Calf Strain

Calf Strain

A calf strain involves a tear (or tears) in the muscles at the back of the lower leg and usually presents as a sudden sharp pain that can range from mild to very severe. Treatment includes rest, ice, and compression during the acute stage, followed by a full rehabilitation program consisting of stretching and strengthening exercises.

On this page:

  • Symptoms & diagnosis
  • Causes & anatomy
  • Treatment & Rehabilitation
  • Sports massage
  • Exercises

Calf strain symptoms

Symptoms of a calf strain vary significantly from a generalised ache during or after exercise to an episode of a sudden sharp pain at the back of the lower leg. The calf muscle will often be tender to touch at the site of the injury and swelling usually develops over the next 48 hours and this may be associated with bruising, depending on the severity of the injury

calf strain assessmentIf the strain is mild, then the pain is more like an ache and the athlete may not realise that they have injured their calf and therefore they may continue to exercise which often makes it worse. When the injuries are more severe, the athlete can usually recall the exact time when the injury occurred and are unable to carry on exercising and may struggle to walk due to pain on pushing off.

Calf muscle strains are graded from 1 to 3, with grade 3 being the most severe. A grade 1 will not require professional assessment or treatment and will usually heal on its own within a couple of weeks, whereas grade 2 or 3 injuries will take significantly more time to heal and recover from and may require specialist treatment and rehabilitation advice from a sports injury therapist.

How bad is my calf strain?

Grade 1 symptoms - A Grade 1 calf strain is a minor tear of the muscle(s) with less than 25% of the muscle fibres affected. The athlete may complain of either a twinge of pain in the back of the lower leg or simply a feeling of tightness. They may be able to carry on playing or competing with minimal pain, however, after exercise, there is likely to be more tension or aching in the calf muscle which can take up to 24 hours to develop. Grade 1 injuries can easily progress into grade 2 injuries if they are underestimated or ignored so it is wise to stop exercising if the ache/pain in the calf does not settle down within 24 hours of exercise.

Grade 2 symptoms - Symptoms of a grade 2 strain will be more severe than a grade one, with between 25% and 90% of the muscle fibres torn. There will be a sharp pain felt at the back of the lower leg and this is usually significant increased when attempting to walk because the calf muscle is used during this activity. There is likely to be swelling in the calf muscle with mild to moderate bruising, however, this may take hours or days to become visible. Pain will be felt on resisted plantar flexion (pushing up onto the toes) and this action will often be weak due to the damaged fibres.

Grade 3 symptoms - Grade 3 injuries are the most severe and involve 90 to 100% of the muscle fibres and are often referred to as “ruptures”. The athlete will definitely know exactly when the injury occurred because there will be severe and immediate pain at the back of the lower leg and the athlete may often complain of a “pop” sensation and will be unable to continue exercising. There will be severe pain and weakness on walking and therefore the athlete will usually limp significantly. It is not unusual for considerable bruising and swelling to develop because of the torn muscle fibres and associated blood vessels, although this may take a couple of hours to be visible. If the muscle is completely ruptured then the athlete will be unable to contract the calf muscle at all due to the torn muscle and a gap in the muscle can often be felt where the injury is located and the muscle above it may bunch up towards the top of the leg.

Calf strain causes & anatomy

The calf muscles The calf muscle group consist of two muscles, Gastrocnemius and Soleus, but together they are known as the calf muscles. The Gastrocnemius is the big muscle at the back of the lower leg. The Soleus is the smaller of the two and is located lower down 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 more powerful muscle which produces propulsion during dynamic movements such as sprinting and jumping. The most common type of injury is a tear to the medial part (head) of the gastrocnemius muscle and this is often referred to as 'Tennis Leg' because the mechanism of injury is often seen whilst playing tennis. The musculotendinous junction is the part of the muscle where the tendon meets the muscle belly and is also a very common area to be injured. The tendon that attaches the Soleus and Gastrocnemius muscles to the foot is called the Achilles tendon and this can also be injured (see Achilles tendinopathy).

Calf muscle injuries usually occur as a result of a sudden pushing off movement or from excessive and forced over-stretching of the muscles, as demonstrated when landing from jumping activities or during quick changes of direction. If the muscles are particularly tight before the exercise begins, then they may be more susceptible to strains. An effective therapist can use sports massage to identify areas of specific tightness in the muscle(s) and work on these before they progress into a strain.

