistance band and use it to apply resistance as you point the foot away (plantarflexion). Start with just 2 sets of 10 once a day and build up to 3 sets of 20 twice a day. If it does not hurt the next day then increase the resistance by shortening the section of the band. If there is any pain during, after or the next day then reduce the load or rest a bit longer.
Seated calf raise is another gentle exercise that will strengthen the soleus muscle. It can be done with no weight at all, to begin with, if necessary. Sit on a chair with the knees bent and lift your heels off the ground as high as possible. Resting a weight on the knees will increase the resistance.
Calf raise is the most important exercise long term. Stand on a step or against a wall and raise up and down on the balls of the feet. Start with 2 sets of 10 reps provided it is pain-free and gradually build up to 3 sets of 20 reps. To be extra keen repeat the exercise with a bent knee to target the soleus muscle.
In the later stages of rehabilitation, more functional or sports specific exercises are important to bridge the gap between rehabilitation and full sporting fitness. These include more explosive, hopping and stepping plyometric exercises related to the specific demands of the sport.
Read more and watch video demonstrations of calf exercises.