The calf muscles plantar flex (push down) the foot, propelling the body forwards during walking and running, as well as raising the body up onto the ball of the foot when standing on tip-toe. They also act as shock absorbers when landing from jumping and running.

Site and type of injury

• Tearing of muscle fibres of either gastrocnemius or soleus most commonly occurs close to the junction between the muscles and the Achilles tendon    (the musculotendinous junction), but can occur in any part of the muscle
• Muscle fibres tear, with associated bleeding into surrounding tissues
• Can be complete rupture of one muscle belly from its attachment to the Achilles tendon
• Must be distinguished from partial or complete rupture of the Achilles itself

Predisposing factors

• Lack of adequate flexibility in the muscles
• Strength imbalance between the two legs
• Muscle fatigue
• A tight lower back, with or without pain (a common contributory factor in repeat injuries occurring late in competition when muscles are already warmed up)
• Neural tension - tighteness in the nerves that run down the back of the leg
• Commonly occurs in athletes who participate in sports involving running, start/stop, sudden changes in direction, sudden acceleration etc.

Symptoms

• Athlete reports being “hit” in the back of the calf, but no-one nearby at the time, or a “pull” in the calf muscle
• Pain on walking, especially on pushing off on the toes
• Tender area in calf
• Pain on plantar-flexing (pushing down) the foot, but no loss of power
• Pain on stretching the calf and on dorsi-flexing (pulling up) the foot
• Often bruising and swelling at the site of injury, or sometimes around the ankle as blood has seeped downwards from broken capillaries

Grades of injuries depending on severity

Grade 1
Mild over stretching of the muscle, causing less than 5% disruption of fibres

Grade II
Partial tear with more significant injury, but incomplete rupture of the muscle/tendon unit

Grade III
Complete rupture of a muscle belly, or rupture of part of the muscle from its insertion into the Achilles tendon. Achilles itself remains intact

Rupture of the Achilles tendon
Partial or complete rupture of Achilles tendon itself

Treatment (grades l to lll, if grade lll doesn’t require surgery)

Immediate post injury treatment using the R.I.C.E. principles (Days 1 – 3 )

• Ice to limit bleeding into surrounding tissues
• Compression of calf, with bandage or tubigrip to slow down bleeding and reduce swelling
• Elevation of the limb to limit swelling
• Rest for 24 hours
• Avoidance of stretching injured muscle tissue for at least 48 hours
• Crutches and a temporary heel lift may be necessary to facilitate walking, depending on severity of injury

Physiotherapy treatment

Days 3 – 7

• Gentle soft tissue massage to reduce swelling
• Modalities such as ultrasound / interferential therapy to reduce pain and soften scar tissues which will be forming
• Begin active ankle range of movement exercises
• Begin weight-bearing stretching of calf muscles, stretching only into the edge of the pain and holding stretch for 10 seconds, no bouncing. Both straight-knee and bent-knee stretches
• Walking without crutches, pain permitting. Heel lift removed
• Compression with tubigrip if swelling persists

1 – 3 weeks

• Continue with weight-bearing stretches
• Begin ankle exercises against resistance using theraband
• Swimming / static bicycle to maintain cardio-vascular fitness

3 – 6 weeks

• Continue with stretching, holding each stretch for 30 secs. Progress to stretches on inclined board or edge of step
• Continue with theraband strengthening exercises, varying speed and resistance
• Calf strengthening in standing; heel raises; wobble board; mini-trampoline
• Treadmill, progressing from walking to running, initially without incline, but progressing to with incline as flexibility increases
• Cross trainer
• Stepper
• Core stability training (Pilates)
• Sciatic nerve stretches in supine progressing to slump sitting
• Lower back mobility exercises if lower back tight, with or without history of back problems
• Introduce ballistic work once stretches and jogging are pain-free. Include sports specific activities such as jumping, hopping, running backwards, sprinting etc.

Criteria for return to sport

• Pain-free stretching of both gastrocnemius and soleus
• Pain-free resisted calf exercise
• Ability to jog, sprint, start/stop, change direction, run backwards, jump and hop without pain

Prevention of further episodes

• Conscientious stretching of hamstrings  (scar tissue never as elastic as original muscle fibres, so creates a weakness at junction between uninjured and healed muscle)
• Maintain balance of strength between two legs
• Maintain lower back flexibility
• Maintain core stability

Surgical repair

• May be indicated for complete rupture of muscle belly
• If complete or partial rupture of Achilles tendon, long term recovery usually much better if repaired surgically rather than treated conservatively by immobilisation in a cast
• Best performed as soon as possible after rupture.

EXERCISES