Another factor that is often associated with calf injuries is flexibility and this is demonstrated in athletes who have chronically shortened muscles due to congenital (genetic) reasons or as a result of poor footwear choices, such as the regular use of high heeled shoes. In the latter, the calf muscles adapt and shorten over a period of time due to the raised heel and then when the athlete wears running shoes with a lower heel, the muscles are stretched excessively this poses a much higher risk for injury. Another consequence of wearing high heeled shoes regularly is that it can either only work the muscle in a shortened position or even “switch off”/“deactivate” the calf muscles leading to a gradual weakening of the muscles over time and this in itself may be another risk factor for developing an injury to the muscle.

Calf strain treatment

Treatment involves immediate first aid principles, followed by active rest and then a gradual stretching and strengthening program to restore normal function to the muscles.

Self Help Treatment

calf supportApply 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 minimise any internal bleeding within the muscles whilst also reducing pain and swelling due to the suppression of the inflammatory response. 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.

Active rest! Whilst it is not advisable to do nothing and completely rest, it is important to allow the muscle fibres to heal and form new scar tissue and therefore stopping activities such as running and playing sport are advised until walking is pain-free. There is significant evidence to support the theory that muscles heal with some stress, but this must be controlled an if in doubt, “less is best”. The more you use the muscle when it is trying to heal, the longer it will take to heal. in the early acute stages, we advise wearing a compression bandage or calf support because this will protect the muscle and help reduce swelling by compressing the blood vessels and encouraging the swelling to be taken away from the area. In the later stages of the rehabilitation program when running and agility exercises are introduced, a compression bandage or muscle support can be used to keep the muscle warm and improve blood flow lin later rehabilitation stages where running and exercises are introduced.

In order to encourage healing and protect the new muscle fibres in the early stages, we suggest wearing a heel pad in the show or boot to raise the heel a little because this slightly shortens the calf muscle, hence taking some of the strain off the muscle. We suggest putting heel pads in both shoes because otherwise one leg will become longer than the other causing other problems. As soon as running is started, it is important to remove the heel raise otherwise the muscle may shorten permanently and this may the risk of reinjury.

When pain allows, begin gentle stretching and strengthening exercises. Stretching exercises can begin once the initial acute phase has passed this is usually a couple of days after the injury occurred. It is very important not to force the stretching and strengthening exercises otherwise this will interfere with the healing process and you may damage the new weakened muscle fibres and scar tissue.

In the later stages of the rehabilitation process, a foam roller (play video) may be used to help mobilise the muscle and fascia (connective tissue which surrounds the muscle) and this will help to keep the muscle supple and ready for action. Performing “self” myofascial release is a way of relieving tension in the fascia yourself, similar to sports massage. Once the injury has healed and you have returned back to playing sport, we advise continuing to use the foam roller to prepare the muscle for activity and keep the muscle supple. “Self” myofascial release is performed by rolling the foam roller up and down the calf muscle and adjusting the pressure accordingly depending on the tightness of the muscle or the pain felt whilst doing it. 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.

For grade 2 and 4 injuries, we advise seeing a professional sports injury 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?

Expert interview initial treatment of a calf strainExpert interview(play video)Neal Reynolds Sports Physiotherapist explains the initial treatment of calf strains.

In more severe cases, a doctor or medical professional may prescribe anti-inflammatory medication e.g. ibuprofen and this can be 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 strong evidence that anti-inflammatory medication (such as ibuprofen) can impair muscle healing so do not take them for more than a few days at the beginning of the injury and taking medication can sometimes mask the pain and may, therefore, be detrimental to the healing process.

An on-field first aider or sports injury therapist may apply a compression bandage immediately to the muscle following injury to minimise 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 then be worn after this for longer periods as the compression is not so intense.

Sports injury therapist may choose to use electrotherapy treatments, such as therapeutic ultrasound to treat your muscle injury. Therapeutic ultrasound is different from the diagnostic ultrasound that is used to look inside the body, such as during pregnancy, but it works in a similar way by transmitting high-frequency sound waves into the tissues that encourage blood flow and facilitate effective healing of the damaged muscle fibres and this treatment is particularly useful in the early stages of the injury.

calf sports massage videoSports massage for calf strains can be used after the initial acute phase has finished. Do not massage in the first 5 days post-injury because this may damage newly formed blood vessels and therefore increase bleeding. After the acute stage of healing has passed, massage will help to stimulate blood flow, mobilise the muscle fibres 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. A skilled masseur may also be able to identify areas of the muscle that may be at risk of injury in the future so regular massages can be beneficial, even when back to playing sport again.

In order to diagnose a calf injury, a sports injury professional will carry out a full assessment of your injury and use a variety of tests to make an accurate diagnosis. Then, if required, they will then treat the injury with a number of treatments such as massage and ultrasound (see above) and then prescribe a full calf strain rehabilitation program consisting of a number of stretching and strengthening exercises and progress it accordingly.

