Calf pain in runners: 9 causes and considerations From footwear to form

One of the most common complaints runners have is calf pain, particularly while running. It might initially come in bouts during just a couple runs, but sometimes it will stick around for weeks and months if left unaddressed. Rest usually improves this discomfort at first, but isn’t typically sufficient for long-term, consistent relief if the person continues to run and doesn’t make any other changes. They’ll complain that their calf muscles feel “tight.” And it’s common for both calf muscle groups to start to feel this way around the same time.

Some runners take the “I give up” approach and assume it’s a necessary part of getting older or running too many miles, so they begin to modify their training around it by planning an additional rest day or cross training instead. They take the “a little running is better than no running” approach, which I think is very reasonable for a true injury, but when something can be improved, why not address it the right way?

For the sake of this article let’s assume we are covering muscle-specific pain in the calf that isn’t too bothersome much outside of running. These are more likely to be muscle overuse syndromes or biomechanical overload syndromes. This cause of pain can be treated while you continue to run, if done correctly.

But there are plenty of other things that can cause calf pain and you will need a medical professional, not an internet article, to rule those out.

Possible (and Potentially Serious) Medical Issues to Rule Out

• Blood clots/deep vein thrombosis

• Nerve mobility deficits or irritability of the lumbar, sciatic, and tibial nerves

• Calf muscle tear/rupture

• Popliteal artery entrapment

What can you do?

Seek professional medical guidance if you have had a traumatic injury (often accompanied by a sudden “pop” or a feeling of being kicked in the calf). We are also very concerned if there is a more persistent or severe onset of pain, or additional symptoms like sensation changes (pins, needles, tingling, burning), fever, swelling, and redness of the calf. It’s important to consider your overall history because factors such as being older, having a history of a particular problem, recent immobilization, comorbidities, and certain medications can all have a role. These issues are very different than a mild discomfort, tightness, or fatigue that occurs only while running. It isn’t to say that some of these problems can’t be treated conservatively but you will have the best chance at success with proper diagnosis. We need to keep in mind too, if you have attempted treatment that doesn’t seem to be helping.

Other considerations:

Calf Strength and Endurance Deficits

Logic would tell you that running demands a ton of work from the leg muscles. At some routine level of activity, the muscles adapt to that work and you keep on going from week to week without issues, just as happily as ever. Now what happens if you chronically demand so much from those muscles that they can’t adapt to what you are trying to have them do? They slowly start to...change…like your best friend from junior high school. At first it was cute but two months later you were just annoyed. The muscles don’t have to be painful, at first. Maybe they just feel more tired and tight. But when you keep running on them and don’t make any other changes they become more consistently problematic.

The muscle and fascial connective tissue isn’t able to adapt to your demands in a positive manner when demand outpaces normal repair over a long period of time. Why couldn’t the muscles withstand the demand? Most likely there wasn’t enough strength or endurance (or both) in the muscle group. Given enough time of chronic repetitive stress on under-prepared tissue, the quality of the soft tissue changes.

Running really requires something called “strength endurance” from muscles like the calf. You might even better call it “strength and power endurance,” but I don’t want the top of your head to blow off right now so forget I said that. The point is that the muscles of the calf have to withstand high forces (strength), very rapidly (power), and with high frequency (endurance).

The calf-strength variations that will show up when tested during a single leg calf/heel raise are often interesting. A runner might have tons of gastrocnemius strength during a straight-knee calf raise, but when the calf raise is re-tested while the knee is flexed, they can’t reach the top end of the calf raise anymore. Often this means they have decreased soleus strength, which is a real problem since, while running, we spend a large portion of the running stride with the knee slightly bent. Or maybe they can’t perform the same amount of reps on one side when compared to the other in either position.

Even worse is when the person can’t perform any type of single leg calf raises without relying on their long toe flexing muscles that come from deep in the calf region. My heart hurts when I see this. These people tend to grip with their toes during calf raises and just can’t get their brain to shut those muscles off while completing the raise because the bigger, outer calf muscles are just that weak. It’s not a surprise that people will run with those toe muscles engaged heavily too.

What can you do?

