Calf Strains in Runners

We are now well into the running season, with only a few months until the Gold Coast marathon and a host of other winter running festivals. Some runners will already be doing long runs of over 2.5 hours and the weekly mileage is creeping up. One very common running complaint suffered by many runners at some stage is calf soreness or calf strains. Usually, runners complain of a dull aching pain but in severe cases, a sharp intense pain is felt and the athlete will find it difficult to walk. A marathon runner’s worst nightmare is to pull a calf muscle during a race or the last few weeks of preparation. Calf strains, however, are not purely the domain of the runner or sprinter, they are also common in other sports that require explosive acceleration such as cricket and tennis.

The calf muscle is a group of 2 muscles at the back of the lower leg. The gastrocnemius muscle (which has an inside and outside portion) is at the top of the lower leg and is stretched with the knee straight. The lower, deeper soleus muscle is stretched when the knee is bent. Both these muscles attach to the heel via the Achilles tendon.

Common causes of calf strains:
  • Overload and fatigue
  • Speed or hill training
  • Ineffective warm-up or cool-down techniques
  • A sudden increase in mileage
  • Dehydration and cramping
  • Calf tightness from behind and sciatic pain
  • Inappropriate footwear that leads to calf tightness

One of the biggest problems is that many runners continue running even after the initial signs of calf strains. Runners simply adjust their running stride to make it less painful. Most commonly they do this by reducing heel strike when the foot lands on the ground. The ideal running technique involves bringing the foot through the swing phase with the toes held up and the foot flexed. This enables the calf to be pre-tensioned, allowing it to act as a spring when it touches the ground. By adjusting the way the foot hits the ground you may exacerbate the condition and cause more severe strains.

A small injury can turn into the end of the season very quickly. Changes in running technique can also cause injuries to other joints, including injuries to the opposite leg due to offloading the symptomatic calf. Unfortunately, it is a common occurrence to see people who have strained one calf to strain the opposite one soon after. Calf weakness or calf tightness can also lead to a range of other lower limb complaints such as Achilles tendonitis, shin splints, stress fractures, and anterior knee pain.


There are 2 quick measures Physiotherapists use to assess the condition of our calf.

1. Knee-to-wall Measure

To assess the flexibility of the calf we get the patient to place a ruler perpendicular to the wall. The patient stands with their big toe on the ruler and, keeping their heel down, bends the knee to touch it to the wall. You continue to move the foot back until you are no longer able to touch the wall with your knee while maintaining your heel on the ground. The last point where you can sustain this position is the measurement. Whilst there are lots of individual differences in this test, as a guide, we are looking for more than 10 cm. At least 5-7 cm is needed to be able to functionally go downstairs, sit down, or squat down. While this gives us a quick idea of your range of movement, it can also be affected by ankle joint stiffness or other restrictions around the ankle apart from calf tightness.

2. Single-leg calf raises

The patient stands on one leg and rises up and down onto their toes as many times as they can. The recommended number that indicates adequate strength is 30 single calf raises on each leg.

It is also important to look at the appearance of the muscle to see whether there is any swelling or bruising which indicates a more severe injury. Feeling through the muscle will also give you a good idea of which particular part of the muscle has been affected. In some cases, an ultrasound investigation is recommended to assess the degree of muscle damage.


Early treatment aims at reducing inflammation and strain on the muscle. This may include:
  • Ice massage over the muscles several times a day
  • Compression to limit the bleeding and swelling in the muscle
  • Stop running and limit activities that aggravate the condition
  • Use a heel raise or shoe insert that helps take pressure off muscle as it heals
  • Use of anti-inflammatory medication may be indicated
  • Elevate the leg whenever possible
  • Early stretching can be done by actively moving the foot up to a point of stretch and where possible using a towel to gently provide greater stretch without having to put weight through the leg or causing pain in the affected areas

In cases of only mild inflammation, around a week of rest is recommended before easing back into things. For muscle strains, between 4 and 6 weeks off is more commonly required depending on the degree of muscle damage. In cases of full muscle tears, rehabilitation can take up to 3 months.

After the initial 4-5 days, treatment can progress to include:
  • Progressive stretching the calf muscles regularly during the day. You could create a stretch block at a 30-45 degree incline that you can stand on to get a slow, sustained stretch through the muscle. Standing on the edge of a step is also a good stretch as is leaning into the wall in a traditional calf stretch (ensuring the back heel is down and the foot is straight.) Remember to stretch the calf both with the knee straight and bent. Never bounce in the stretch.
  • Mobilising the ankle joint to avoid secondary stiffness from developing
  • Soft tissue techniques including massage, trigger point release, and dry needling
  • Addressing any nerve involvement
  • Graduated strengthening program

Any training or bio-mechanical problems should also be corrected before an athlete resumes normal training following injury. This may involve visiting a podiatrist or conducting a running assessment.

To return to normal function, a graduated strengthening program is essential to prepare the muscle for the forces it must accept during running. It should start by going up and down on your toes at an amount that doesn’t cause specific pain in the area. The program is gradually increased by adding more repetitions and more force, by moving onto a step, one foot at a time, and then a weighted backpack. Your Physiotherapist will eventually introduce jumping activities and exercises such as hopping up and down stairs. Occasionally the speed of exercises will be varied to mimic running.

It is important to understand that muscles function in different ways. When shortening, such as going up onto your toes, the muscles contract concentrically and when lengthening, as when lowering you back down, it is called an eccentric contraction. This controlled eccentric lowering is surprisingly harder for the muscle to achieve and your Physiotherapist may specifically target this type of contraction. Your Physiotherapist will also instruct you on the exact strengthening program you should follow. The program that is required is going to be different for everyone so it is best to have one that is specifically designed for you.

As always prevention is key:
  • Include the calf in warm-up and cool-down routines
  • Avoid dramatic increases or decreases in training loads
  • Don’t work through the pain, as that can make it worse
  • Consider decreasing your running loads when fatigued
  • Wear good quality, supportive shoes appropriate to your sport
  • Avoid wearing high heels regularly
  • Keep well hydrated

Return to Running

When you are given the green light to start running again it is a gradual process. The most likely time to re-injure your calf is when fatigued, such as during a speed session the day after a long run. Because of this, it is highly recommended that speed work and hill training are not reintroduced straight away. Depending on the severity of the calf strain and how long you haven’t run, you may be initially advised to start with an alternating walking or jogging pattern such as running for 2 minutes, walk for 1 minute, run for 2 minutes, etc. This way you work on maintaining and improving your fitness without exhausting the muscle.

As you progress, the running time may be increased compared to the walking time, for example running for 5 minutes, walk for 1 minute, etc. Gradually this should be built up until you are back running for the entire length of your training run. At this point, you may start reintroducing speed sessions into your training being particularly mindful not to do it when your body is already fatigued.

When treating runners one of the most difficult things is to convince them of the need to take time out from their running schedule to let their injuries heal. As a runner this can be mentally challenging, and you may feel like you will lose all your fitness and undo all your hard training. The good news is that research points to the fact that endurance training doesn’t disappear overnight. In fact, the benefits of those long runs last upwards of 6 months! Also, cross training and particularly water running have been shown to maintain your fitness while you are out of action. The priority is recovery to prevent re-injury or a change in running style, which can result in continued injuries and long-term problems.

Hopefully, this keeps you on track for your running goals this year. For any queries please contact us at 3891 2000 or email reception@qsmc.net.au

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