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Rehabilitating A Calf Injury

A few weeks ago I (Andrew) picked up a calf injury whilst running in Sandbach. I blame the dog as he kept stopping, preventing me from warming up properly (come on I’ve got to blame someone).

The first thing I need to point out is we no longer follow RICE, (Rest Ice Compress Elevate). This was replaced by POLICE (Protect Optimum Load Ice Compress Elevate) which was subsequently replaced by PEACE and LOVE which you can see below. The PEACE part is for the initial injury usually 1-3 days, LOVE is the long term rehab phase.

Inforgraphic showing how to rehabilitate a tendon injury
PEACE and LOVE - British Journal Sport Medicine April 2019

Here is how I rehabilitated my injury.

The first task during rehab is to work out the final aim and your starting point. My final aim was to be able to run 5k 4x a week. 2 days after the initial injury I could:

1. Could walk comfortably with some pain during the first 15-20 minutes of starting out.

2. Carry out a 2-foot isometric calf raise (standing with my toes on a step and my heels overhanging the step) but I could not achieve this on my right leg alone.

3. I could walk up a steep hill with a slight increase in pain.

4. Both ankles had the same range of dorsiflexion.

After identifying the start point and the end point, we can break the rehab process down into key objectives. This helps add focus to rehab, stops the process looking long and unachievable and reduces the chances of us progressing too quickly and causing further injury.

Phase 1 - Strength

My first objective was to develop strength in the calf complex (gastrocnemius, soleus and achilles):

  1. Build strength in my calf so I could hold an isometric calf raise on my right leg for 45 seconds with 1.5x body weight.

  2. Walk up a hill with no increase in pain.

I achieved this by carrying out 2-foot isometrics holds and gradually increasing the load going through my right foot by lifting my left foot. I achieved my first 2 objectives in 3 days and at the same time I was able to carryout 10 single leg calf raises with 1.5x body weight, so I was making rapid progress.

Phase 2 - Functional strength and power

My objectives were:

  1. To increase the volume (number of sets and reps) of single calf raises whilst keeping the intensity (weight lifted) the same. Keeping a rhythm of 4 seconds to go up (concentric phase) and 4 seconds to lower (eccentric phase). If I could complete the lifts faster than 4/4 then more weight was added to the bar.

  2. Carry out the same number of calf raises with the same weight with my knees bent, to added emphasis on soleus rather than gastroc.

I achieved this by carrying out 2 sets of 8, then 2 days later I carried out 2 sets of 8 and 1 set of 5. 4 days later I was able to carry out 4 sets of 8, 2 sets with a straight leg and 2 sets with a flexed knee. I took a little over a week to achieve the second set of objectives. During exercise sessions pain increased for the first few lifts then decreased. The next day my ankle would feel stiff in the morning but the pain would disappear after a few minutes of walking

This video gives examples of the exercises that I carried out at each stage of rehab.

Phase 3 - Plyometrics (elasticity)

At this stage I was 10 days post injury and I had been building strength and power in my legs. Now it was time to start developing elasticity in the muscles and tendons. The elasticity of muscles and tendons help improve the energy efficiency of running. It’s one of the reasons skilled runners look like they are gliding across the ground whereas novice runners appear to be putting a lot of effort in.

My next objectives were:

  1. To skip comfortably on my right leg for 2 sets of 45 seconds.

  2. Run 5km, walking any steep uphill sections.

Again, I achieved these objectives in approximately 1 week by progressively building up the volume and intensity of exercise. I was back to running 3 weeks after the initial injury. I was not up to full capacity. I was slow and running was hard work, I lacked a spring in my step especially going uphill. It’s important to note that although I was running, I had not yet achieved my final goal of running 5k 4x a week over varied terrain, my rehab was still a work in progress despite returning to activity.

Phase 4 - Return to running

‘Return to activity’ is a tricky phase of rehab. When people have been away from their sport for a period and built strength in the gym, they often feel strong and niggle free, a positive side effect of rehab. As a result, people go for it too quickly. This often results in the injury recurring or a new injury starting. At ‘return to activity’ patience is needed, just because you are running again it does not mean your rehab is over. It is vital to continue building exercise capacity by continuing to develop strength, power and elasticity in the gym and out of the gym running frequency, volume and intensity.

Phase 5 - Progressing and monitoring.

1 month post injury I can comfortably run 5k 2-3x week but steep uphill sections still aggravate more pain than I would like. My rehab is ongoing and I'm a little behind at the moment. It's conference season for the podiatry world so I have not been exercising as consistently as I'd like but that's life. I am sure in the next few weeks I'll achieve my end goal, then it will be time to focus on getting faster!!

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