Build the strength of the calf muscles using calf raises, with the knee slightly bent and straight, without gripping with the toes, and with just a single leg at a time. Full ankle range of motion is key. Causing calf muscle fatigue is the goal. That might take five reps or 20. Don’t hammer it to death because you’ll probably become sore for two days. Early strengthening with bodyweight is good but after 2-3 weeks of 3-4x/week, runners should be able to add extra resistance, even beginning with something like 10 pounds. The calf needs to be strong, but...

Other Strength Deficits

I am stating the obvious here, but it takes more than the calf muscles to propel a runner. Lacking hip or thigh strength could lead to a trickle-down of abnormal demand into the calf muscles. The calf could actually be super strong but just have to endure too much stress every time you go running because something else stinks at its job. End result: too much work being done by the calf muscles that leads to stress-induced discomfort.

What can you do?

Ensure you have full strength of the hip and thigh muscles (eg. gluteus maximus, gluteus medius, hamstrings, quadriceps). Strengthening exercises for these areas is beyond the scope of this article, but the point is you need to look outside the area of symptoms if you want to actually fix the problem. Remember to emphasize single-leg strengthening to ensure symmetry. If you can only do eight single leg bridges on one side and 20 on the other then you’ve got some extra work to do on the weaker side.

Neuromuscular control

Your awareness of and ability to modify the way your body moves at any given instant is a good indicator of overall athleticism. Remember, our muscles only know how to function based on what they are told by the nervous system, particularly the spinal cord. If your nervous system can’t figure out how much force to generate from the various muscles at any one moment then your movement isn’t refined. Picture a gymnast on a balance beam. It doesn’t take much error to result in falling off the beam. They really have to own their movements with precision and certainty. Kinda, sorta knowing where their feet are isn’t going to cut it. Or imagine an infant learning to crawl. They are constantly on the edge of failure until their nervous system figures out the best way to coordinate muscle contractions to keep their body stable. Your calf muscles must contract with correct amounts of other muscle contractions in that leg with every footstrike.

What can you do?

Working on drills to improve your balance and proprioception is key. As previously mentioned, single-leg work is a necessity. And I don’t mean sit on a machine to do knee extensions, calf raises or leg presses one leg at a time. When you use machines, there’s no real demand that requires the nervous system to learn how to stabilize your body. Single leg balance that progresses into single leg deadlifts, single leg squats, single leg hops, single leg box jumps, single leg calf raises, the options are many. The point is to emphasize standing on one leg while you move the rest of your body.

Foot, Ankle Structure

An individual with a more flexible foot or ankle type that allows an inward collapse of the heel bone or inner foot arch could be placing more demand on their calf. These people are generically labeled as “flat-footed.” Though the more superficial calf muscles are mainly producing force for the forward/backward sagittal plane, there are additional forces that this outer calf and much deeper calf must withstand in the side-to-side or frontal plane. And then we must consider that the deeper calf muscles, like the posterior tibialis, that help to control the side-to-side ankle and foot motion, are also notorious for being part of the cause of pain.

What can you do?

Build the strength of the muscles that assist in stabilizing the ankle and foot that also come from the lower leg, like the peroneus longus, peroneus brevis, anterior tibialis, and posterior tibialis. One way of doing this is with resistance bands. This is also why I love single leg strengthening exercises like single leg Russian deadlifts that also require a person to balance and stabilize like a circus elephant on top a ball. As discussed below, you should perform routine soft-tissue maintenance on all of the calf muscles, superficial and deep.

TheraBand Professional Non-Latex Resistance Bands For Upper and Lower Body Exercise, Strength Training without Weights, Physical Therapy, Lower Pilates, and Rehab, Yellow & Red & Green, Beginner Set Buy on Amazon

Maintenance Habits

Here’s a big one. So you run for hours at a time or try to run really fast, essentially beating down the calf muscle fibers and their surrounding fascia and tendons, but then you don’t do anything good for those tissues? Resting is supposed to fix it all? It probably would if you weren’t trying to run most days of the week.

What can you do?

