Bloody hell it was sore. Two or three steps with a slight tightness in my right calf but the next step was like being electrocuted! Deep, severe pain with a definite "electric" like quality. I was stopped in my tracks and faced a 3km hobble back to the car....in the rain.
Frustration was the overriding feeling as I racked my brain as to why it happened and started thinking about how long I would be unable to run for. The fact that running was a key part of staying sane during lockdown was definitely adding to the frustration!
Although the walk back to the car was pretty unpleasant it gave me time to stop feeling sorry for myself and begin planning my recovery. Before getting into the detail of the injury and the rehabilitation I want to highlight some of the decisions I made in the first 48 hours. I believe these transfer well to most muscle injuries and may seem like they go against conventional wisdom.
First 48 Hours
My first task was getting home which involved a 25 minute drive. On the walk to the car I took a detour to pick up a protein shake and a strapping for compression. At this stage I wanted to be sure I had started rehydrating and had easily digestible protein in my system. This also helped me feel like I had started working on my recovery while I was sitting in the car driving home.
On landing home I had two key priorities. I wanted to eat a decent meal to ensure I was providing my body with the nutrients required for recovery and I wanted to get off my feet as quickly as possible.
It is likely you are familiar with different acronyms for helping injuries such as "RICE" (rest, ice, compression, elevation) or "POLICE" (protect, optimal loading, ice, compression, elevation). I followed these to some extent but did make a few changes that are more in line with the "PEACE and LOVE" approach.
No Ice or Anti Inflammatories
This may come as a surprise to some of you but I decided against using ice or taking anti inflammatories. My primary aim during this 48 hour period was to protect the injured tissue and promote healing as well as possible. There is a school of thought that trying to mediate the natural inflammatory response is unnecessary and can even impair the quality of healing.
With regard to anti inflammatories we do have some evidence that they can reduce pain levels in the acute phase post injury. However, you could get the same benefits from paracetamol which doesn't attempt to mediate inflammatory processes.
The role of anti inflammatories in injury recovery is a contentious issue and I accept that they can play a role in certain scenarios. Excessive or prolonged swelling of a joint post injury would be a good example. In my case I was comfortable foregoing them.
Similarly, whacking ice on an injury can certainly provide a pain relieving (numbing) effect. Non medication based strategies to reduce soreness can be very useful but ice application deserves a little more exploring. The criticism of icing would be that it slows some of the necessary parts on the inflammatory process, namely, infiltration of neutrophils and macrophages into the damaged muscle. This article is not the place to dive into biochemistry but basically neutrophils and macrophages are involved in helping clear out damaged tissue and kickstarting muscle regeneration. In my case I was happy to forego the pain relieving effects in a hope to facilitate optimal inflammatory and repair processes.
Clearly these choices were made with relation to my injury and I wouldn't strictly impose these decisions on patients I treat. There isn't enough solid evidence to label ice or anti inflammatories as "harmful" for longer term recovery but the automatic use of these steps is well worth questioning.
Protection
Getting this bit right can be tricky. Essentially, you are looking for the sweet spot between enough rest to avoid extra damage to the freshly injured tissue and resting too much to the point of deconditioning. You also risk missing the chance to allow mechanical stimulus help promote early tissue healing.
As I got home at about 6pm on a Friday evening I was quite happy to put my feet up and limit my walking to absolutely necessary moving around the house. My step count for the following day was a lowly 3,166 and on the Sunday it was 4,454. This allowed me to move around the house and take one short trip outside to get some air each day. I was not comfortable walking and moved with a definite limp. I was avoiding pushing off that foot during the gait cycle. This is an example of a positive adaptive response, I was okay moving like this as I knew it helped me protect the injured tissues. It also gave me a nice marker to track recovery. My walking returning to normal would indicate being able to tolerate more stress through the healing tissue.
If I was being ultra conservative I could have completely offloaded for 24-48 hours and used a crutch to help me get around. Being honest, I didn't want the hassle of a crutch and I didn't feel I was doing extra damage by weight bearing a small bit.
