Acute Phase
Rehabilitation Program
Physical Therapy
Initial treatment of a medial calf injury includes relative rest, ice, compression, elevation (RICE), and early weight bearing, as tolerated. The initial treatment should continue for 24-72 hours. Ice therapy is best instituted over a damp elastic wrap, which also provides compression. Preventing the limb from hanging dependently prevents further swelling. The use of crutches with a feathering gait and bilateral heel lifts is indicated if normal gait is compromised. Active foot and ankle ROM can be carried out if there is pain-free ROM.
Medical Issues/Complications
Pain management should include analgesics as indicated. Caution should be used with nonsteroidal anti-inflammatory drugs (NSAIDs) during the acute injury phase, as these agents can predispose the patient to increased bleeding and hematoma formation in the initial days after an injury. Theoretically, cyclooxygenase-2 (COX-2) inhibitors may provide pain control without the risk of bleeding in acute injuries, which is a concern with traditional NSAIDs.
Other Treatment
Ankle/foot bracing should be used to keep the ankle in a position of maximal tolerable dorsiflexion. Studies have shown an increased rate of healing with this intervention.
As with any large muscle strain, hematoma formation can be complicated by heterotopic ossification resulting in myositis ossificans. Studies do support the use of nonsteroidal anti-inflammatory medication, which may help prevent this.
Recovery Phase
Rehabilitation Program
Physical Therapy
Ice therapy and active resistance dorsiflexion exercises can be undertaken until the athlete is pain free. Then, light plantar flexion exercises against resistance are initiated. Progression of therapy includes reduction in heel-lift height and gradual introduction of stationary cycling, leg presses, and heel raises. At this stage, ultrasonography, used with or without phonophoresis, and muscle stimulation are also applicable. Massage techniques can help with the removal of interstitial fluid. Apply compression dressing from the metatarsal heads to the gastrocnemius for the first 2 weeks. Partial weight-bearing ambulation should begin as soon as tolerable to maximize the contact of the sole of the foot to the ground, then progress to increased cyclic loading, advanced proprioception and balance training, and eventual full weight-bearing ambulation, with dynamic change of speed and direction as tolerable.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Once the athlete is pain free with full and symmetric ROM and full strength is regained, sports-specific activities can be resumed. Strengthening and stretching of the injured area should continue for several months to overcome the increased risk for reinjury due to the deposition of scar tissue that is involved in the healing process.
A 2014 randomized trial reported that the use of shock-absorbing insoles during 3 weeks of training on artificial turf resulted in a significant increase in the pain threshold for the medial head of the gastrocnemius muscle. [16]
Return to Play
When an athlete will be able to return to play is predicated on the patient being pain free and recovering full ROM. This period can last 1-12 weeks, depending on the degree of tissue damage that was sustained. Strength testing should reveal that more than 90% of the uninjured side accounts for the patient's dominance preference.
Prevention
A medial calf injury may not be preventable, but regular physical activity with maintenance of flexibility in the gastrocnemius muscle may help to reduce one's chances of sustaining such an injury.
Instructions for appropriate stretching and warm-up techniques should be provided to the patient for the implementation of maximal prevention of reinjury.
