Building on top of our previous blog, this one delves into the ins and outs of strength programming for a calf strain.
Calves are notorious for recurrent re-injuries. Often, this is due to insufficient time to allow:
a) Natural history of healing to occur and
b) Enough time for the tissue to adapt to graduated loading stimulus.
Important to note here also, is the importance of adherence to rehabilitation/ return to running/activity. Allowing time and structure to take effect will ensure setbacks are less likely and pain-free activity can resume as soon as it is safe to reintroduce it.
There are three main focuses of rehabilitation following calf strains:
Reducing pain and symptoms
Progressive loading to stimulate adaptations to the muscle fibres – this period is about rebuilding calf capacity and addressing any imbalances along the kinetic chain
Return to running / activity
Staging the phase of rehab is contextual to each individual. It is never a one size fits all approach, and is determined by several factors, including but not limited to:
Pain and dysfunction identified within assessment
Severity of the injury and location of the injury (ie. muscle, tendon, musculo-tendinous junction)
Stage of tissue healing of the injury
History of similar or recurrent episodes
Exercise history and current condition of athlete
Timeline with goals and where in the season/ training regime is the athlete? i.e. are they toward the end of the season with football, is it their preseason of netball, are they in the lead up to a half marathon event?
Any dysfunction up or down the kinetic chain (ie. hip or ankle) that will alter load and tissue response to injury site
Early Stage Rehab
Depending on pain and level of dysfunction, an athlete may be prescribed low loading or isometric exercises in the beginning. An isometric exercise is an exercise where the length of the muscle remains unchanged through range of motion whilst is it held for a duration of time. Isometric exercises early in rehabilitation can be beneficial for:
analgesic effects if tendon related pain is also present
to enable loading to damaged tissue without stretching or lengthening the healing tissue in the acute phase
to encourage increased motor unit recruitment of muscle fibres that are inhibited by the brain due to painful stimuli. This enables more of the muscle tissue to be active and exposed to stimulus as athlete is progressed through stages
Examples include double leg calf raise holds, single leg calf raise holds, soleus wall sits, tip toe walking
Once isometric loading is comfortable, walking is pain-free and symptoms are well controlled, exercises will typically be progressed through range of motion targeting both concentric (shortening phase of contraction) and eccentric (lengthening phase of contraction) ranges to strengthen the muscle through its full-strength curve.
This is also a great time to work on other areas of the kinetic chain that are dysfunctional that do not directly load through the injured area, so movements can be integrated functionally into middle and late-stage rehab where sports specific movements are programmed. For example, core/hip strength, knee strength, ankle stability and balance/proprioceptive exercises.
Middle Stage Rehab
During this phase of the rehab, we will aim to challenge the tempo, range of motion and pliability of the tissue through several weeks. This is also the phase we will integrate exercises that are functional and challenge the kinetic chain / replicate demands of the sport/activity relating to athlete’s goals. Some ways this is achieved include:
Changing the time under tension – typically lengthening the duration of the muscle contraction to expose the muscle to greater tension for longer. This stimulates both muscular and nervous system responses.
For example, 3-1-3-1 tempo calf raise – where exercise is performed by 3 seconds concentric, 1 second pause at top, 3 seconds eccentric, pause at bottom for 1 second.
Increasing the range of motion further to meet functional demands
i.e. calf raise off step where strength is challenged through greater range of motion at the bottom of the movement
Changing the tempo of the contraction – the speed at which force is generated
i.e. fast concentric, pause, slow eccentric
keeping with calf raise example, exploding to top of movement, pause and lowering slowly back down to starting position
Adding plyometric exercises which challenges tendon stiffness and is functionally relevant for running based athletes / sports.
i.e. pogo jumps, skipping, forward hops which are usually prescribed on time basis rather than repetition basis
Kinetic chain involvement: where movements become more functionally meaningful and link together the kinetic chain in preparation for sports specific exercises
i.e. front foot elevated split squats, runner box step, triple extensions
This is also the phase where running based drills may also be introduced to prepare athlete for return to running program
Drills can include: A-Skips, B-Skips, Shuttle Runs
Return to Running:
This will often be in addition to rehab specific exercises/days.
Running will typically be prescribed as 2-3 runs on non-consecutive days.
These are often incremented within a shuttle running structure to allow tissue to build up capacity and load exposure. The focus initially is often around time and volume as goals. i.e. 30 seconds running 60 seconds walking x10
Running speed is typically the last factor to be reintroduced due to the demand on the calf musculature and risk of symptom provocation/set back. One desired volume is achieved, speed may be reintegrated back into sessions, when we are comfortable the tissue has reached relative robustness to tolerate it.
Things to consider along the way that can often affect progress on calf recovery:
Avoid over stretching – especially when injured tissue is healing. This is why isometric exercises are often introduced first/in the acute phase so we are not working against the body’s healing processes.
Not avoiding strengthening exercises / completely de-loading calf / lower limb complex in time of injury. Reducing activity whilst sore, skipping the middle step and then returning to running without addressing the deficiencies will only lead to recurrent re-injury down the line. Having a tailored rehab program will help avoid this pattern and streamline your return to running/activity
Not progressing exercises with enough load or stimulus that allows for healthy loading to meet the demands of activity. Ensuring your program is designed to progressively overload your calf complex to allow adaptations great enough to withstand the activity you are trying to return to is incredibly important. This is how we build robust and resilient muscles.
Calf strains aren’t always driven from the calf muscle. Keep in mind, there are other structures and injuries that can present or feel like a calf strain, such as neural irritation from the lumbar spine. It is important to have it assessed and diagnosed so you can ensure you are treating the appropriate driver of your pain/injury.
Consult with your physio to ensure your calf injury is assessed to identify where your pain is coming from exactly and to ensure your tailored loading program meets the demands of the activity you are wanting to return to. This will also ensure you are targeting the whole kinetic chain and reducing risk of injury elsewhere too.
Evolved Physio is a welcoming Physiotherapy clinic located in the Footscray/Maribyrnong area of Melbourne. Our experienced physiotherapists specialise the treatment of musculoskeletal injuries. Our therapists are also exercise science trained so they are experts in incorporating strength based rehab training into your injury programs. Find out more at www.evolvedphysio.com
References:
Counsel P, Comin J, Davenport M, et al. Pattern of fascicular involvement in midportion Achilles tendinopathy at ultrasound. Sports Health. 2015; 7:424–8.
Green, B., & Pizzari, T. (2017). Calf muscle strain injuries in sport: a systematic review of risk factors for injury. British journal of sports medicine, 51(16), 1189-1194.
Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy. 2017;103(4):446–452. doi:10.1016/j.physio.2017.03.002
Hreljac A. Etiology, prevention, and early intervention of overuse injuries in runners: a biomechanical perspective. Phys Med Rehabil Clin N Am. 2005;16(3):651–vi. doi:10.1016/j.pmr.2005.02.002