Additional Early Steps
1) Skipping the Booze - Although the open bottle of wine was tempting I knew skipping it would be a good idea. Alcohol has immediate effects that can impair immune and endocrine function. In this stage we want all the good stuff from an inflammatory response, alcohol basically slows this down. Alcohol can also reduce vasoconstriction in muscle post injury which helps limit bleeding and swelling. Testosterone and human growth hormone secretion is also impaired with alcohol consumption. The amount of alcohol does make a difference with more alcohol leading to more severe impairment of typical function. In my case, I find even small amounts of alcohol (one or two glasses of wine) can seriously impact my sleep. This was my main reason for skipping it!
2) Make the Most of Sleep - If alcohol impairs immune and endocrine function, sleep can optimise them. If we're thinking practically too, a longer sleep leads to less time up and about so can help with protecting the tissue.
3) Diet - Optimising diet to help injury recovery is a complex area that deserves an article in itself....preferably from somebody more qualified than me! From the formal study I have done in this area and from speaking to experienced dieticians and nutritionists over the years I was confident there were positive steps I could take.
Energy Balance: It is tempting to feel like you need to drastically reduce your food intake after an injury but often this is not necessary. There is sense to reducing total caloric intake but only to the point of matching new levels of energy expenditure. I planned on staying as active as possible by starting rehabilitation early and training non injured body parts from the start. After acute injury there is a hypermetabolic response. This means your resting metabolic rate increases (you use more energy). I decided to reduce carbohydrate intake and increase protein intake from day one while maintaining my typical calorie intake. Weighing myself on a daily basis was a key part of monitoring this strategy.
Protein Synthesis: Increasing dietary protein aimed to increase the rate of protein synthesis. Ultimately, the aim was to maintain as much lean body mass as possible. I aimed to have between 20-30g of protein with each meal and supplement with whey protein twice per day (21g / serving). At approximately 80kg bodyweight this would work out at a ratio of 1.6g of protein per kg of bodyweight. There are guidelines that suggest over 2g of protein per kg of bodyweight but I felt that target was over the top for me. You could argue it would have influenced my recovery for the better but it would have been an extreme change to my diet. I would also have been stricter on this if I was a strength or power athlete.
Injury Diagnosis
Okay, we better move onto the actual injury. In the introduction I mentioned my right calf being where I felt the pain. Most people would describe the soft tissue at back of the lower leg being the calf and most would be confident picking out the achilles tendon. However, the anatomy is a bit more complex and deserves further explanation.
The first image below shows the back of the lower leg where the gastrocnemius (calf) muscles (medial and lateral parts) are visible. The central image gives a clearer look underneath the gastrocnemius muscles and removes the more superficial layer of the achilles tendon. This reveals an absolute beast of a muscle! This is the soleus. The image on the right shows a soleus muscle of a cadaver, we can also see intramuscular structures here such as the central tendon (CT) which are important. It's clear to see that this a wide and long muscle and it's role in running is absolutely critical.
Ref: Essential Anatomy App Ref: Balius et al (2013)
Soleus Muscle
Discussing the anatomy of the soleus in detail is outside the scope of this article but I would like to highlight some key points.
- During running the soleus produces vertical forces of approximately 8 times bodyweight.
- This huge force production capability is possible due the physiological cross section area of the muscle. It is 3.5 times larger than the medial gastrocnemius and by far the largest in the lower limb in terms of physiological cross section area.
- The achilles tendon accounts for 30-50% of the elastic energy storage during running and the soleus runs directly into this structure along with the gastrocnemius.
- Although the soleus can produce massive forces it is actually 80-90% type 1 fibres, which contract more slowly than type 2 fibres. This enhances the aerobic ability of the soleus muscle and increases it's ability to recover between bouts of loading.
With this in mind I clearly wanted to be accurate with my self diagnosis. Maximum point of tenderness to touch and the fact that pain was worse when heel raising with my knee bent compared to with my knee straight was a key part of making my diagnosis. The onset of pain occurring during running at a steady pace also made sense for a soleus injury.
What About a Scan?
This is a fair question and I did consider it. When I really thought about it I became confident that a scan would only confirm a diagnosis of some sort of soleus muscle tear. It would have given great detail about where exactly in the muscle it was and whether it involved myotendinous junctions, central tendon or myofascial structures but that only leads to the next question....would it change how I manage it?