Exercises for calf strains

Both stretching and strengthening exercises are important for calf injuries but should only begin after the acute stage of healing has been completed and should always be performed pain-free.

Stretching exercises

Active calf stretches/movements are recommended once the early stages of injury recovery have been completed and should start with a gentle stretch to the muscle. To perform this on the Gastrocnemius muscle, lie yourself down or sit with your legs out in front of you and pulls your toes up towards you and this stretches the muscles at the back of the leg. Hold the stretch for a couple of seconds and then relax and then repeat this for 10 to 20 repetitions. To stretch the Soleus muscle, sit with the knees bent and perform the exercise in the same way, starting with the feet on the floor and then pulling the toes up towards you.

Calf stretchTo develop these stretches, you can stretch the Gastrocnemius muscle in standing and this is achieved by keeping the back leg straight and then either leaning against a wall or if you have flexible calf muscles, then you can perform this off a step to increase the stretch. Make sure that you ease slowly into the stretch, until you feel a tightness (but no pain) in the calf and then hold for 20 seconds. If the tightness feeling gets easier, then increase the stretch by leaning forward more or drop the heel of the foot further off the step, but do not push too far and especially in the early stages. We suggest performing this for 3 repetitions and repeating this 3 to 5 times a day.

soleus stretchAs mentioned before, the deeper soleus muscle must be stretched with the knee bent. Therefore, to perform this stretch in the latter stages of rehabilitation, stand with one foot in front of the other (see picture) and bend the back knee (the leg being stretched) to stretch the muscle. This position biases the Soleus muscle and reduces the stretch on the Gastrocnemius muscle because the Soleus attaches below the knee whereas Gastrocnemius attaches above the knee and therefore knee movement changes the length of the latter. To stabilise yourself whilst performing this stretch, you can lean against a wall with the leg to be stretched behind you. Bend the knee keeping the heel in contact with the ground until a stretch is felt and then hold for 15 to 20 seconds and repeat three times. Read more and watch video demonstrations of calf exercises.

Strengthening exercises

To improve strength in the calf muscles, plantar flexion can be performed with a resistance band (play video) and this is a gentle exercise to start with. Hold a loop of resistance band around your foot (as shown) and use it to apply resistance whilst you point the foot away (plantarflexion). Start with just 2 sets of 10, once a day, and then build up to 3 sets of 20 repetitions, twice a day. If there is no reaction in the muscle and it does not hurt the next day, then make the exercise harder by either increasing the resistance of the band by shortening the section of the band (or use a more resistant band) or increase the number of sets and repetitions. On the contrary, if there is any pain whilst performing the exercise or the day after, then reduce the resistance, reduce the number of reps and sets next time or increase the rest time between exercises.

Seated calf raise is another gentle exercise that will help strengthen the Soleus muscle. To begin with, it can be performed with no weight at all, but then as the muscle gets stronger, then you can use a weight on the thighs to increase resistance. To perform this exercise, sit on a chair with your knees bent and lift your heels off the ground as high as possible. Resting a weight on the knees will increase the resistance.

A standing calf raise is the most effective exercise to use in the long term. Stand on a step or against a wall and keeping your knees straight, raise your body up and down on the balls of the feet to strengthen the calf muscles. Start with 2 sets of 10 reps provided it is pain-free and then gradually build up to 3 sets of 20 reps. To bias, the Soleus muscle, repeat the same exercise with a bent knee.

During the later stages of rehabilitation, it is important to introduce more functional or sports specific exercises to bridge the gap between controlled indoor rehabilitation and returning to full sporting fitness and preparing the healing calf muscles ready to withstand the rigours of sport. Examples of these exercises include explosive jumps, hopping, stepping plyometric exercises, changes of direction, sprinting, long distance running and any other exercises that mimic the specific demands of the sport.

Read more and watch video demonstrations of calf exercises.

References

  • Koulouris G, Ting AYI, Jhamb A et al. Magnetic resonance imaging findings of injuries to the calf muscle complex. Keletal Radiol2007;36:921-7
  • Orchard J, Alcott E, James T et al. Exact moment of a gastrocnemius muscle strain captured on video. Br Journal Sports Med 2002;36:222-3
  • Kwak HS, Han YM, Lee SY et al. Diagnosis and follow up US evaluation of ruptures of the medial head of the gastrocnemius ('tennis leg'). korean J radiol 2007;7(3):193-8

This article has been written with reference to the bibliography.