Calf Injuries and how to rehab them

Last updated: 31-Oct-18

By Karina Teahan, Chartered Physiotherapist

Calf injuries are very common in sport, accounting for 13% of football muscle injuries and more again in runners. It may be felt as a sudden sharp pain at the back of the lower leg causing you to immediately pull up or something more insidious that just builds up during your run.

The former used be referred to as “tennis leg” as was noted in tennis players due to a sudden dynamic push off causing a calf tear. What we as distance runners more commonly experience is a non-traumatic fatigue injury in our calf muscle.

This will present as a more diffuse ache over the middle part of your calf. It may feel achy/crampy/tight and come on while running but ease once you stop. It may then start to come on earlier and earlier in your runs to the point that you cannot run with it.

The causes of this fatigue induced muscle injury include:

  • A recent change in training such as:
  1. Increase in training pace – our calf muscles have to provide most of this dynamic force
  2. Increased training volume
  3. Lack of recovery days
  4. Something that results in our calf muscles not having the capacity to cope with a new or sudden increase in training load
  • Loss of calf muscle flexibility
  • Change to forefoot running or to a minimalist shoe without taking time to adapt
  • History of a previous calf injury or loss of calf muscle bulk & capacity
  • Fatigue
  • Stress
  • Weakness in gluts or quads further up the chain which we need to absorb large loads while running
  • Weakness around the toes/foot & ankle
  • Running style: a very bouncy up/down running gait increases calf load. Over-extending stride and prolonged ground contact time as well as a narrow, almost cross over, running style will place extra demands on your calf muscles.


Usually a scan or MRI will be clear with a fatigued induced calf injury so are not useful for diagnosis. The history and your symptoms should help make the diagnosis. However it is important to rule out certain other things that may mimic a calf muscle injury. I will briefly mention them here but if in any doubt get them checked out by your physiotherapist.

Diagnosing different types of calf injury

  • Muscular: calf tear. This will usually be a more traumatic acute onset. Often felt on the inner side of the back of the calf up towards the knee. There may be pain, swelling, difficulty walking immediately, a feeling like you have been kicked in the back of the leg or a sensation of a pop.
  • Neural: it may be coming from your lower back.
  • Vascular: such as popliteal artery entrapment syndrome (more info here). This can really mimic the crampy/achy/tight feeling of the fatigue injury that feels worse with running and better with rest but there will be some subjective differences. Your physio can check your pedal (foot pulse) after you exercise to note any changes and refer you on appropriately.
  • Vascular: DVT (deep vein thrombosis). This cannot be ignored and if you have any suspicion of having one you need to go to the Casualty Department. Common signs are: redness, heat, pitting oedema, pain in your calf along with risk factors such as: previous DVT, long haul flight (or even short flights), period of immobility due to illness/surgery, history of cancer or heart failure, trauma, pregnancy, smoker, increased BMI.

Treatment & Management

Firstly, identify what you think brought it on based on the risk factors mentioned above. It may be a case of balancing your training load so you do a speed session on fresh legs after a rest day rather than after a long run.

Remember that work, lack of sleep, long commutes/travel, financial worries etc. are also loads on our system and need to be addressed and managed.

Identify your targets for strength and conditioning. Start with the calf muscle. Your target is 15-25 single leg calf raises, see where you are at now. (I can just about manage 18!). You may need to start with a double leg calf raise initially. Aim to do them on the edge of a step so you come from dorsiflexion (heel below step) to full plantar flexion up on your toes. Do these with knee bent and straight so you get both components of your calf muscle (gastroc & soleus).

Once you have achieved this, start to add weights. You need to load up your calf muscle to get it ready for your running demands. Begin with a 15 rep max (RM) weight and progress to 8-12 RM. You can do this in standing or using the leg press in the gym.

A weighted wall squat will work your lower calf muscles effectively (as well as your quads).

Our quads and gluts are vital for absorbing load while running and any deficit will place more demand on your calf. Effective exercises to address any deficits here include: leg press, squats, lunges, single leg knee extension machine, single leg rise test (aim 10-15 left and right).




Weakness in our toes flexors are also noted in calf injuries. You can do isometric toe flexor exercises by resisting your own toe flexion. Hold your toes back for 3 seconds at 90% MVC, rest for 3 seconds and repeat x 5. If you feel your foot in cramping then you know you need to strengthen them up.


Strength the muscles around your ankle with a theraband.

Neural Mobility

I will not go into too much detail hear as you really should get your back checked out if you think it is contributing to your calf pain but here are 2 ideas to improve neural mobility:

  1. Knee rolling
  2. Sliders & gliders in slump, low reps (3-4) but regular. Don’t irritate your back.



Return to running

This depends on how quickly you stopped to address your calf injury and its severity. If you cannot run at all then you need to address the above and build up your calf muscle capacity to tolerate running. Once you have done this start running for a few minutes at a time and see how your calf reacts.

If it starts to become tight then stop, and next time do slightly less running but keep at the strength & conditioning to increase your calf capacity. Gradually introduce some pace in the form of short intervals.

You will be much better in 6-8 weeks but do address your deficits. You may also need to do some slight gait retraining but remember make small changes, nothing too quick or radical as the rest of your body has to adapt. 

Best of luck & enjoy your rehab!


All images by Karina Teahan.



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