Firstly, Ouch! Pulling a muscle is painful and very debilitating. I should know, I have even strained my calf before!
You can see my story here in these two videos and this is close to how I would treat your calf strain at Hawkes Physiotherapy:
Firstly lets’s talk about the anatomy of the area. In the calf, you have two main muscles, the Gastrocnemius and Soleus. The Gastrocnemius is a two joint muscle, as it has the ability to flex (bend) the knee and also plantarflex the ankle (point the toes). The Gastrocnemius has two heads (not literally)! A medial (inside) and lateral (outside) head and inserts into the Calcaneus (Heel bone) by the Achilles tendon. The Gastrocnemius is made up of more fast twitch fibres, and so, is very powerful and creates a lot of propulsion. The Soleus only crosses the ankle joint, and so, can only plantarflex the ankle. The Soleus is also deep to the the Gastrocnemius and it is more slow twitch dominant and so plays more of a postural role. It also attaches into the Achilles tendon.
Out of the two main muscles the Gastrocnemius is much more commonly pulled or torn and in this muscle it is also more likely to tear the medial (inside) head.
Why do you pull a muscle?
Muscle is pulled or torn or strained, which all mean the same thing, from an overloading force. So basically exceeding it’s capacity to take load or load with stretch. So muscles being too weak are a major cause of injury.
What should you do straight away for a Minor partial tear, moderate partial tear & subtotal/complete muscle tear? (Mueller-Wolfhart et al 2013).
It used to be said that in the first 72 hours you should use R.I.C.E. which is:
- Rest
- Ice
- Compression
- Elevate
However, this now considered to be incorrect. The latest acronym is P.E.A.C.E. & L.O.V.E. this goes as follows:
- Protect
- Elevate
- Avoid ice & Anti-inflamatory mediacation
- Compression
- Education
Followed by:
- Load
- Optimisation
- Vascularisation
- Exercise – Rest is bad!
MUSCLE STRENGTH DECREASES BY 2-6% FOR THE FIRST 8 DAYS OF IMMOBILISATION (Muller,1970).
Is ice bad?
New thinking is moving away from the icing of acute injuries as it doesn’t help and may even hinder. The reasoning here is based on when you apply ice you get vasoconstriction in the skin and superficial area, which is designed to stop the blood from cooling too much. This blood has to go somewhere else and that place is deeper. meaning you have to vasodilate deeper, which will increase blood flow to the injury site, hence worsening the bleeding and swelling. It’s obvious when you consider that cryochambers are used by athletes to speed up recovery from injury and training and how does this work? It INCREASES blood flow!
For more information on why ice may not be the correct approach, click on the ice below:
Why no anti-inflammatory medication?
Now remember this is a rough guide, but inflammation is what essentially heals your body so why would you want less? Surely this will slow down the healing process? However here is the caveat, if the pain is impeding your ability to progress your rehab then it may be worth taking them to lower pain and improve function but you shouldn’t use them for long and avoid them if you can. The rest of your body isn’t injured remember!
Train your upper body and the other leg as this is not a problem. Plus there is a phenomenon called the cross over effect, which is where you can actually increase strength in the untrained limb (Andrushko et al 2018). So why not! Don’t forget Cardio too! you can train the upper body in things such as swimming or a hand bike so again, why let this deteriorate for no good reason!
What do you do next?
As stated above rest is bad and this was shown in a study by Bayer et al (2017). They found that patients with calf strains who started to rehab their injury at 2 days after their injury, got back to sport 3 weeks earlier than if rehab was started at 9 days after injury. They also found no increased risk of re-injury too. So this obviously doesn’t mean just hammer things on day two. You need to work is within it’s tolerance levels, monitoring after and next day effects on pain and swelling. As long as no negative effects occur then you are rehabilitating things at the correct level. This is what we can guide you on at our Physiotherapy clinics in Stoke-on-Trent.
Other treatments:
Sports massage: There is an accelerated recovery of muscle function from massage-based therapies (Best et al 2013).
