Calf strain
In this installment of our “injury of the week” series we’re going to be talking about calf strains. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system.
What causes calf strains?
The first thing to realize is that the calf muscles play a major role in shock absorption as you step onto your foot. They also provide control and balance as you move over your foot/ankle from double to single leg stance, and assist in propulsion as you push off of your toes at the end of the gait cycle. With that in mind, they are a common source of problems in the lower extremities. Tight calf muscles can lead to problems both in the foot and shin, as well as, up the chain into the knee, hip, and back.
By now, most everyone is familiar with the two big muscles in the calf- the gastroc and the soleus. The gastroc is the easiest and most visible of all the calf muscles- it’s the two bumps that pop out when you step up on your toes. The soleus muscle is underneath the gastroc and lower down the leg (think just below the two muscle bellies (bumps) of the gastroc on either side of the achilles tendon/ or mid-way between the knee and heel). Both of these muscles become the Achilles Tendon which inserts into the back of your heel. The main difference between the two muscles is in how they work. The larger gastroc muscle helps you push off of your toes when the knee is straight versus the soleus muscle which does the same thing while the knee is bent.
It’s the third, deeper muscle in the calf that people forget- the posterior tibialis. This muscle is located deep to both the soleus and gastroc. It runs down the middle of the back of your lower leg before moving towards the inside of the leg and down the tibia. It’s tendon can be felt as it wraps around the inside ankle bone (medial malleolus) and inserts into the arch of your foot.As the larger calf muscles fatigue/stiffen, it is very common for the posterior tib to help compensate by helping with push off and toe clearance. The result is frequently the foot swinging through with the arch positioned up towards the sky instead of down towards the ground.
Okay, so now that we’ve reviewed the anatomy lets get to the actual causes.
#1 Abnormal rotation of the foot. Meaning that the foot is twisted too much or too little during the weight bearing process (i.e. overpronation or under-pronation). This is where shoe selection comes in. To plant the foot and propel off it, you need to get your foot flat and come over the ankle to push off your big toe. Too much/too little arch support will prevent this.
#2 Bunion/loss of big toe extension. In the event that motion becomes restricted in the this area, the foot will become unable to fully load the big toe in preparation for push off. Over time this will lead to compensation and rotation of the lower leg and ankle to allow the foot to fully flatten to the ground during full weight bearing. Typically this is seen as the foot pointing out and push off coming off the side of the big toe. The problem here is that as the rotation occurs, the big calf muscles become less efficient and the smaller muscles of the lower leg must assist with forward propulsion. The foot isn’t designed to work like that.
#3 Ankle restrictions. In particular, not enough dorsiflexion of the ankle (being able to pull your foot up towards your shin). When this is limited, you’re stride is shortened and your push off decreased. The larger muscles will be unable to fully help and the workload will shift from the big toe to the mid-foot and arch. Sprain your ankle often or break it as a kid? This is where old sprain/strain injuries and fractures can sneak back up on you.
#4 Restrictions up stream. Just like the ankle can be a huge factor, so can the knee and hip. I know we’ve all heard “it’s all connected”, and probably rolled our eyes, but it is very true. For example, the gastroc (large calf muscle) and hamstrings criss cross behind the knee. Restrictions in one, will affect the other. Period. Sometimes the problem isn’t the calf at all. Sometimes it’s restrictions in the hip and the ankle/lower leg gets all jammed up trying to make up for it.
Tired of battling chronically tight calves that won’t loosen up no matter how much you stretch/foam roll?? Take a look at this link and compare your mobility to the self evaluation tips the article talks about.
My calf hurts? NOW WHAT?
1) The first step is determining if it is truly a calf muscle strain or something else. Remember, the goal of this series is not to keep you away from your doctor so that you can self treat everything. It’s to teach you how to catch the early symptoms and take care of them before it becomes a full blown injury. That being said, calf strains starts as pain and stiffness in the muscle belly itself (not down in the tendon). These symptoms are worse with activity/motion, better with rest. Essentially all strains are tears in the muscle. The grade depends on the severity. A big tear will result in bruising and swelling. If you fall into this camp, see your doctor! Numbness/tingling/skin temperature changes? See your doctor! If the symptoms are sharp and not improving, or you have pain at rest, it’s time for the doctor.
2) If after reading number one, you fall into the strain camp, then the good news is that there is a lot you can do to calm this down on your own. Be smart though. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait months and even years before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:
- Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. A cranky calf will require some hands on/massage work. Exercise alone won’t cut it most of the time.
- Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Not really. Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.
How to treat it.
**download PDF with links, sets, reps, progressions, etc here**
Step 1- Traditional R.I.C.E. treatment:
When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage when working to heal an injury!
Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.
Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.
Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them or calf socks). You can also use a store brought ace wrap to accomplish this. Start the wrap below the injury using good tension on the bandage and move up above the injury. This will help keep swelling from moving down into the ankle/foot.
Elevation: This is critical in the early days following acute injury where swelling may be present. In the case of an ankle injury for example, elevate the leg so that it is above chest level. This can be accomplished by laying down and propping for your foot up on the arm of the couch with pillows.
Step 2- Kinesiology taping:
By now you’ve probably seen athletes covered in all kinds of colored tape. Some of you have probably even tried it out. Make sure to read the application instructions first! This stuff should last 3+ days, not fall off in an hour.
1) Calf strain taping application. Click here.
2) Here is a second application for the posterior tibialis. Click here.
Step 3 – Getting mobility back
The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a muscle sprain/strain isn’t about no pain, no gain. The muscle needs to heal! Don’t overdo it in an attempt to speed up your recovery.
1) R.I.C.E. + gentle stretching. There should be no pain with stretching.
Begin using the foam roller AROUND the injured area. The goal here is to start getting slack into the muscle without aggravating the injury itself. No tennis ball work or active/joint mobilizations. The order should be foam roll around injury -> stretch -> RICE.
3) Begin using the foam roller over the injured area to tolerance. The order should be foam roll around injury-> over injury -> stretch -> RICE.
4) Begin using the tennis ball for mobilizations. The order should be foam roll around injury -> over injury -> mobilizations -> stretch -> RICE.
5) Begin using the tennis ball for cross friction + trigger point. These are the deepest of the soft tissue techniques so you want to save them for last to target specific adhesions and restrictions. Consider this your fine tuning step.
How long do you need to R.I.C.E for??? Until it’s 100% gone.
Here’s what it looks like. Use the guidelines above.
Step 4- Strengthening
We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.
What you’ll need: 1) resistance band/tubing. This is easy to find in any sporting good store these days. You can probably even get it in walmart or target.
Optional equipment: a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20.
Video’s for each level are here. Please note, in the PDF download you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.
Level One
Level Two
Level Three
To help put it all together, I’ve also created a PDF you can download to walk you through what a “treatment session” would look like. In it you will find everything you need including links to the videos and posts. Click here.
Hope that helps, and fire away with any questions in the comments.
References
1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.
2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.
5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.
6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.