Cross sectional slice of lower leg MRI scan Rosso et al (2013)
As the main site of soreness was central and quite low I had a suspicion the central tendon may be involved. There is conflicting research about whether soleus injuries involving the central tendon take longer to recover so I took this on board. Ultimately, I don't think a more accurate diagnosis with the help of MRI would have changed my approach.
Clearly, others may opt to have a scan and that is okay as long as there is an understanding that the imaging results may not lead to a change in management. Scan results on their own do not provide an exact answer ast to when someone will return to their sport either. In elite sport imaging is more common but unfortunately I do not fit that criteria!
Why Did it Happen?
On the diagnosis side of things there was one more obvious question. Why did this happen? In truth, I don't know exactly why but I do believe it's possible to identify contributory factors. As training error is estimated to account for up to 70% of running injuries that is a good place to start.
A typical training week would include 3 or 4 runs. During November and into the first week of December I included a session where I ran 1km at 3min 45sec pace - 3min 50sec pace and then recovered with an easy pace for 500 metres. The 1km part of this would be a fairly hard effort for me. I'd repeat this 4-6 times. From looking at my training log (thanks Garmin Connect) I could see for the last three weeks in December my running frequency was three times per week and I didn't include this harder interval style session. I did have one shorter hill sprint style session but the demands of this would be quite different to the interval session.
I ended up not doing the interval style session for 25 days. Clearly when I picked up my training in the new year I was keen to start getting this type of session back into my routine as I did three of them in 12 days! Over Christmas I had decided with some friends to set up a virtual race for March 6th. In short, the week before this injury I did two hard interval style sessions and one of them pushed the interval distance to 1.5km. I did a fairly easy 10km run on the Wednesday and it was during a run on the Friday I had the injury. There would be a good argument to be made that increasing the frequency and intensity of the harder interval sessions contributed to this injury. Increasing pace increases the force required of the soleus. This changes a bit during maximal speed running but I wasn't sprinting for these efforts.
Other considerations would be that I had lost strength and power in my gastrocnemius and soleus muscles due to reduced exposure to heavy resistance training. With access to gyms I would use a Smith machine and seated calf raise machine to perform heavy straight leg and bent knee exercises one or two times per week. I found this very difficult to replicate at home.
These would be my main two contributing factors. I do remember on the day of the injury I really didn't feel like running. I was after a long Friday in work and it was getting dark. I basically had my mind made up I was going to go home and would do my session the next morning but as I was packing up I saw a few WhatsApp messages coming in from friends in a running group. They were posting the runs they had done that day so I changed my mind and stuck my gear on. "Listening to your body" is a phrase thrown around quite often and at times I think it can be used as an excuse not to do anything when you're not feeling 100%. I think if you give in to this every time you get that feeling you would basically hardly ever train! In saying that...maybe I would have avoided injury if I waited until the next morning.
Getting Back to Running
This section will provide a look at how I progressed form limping about to running consistently again. I will touch on the reason why different exercises or drills were included and hopefully highlight clear progression through the videos. Feel free to contact me if you have specific questions about anything included.
Early Phase
I have spoken about protecting the injured tissues being important for the first 24 - 48 hours. Despite this you don't need to be completely inactive. The day after the injury I was comfortable including foot exercises and single leg balance exercises. In addition to the gastroc and soleus the toe flexors help plantar flex the foot and ankle so training these made sense. Any injury can impair sensorimotor function so including simple balance exercises can help address this. Within the first week I was also comfortable performing banded plantar flexion exercises, single leg bent knee heel raise holds and on day 4 post injury I started single leg bent knee heel raises.
I maintained regular training of uninjured body parts from day 1 post injury. There is really no reason not to keep this going. I modified exercises to avoid the injury as needed.
There is a startling amount of information floating around social media and the internet in general when it comes to injury rehab. Some of the information is good quality, some of it is rubbish. Part of my job is knowing what has a sound physiological underpinning and in most cases has been tested in pretty good scientific research studies. Many of the exercises below are quite simple and they certainly won't be the most exciting movements you will ever see. In saying that, there is a clear rationale and most importantly a progressive degree of difficulty for the plantar flexor muscles.
