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Table 2 Restoring foundation calf and lower limb function, and loaded strengthening after a calf muscle strain injury

From: The Assessment, Management and Prevention of Calf Muscle Strain Injuries: A Qualitative Study of the Practices and Perspectives of 20 Expert Sports Clinicians

Guiding clinical principles and primary actions

Key quotes

Foundation calf and lower limb function

 

 Normalise the walking pattern as the first step to normalise movement

“Get them walking normally as quickly as possible. Get them with normal stretch left versus right as quickly as possible, both gastroc and soleus. And, like I say, ‘load it.’ And it will be more ‘capacity-loading’. Load it safely, pain free, a number of times throughout the day.” Expert 5

 Find the optimal starting point to commence therapeutic calf loading, being specific to the muscle injured from the outset

“I’m almost exclusively going with load-based or muscle activation exercises. And really the decision is “how much load?” And where possible you’re trying to be as specific as you can with that load. So if it is a soleus-based pathology, then trying to find a way to make sure that they are loading over that area that is injured, they’re not just taking over with other parts of the muscle, or taking over with… you know, if it’s a medial gastroc injury, they’re not just taking over with soleus and you see that the medial gastroc is still just quite flaccid when they’re doing whatever activation exercise it is that you’ve given them.” Expert 18

 

“Start strengthening probably day 2, day 3. And that will be if you can do band exercises, we’ll do band exercises. If you can do two-leg weight bearing, we’ll do two-leg weight bearing. If you can do one-leg weight bearing we’ll do one-leg weight bearing. And so we try and find where your barrier is every day, and work just below that barrier.” Expert 12

 Prescribe multiple loading bouts per day to offset the likelihood of post-injury sequelae

“Players come in at 9 o’clock in the morning, and sometimes they are gone by 2 o’clock. Which is ok in some injuries but I am of the thinking with the calf you need to be giving them homework, or you are keeping them with you. If I can load them on four different occasions that day, pain free, safely, then I think you are getting capacity very, very early,” Expert 5

 Use activation exercises to ensure inhibition does not negatively impact higher-load activities

“Gastroc particularly, just gets very quickly inhibited. So we’ll just do some non weight bearing initially just to get some activation in it, which can be quite hard…. otherwise it could only be your flexors and your soleus doing all of the plantar flexion. So we teach them how to activate just by doing a non weight bearing one…that’s sort of more for the severe ones, but even for the milder ones, just to make sure.” Expert 19

 Foundation exercises can be progressed to include more dynamic actions of muscle–tendon unit

“Once they can do something like 2 sets of 15 slow and controlled up, on a single leg, then add 1 set of oscillations. We do our oscillations ‘up-top’, so in this position (end range for a calf raise), and then down to plantar grade, and then off a step in dorsiflexion, but that’s done not off reps, it’s done more on time. So 15 s, 15 s, 15 s… when they can do that they go to the more violent ‘drop and catch.’ ‘Drop and catches’ at plantar grade, and then ‘drop and catch’ down in dorsiflexion, for the reason that they spend a lot of time changing into this position for push off. So you have to get them into that range.” Expert 14

 Condition uninjured body regions at the highest intensity possible, while respecting pathology

“You do not want to let detraining occur in any uninjured muscles. So if you don't have any reasons to stop their other gym exercises, then don't. Keep their same routine. You do not want their general conditioning to lapse as well,” Expert 9

 Use this opportunity to establish the complete injury situation—address potential predisposing and risk factors

“It will also give us an opportunity to look at any other deficits that they might have. So for example, if there was a quads deficit or there was a posterior glute deficit on that side that was causing them to compromise their triple-extension, then we would look at that. And then we would progressively overload the calf. Looking at getting some endurance back. Looking at the manner in which we do that. Looking at the rest of the intrinsic foot strength. So tib post, peroneals, tib ant. Again, easy to get early value day 1 or day 2 post injury around that while you are respecting the injury itself. And then progressing that on, as appropriate.” Expert 7

 Avoid excessive eccentrics and prolonged passive stretching

“Range of motion probably takes care of itself. I think that, yeah they might have a painful lunge stretch to begin with but I see that as more an assessment tool rather than an impairment that I need to work on specifically. So I don’t really prescribe stretching exercises as a treatment.” Expert 19

Loaded strengthening

 

 Have a foundation of single leg calf raise capacity prior to loaded strengthening

“get some good endurance work—single leg, body weight, and be getting good at that. As a baseline marker it's 20 to 25. Yes, as an end stage or global benchmark I’d like that to be higher. Once I feel they are hitting that in rehab then I will transition them to adding load and less reps. Once we do get through the first cycle of loading, we load heavy. You know, your shorter reps 3 or 4 sets of 6 to 8, and then have a mix of some sets in there where it is probably longer, slower isometric holds.” Expert 11

 Maximising capacity is the first priority

“I’d potentially start loading them with a straight raise, as in with additional load, and then as they can tolerate their bent knee calf work they can do it seated using a Smith machine. I’d start loading from there. Initially higher reps: 10–15, 10–12 in the first few sessions, and gradually bring that down to your 8’s. And then with increased loading to sort of 3–4 sets of 6.” Expert 11

 As rehabilitation progresses, sports-related strength qualities trump maximum strength

“While I get their strength up, I think there is that whole strength-endurance component that they’ve really got to build into their rehab.” Expert 13

 Horizontal strengthening is an important piece of the puzzle

“We also load them in a position in which it mimics most, kind of that ‘leaning tower’ position of running. So rather than just that vertical loading, we are getting them into that ‘leaning tower’ position. So we can get that bar, the bar you might use for a high-bar back squat, and we get them leaning into the racks to do that calf loading.” Expert 7

 Progress loaded strength exercises to restore the range of attributes of the sport—consider work duration, axes, and velocity

Work the endurance and work towards velocity over time, as well as building the good old fashioned strength and strength-endurance,” Expert 6

 Shape single leg strength to be the foundation for dynamic exercises

“We probably wouldn’t spend too much time loading up double leg stuff. We’d go to obviously the next progression up is single leg, is to weight up single leg stuff. And so again, once you can do weighted single leg stuff, then you’d do jumping. And then from jumping to hopping. And then from hopping to running.” Expert 12

 Ensure soleus load tolerance prior to progressing severe or ‘problem calves

“where there have been recurrent injuries or where there’s been a higher grade of injury, then we tend to tap more into, particularly soleus strength, as a thread of their rehab. We’ve debated over the journey as to whether that’s a seated or a standing version, and still flip between the two, but we certainly like to have a thread of the strength as well as the strength-endurance that then ultimately underpins that elastic cycle.” Expert 16

 Load compound exercises to complement calf rehabilitation, initially taking care to not overload CMSI dynamically

“Before they are getting back into training, as a rehab tool get help from glutes, hammies, quads, hip flexors; training all of those things concurrently in rehab. And you can do that pretty early in rehab. Even from day two, just get them to squat, lunges, pulling motions…” Expert 1