Neuromuscular electrical stimulation (NMES): This can be used on light recovery settings, that basically reduce pain, increase circulation and relax the tone of the muscle.
What rehab should you do to build things up?
So this really starts on day two (as previously mentioned). The most important thing with rehab is how it feels and reacts after the rehab and the next day. Basically, whatever you do, there should be no adverse effects.
Neuromuscular electrical stimulation (NMES): When you have pain and swelling, muscle function reduces and in extreme cases can inhibit to no voluntary activity at all. This is what happened to me for the first 5 days of my injury! So how did I minimise de-conditioning when I couldn’t start loading rehab until day 5? Simple, I used the NMES to involuntarily contract the muscle on day 2. This started the rehab process, when otherwise I wouldn’t have been able to. Even if your muscle still works, it doesn’t work well, and the muscle stim can help here too.
Fast twitch fibres need a lot of load to work and train, but you can’t do this from the start. According to Gondin et al (2011), the muscle stim significantly develops strength and can easily recruit fast twitch fibres at low force levels, making it ideal in the early stages of rehab.
Stretching: This should be very gentle at first because the fibres are fragile. The way that I would describe things is to coax the movement and not force anything. The key here is little and often.
Loading: As you can imagine, the muscle won’t be able tolerate much here at the start, so what you should do, is begin calf raises from the floor (not a step) but you need to work out how much weight you should place thorough your good and bad side. You can even start with no load, so the bad side is going up onto the toes but the good side is literally doing all the work. The amount of load that you place, again depends on the after and next day effects.
The aim over each day that passes is to build slowly up the intensity of the NMES, the range of movement in the stretches and the amount of loading that you take. Once the range is getting close to full, now you can transfer the calf raises onto the edge of a step as to load into the dorsiflexed (stretched) position. Once you get the loading all the way over to your injured side and you are performing them on one leg, then you need to add weights to the exercise and progress this slowly.
Next phase
Once some substantial weights are being lifted without any problems then you can start walking and build this up. Start on the flat and don’t walk too far. Once this is built up then speed the walk up to transition to a jog then a run. Alongside this you can start to do some plyometric exercises. These should start with very littel lift from the ground and start with 2 legs first and then progress the depth and height and move onto single leg work when ready. Here is an example of a plyometric exercise:
How long does it take to recover from a calf injury?
This depends on many factors, such as severity, treatment, earliness of rehab commencement etc. Another reason is the level that you need to get back to. For example, running places a lot of load though the Calf and Achilles. It has been measured at 9kn, which is about 12.5 times body weight (Maffulli et al 2004). So if you need to get back to running or even more loaded activities that involve jumping etc. then you need to build up to a higher level than a couch potato and this will take you longer.
Although you need to take this with a pinch of salt this is what the averages are:
Gastrocnemius muscle tears generally take longer to recover due to there role in the body and they can take weeks if not months to recover (Dixon et al 2009).
Soleus muscle tear recovery was on average 29 days (Pedret et al 2015)
Also a re-injury of a muscle can take 30% longer to return to sport than the original tear (Ekstrand et al 2016)
Are you likely to re-tear again in the future?
Unfortunately yes. This is due to the scar tissue that repaired the injury site. Scar tissue is not as flexible nor strong as the original muscle. However, you should make sure that you have adequate flexibility and get as strong as possible to combat this risk. So what can you do to reduce the likelihood of tearing it again in the future?
- Build muscle and get strong – Muscle-building exercises reduces the risk of sporting injury by 68% (Lauersen et al 2014).
- Only stretch if you have length deficiencies – Stretching was found to make no difference to the risk of sporting injury (Lauersen et al 2014)
- Get your sleep and recover properly – Athletes who slept less than 8 hours had 1.7 times greater risk of sporting injury than those who slept for 8 or more (Milewski et al 2014).
So if you have this injury then we can help you. So just get in touch to book yourself in.