*You will see exercises with bent knee and straight knee positions. Bent knee positions are used to bias the soleus muscle. The gastroc crosses the back of the knee and attaches to the back of the femur. By bending the knee you reduce the ability of the gastroc to produce force and rely on the soleus more.
Started the day of the injury. Within comfortable ranges.
I introduced these the day after the injury. Typically did 20 second holds x 5 reps.
Same as above, introduced on day 1 post injury and I typically did 15 squeezes x 3.
Introduced on day 2 post injury. Typically, 15 - 20 reps x 3 sets.
Same story as above.
And again! Soleus contributes to subtalar joint inversion.
Introduced on day 3. I tried this on day 2 but it was quite sore. Felt more manageable on day 3. Only did 20 second holds and didn't use anymore knee bend. Typically would do 5 sets.
Introduced on day 3. I was surprised to be able to manage these but there was minimal discomfort. I only did about 8 per set and 3 sets.
I tried these on day 3 but got a sharp tugging at the site of injury - definite sign to ease off. The following day they felt okay. I was pretty wary with the amount of knee bend and did 8-10 in a set for 4 sets.
These were manageable on day 4 - I went for 15 reps x 3.
On day 4 I also started bent knee single leg heel raises. There was a small bit of tenderness at the injury site but nothing getting me worried.
Day 5 was the first day I felt like I could walk completely normally. I could push off my right foot and not experience any discomfort. Walking pace was back to normal too. This felt like a big positive and it was nice to be able to get out and be more active.
These exercises were the mainstay of my routine for the next 3 or 4 days. I used a 16kg kettlebell to add external resistance. I will come back to this point! I clocked up 12 kilometres of walking on day 8 without any issues so felt good about how things were going.
Running Preparation and Return to Running
On day 9 I was comfortable introducing sets of mini double leg hops. These felt okay and two sets of single leg easy hopping was also manageable. With this milestone ticked off I felt like I was getting closer to running.
The next day I started to introduce running style drills during my walk in the mornings. I got a few strange looks but these allowed me explore further how much force I was comfortable putting though the healing tissues.
Emphasis here is on a good range of movement through plantarflexion.
The aim here is to land on the midfoot with some pre tensioning through the gastroc and soleus by holding some dorsiflexion at the ankle joint.
This one I'm looking to drive the foot down into the ground and quickly pop back up (a small amount).
This got the most strange looks from passersby but little did they know this tested ankle stiffness with a shorter ground contact time and plantarflexion maintained at the ankle.
By the end of my second time completing this routine I felt ready to try a short run. With the knowledge that recurrence rates for these injuries are quite high I needed to ensure I didn't get carried away. I completed 4 x 30 seconds of running with a 60 second walk recovery between each run. I then did 2 x 60 seconds of running with a 60 second walk recovery. That was it....but I was running.
Over the next 2 weeks I followed a progressive running plan outlined in the table below. I made a point of ignoring the pace on my watch and focused on the amount of time I was continuously running for. In this early phase that was the only variable I cared about increasing. Without feedback from the watch about pace I ran at a pace that just felt easy.
Running programme started 11 days post injury.
In addition to these sessions I did a hill based session on Feb 11th where I did 200 metre effort at 3:45min/km pace x 8 reps with a walk back recovery. The final session I classed as a rehab run was a continuous 12km run on Feb 13th that I did at 4:34min/km pace.
I had the occasional "awareness" of my right calf during these sessions. I like that phrase as it acknowledges a feeling of something slightly unusual but it isn't pain. "Not the same as the other side" is a phrase I often hear too. I was happy to continue running with these sensations but if I had felt a progressive build up of soreness I would have stopped.
I used plyometric exercises before these running sessions to further develop force production and ankle stiffness. There is more demand to produce maximal force in these drills compared to the running drills above. The running drills remained as part of my warm up before starting the plyometric exercises below.
From mid February I began to look at my pace more closely and programmed more tempo based sessions. Basically, trying to hold a faster pace for either a set amount of time or distance during my run and then easing off between the efforts. I completed fairly basic strength exercises on the same day after my run or the following day. I felt the running itself and plyometric exercise was conditioning the calf well.
By the end of February I was quite confident in handling quicker paces and I agreed to that virtual 10k time trial with some friends on March 6th. I was slightly apprehensive about pushing myself hard for 10km but I had a few tougher sessions behind me and the block of training I had done before getting injured was solid. I felt good early in the run and other than the standard horrible feeling of running fast for a decent distance I came through it well. My watch told me afterwards I had actually equalled my previous best time over 10km. I took this as a nice marker that rehabbing this soleus was done to a decent standard!
What Would I Do Differently?
The lack of access to a gym definitely shaped my rehab. If this was pre Covid I couldn't imagine going through a calf rehab programme without a strong emphasis on heavily loading the gastroc and soleus. The Smith machine and seated calf raise machine would have been "go to" pieces of equipment. Going through this process has caused me to consider the potential of early hopping and plyometric drills more. The heaviest external load I used was 36kg (1 x 16kg kettlebell & 2 x 10kg dumbbells) and I got the result I was looking for.
On the nutrition side of things I had planned on supplementing with gelatin but found the product outlined in the linked study tricky to get my hands on. I'm sure I could have used something similar but I abandoned it after a couple of failed attempts. The Brexit shipping scenario didn't help!
Another key reflection point was that there were exercises or drills I tried that didn't really match my expectations. What I mean here is that some of the movements I thought would be no problem actually caused some discomfort, while others that I thought may be pushing things were fine. It's easy when experimenting on myself but this reinforced how important it is to trial each exercise thoroughly with anyone I am helping in the clinic.
Have You Noticed What I Didn't Do?
The following were not considered for my own recovery; needles, cupping, foam rolling, K-tape, massage guns, electrotherapy (ultrasound, TENS, shockwave, laser).....you get the drift. You can draw your own conclusions from this.
Wrapping Up
Alright, I hope you have taken something useful from this piece. The parting messages I'd like to reiterate are that muscle tears need to be respected. There is a healing process that has to take place and there really are no shortcuts. This took three weeks to be able to manage 30 minutes of continuous running. Applying mechanical stimulus through progressive exercises to the muscle tissue is by far the most important aspect of recovery. These exercises don't have to be overly complicated and should be reasonably comfortable to perform....but not easy.
Thanks for reading, I'm happy to chat further through email or any of my social channels.
Patrick Carroll
Old Quarter Physiotherapy Clinic
References
*in order of appearance in article.
Dubois & Esculier (2019) "Soft-tissue injuries simply need PEACE and LOVE" British Journal of Sports Medicine : https://bjsm.bmj.com/content/54/2/72
Paoloni et al (2009) "Non-steroidal anti-inflammatory drugs in sports medicine: guidelines for practical but sensible use" British Journal of Sports Medicine: https://bjsm.bmj.com/content/43/11/863.info
Oishi & Manabe (2018) "Macrophages in inflammation, repair and regeneration" International Immunology : https://academic.oup.com/intimm/article/30/11/511/5079207?login=true
Barnes (2014) "Alcohol: Impact on Sports Performance and Recovery in Male Athletes" Sports Medicine : https://link.springer.com/article/10.1007/s40279-014-0192-8
Irwin (2019) "Sleep and inflammation: partners in sickness and in health" Nature Reviews Immunology : https://www.nature.com/articles/s41577-019-0190-z
Close et al (2018) "Nutrition for the Prevention and Treatment of Injuries in Track and Field Athletes" International Journal of Sport Nutrition and Exercise Metabolism https://journals.humankinetics.com/view/journals/ijsnem/29/2/article-p189.xml
Balius et al (2013) "The soleus muscle: MRI, anatomic and histologic findings in cadavers with clinical correlation of strain injury distribution" Skeletal Radiology : https://pubmed.ncbi.nlm.nih.gov/22945301/
Dorn et al (2012) "Muscular strategy shift in human running: dependence of running speed on hip and ankle muscle performance" The Journal of Experimental Biology : https://jeb.biologists.org/content/jexbio/215/11/1944.full.pdf
Kallio et al (2013) "Motor Unit Firing Behaviour of Soleus Muscle in Isometric and Dynamic Contractions" PlosOne : https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0053425