Buy and use a massage stick, foam roller, or lacrosse ball to routinely massage the muscles of the legs. Be sure to emphasize routine soft tissue maintenance for every major muscle group. The technique doesn’t matter as much as just doing something positive regularly for the muscles to keep them more supple and loose. Before the pain rules your life. Once the pain is consistently present, I can use techniques to get it to go away quickly and then you need to take over with a maintenance program.

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Calf Muscle Length

In many instances, you can think of calf muscle length as an indicator of something besides true structural muscle fiber, fascia, or tendon length. The chronic abuse of running very often leads your nervous system into thinking a higher level of nerve-dependent activity is needed in the calf when it really isn’t. That keeps the fibers holding a greater tension at all times, which makes the calf muscle appear shorter than it really is structurally. So there’s a big difference between your nervous system telling a muscle to behave as if it is tight and a muscle that truly, structurally is short and tight. Weird, I know.

What can you do?

Calf stretching with the runner’s stretch or dropping your heel off a step is typically what runners choose to do if their calves feel tight. But if you want a change in actual muscle structure and length, be prepared for it to take multiple weeks of frequent and prolonged stretching. Like three 60-second stretches at least three days per week. A deep full squat will more likely max out the ankle joint motion and soleus muscle length while a straight leg heel drop on a step is meant to be a gastrocnemius stretch. But I would rather rely on the other soft tissue techniques mentioned above as maintenance, like self-massage, myofascial release, or dry needling to make the muscles relax, which automatically improves their length in many people. Remember, the goal probably doesn’t need to be improving the muscle fiber lengths, it’s convincing your nervous system to let the darn muscle relax.

Running Technique

Certain techniques tend to stress certain tissues more over time - that is neither bad nor good. If there were ever a predictable running method to stress the calf muscles, it would be a forefoot initial contact style, particularly if the runner doesn’t allow the heel to reach the ground after making contact. With about 2.5x to 3x your bodyweight coming through the limb while running, there are huge lengthening or eccentric forces coming through the calf tissue when the forefoot touches the ground before any other part of the foot. This could be the case with midfoot striking too. Depending on the runner’s individual style though, midfoot contact can decrease calf stress. Heel striking itself doesn’t necessarily tend to load the calf the same way a forefoot contact might, but rest assured those people have their own set of problems at the knees, thighs, and hips. Overstriding, which commonly accompanies heel striking, can be more stressful though.

What can you do?

By choosing to use a forefoot contact you should know the calf area is at risk for injury and perform your due diligence with the maintenance just mentioned to keep the calf muscles loose, relaxed, and happy! You may not immediately need to modify your technique to a heel or midfoot strike but could do so temporarily to maintain running fitness until the calf muscle status has been improved. Overstriding needs addressed in any instance. This is where we often need to address hip strength and control, hip flexor length, and other possible issues throughout the entire leg.

Paces, Distances, Training Program Design

What type of running have you been doing lately? Fast, slow, mixed speed, uphill, downhill, shorter distance, longer distance? Are these methods what you have always done or has your training changed recently to incorporate more speedwork, racing, or hills?

What can you do?

If you changed your distance, terrain, or speeds, and the changes contributed to the symptoms, temporarily remove or decrease those stressors for a week or two. Uphills and running faster are the most potent instigators of calf pain. Know the threshold of when the pain would begin while running and then try to stay just beneath that point for a couple weeks while the strengthening and other soft tissue treatment take hold. Be sure to have a full recovery day without sports or running that doesn’t stress the calf muscles.

Footwear

So you thought the zero drop or minimal shoes were great choice? Well, they are, but not if all this other stuff is off and you suddenly change the shoes too. They cause at least a 10% increase in calf load compared to a traditional shoe. Add that onto your already lackluster muscle tissue quality and we have a recipe for trouble. This is also an issue for runners when they switch suddenly from their base training shoes into their racing flats or spikes for competition.

What can you do?

Work your way into minimal or zero drop shoes gradually if you haven’t used them before. Two or three runs per week of 5-10 minutes is plenty in the first month. Run your warm up with them and then switch into your old training shoes. Gradually add faster workouts with spikes and flats into your training instead of just competing in those shoes. Spend more time barefoot at home and be sure to do the maintenance piece mentioned above to get the muscle tone to decrease. Here’s a nice article on transitioning to minimal footwear.

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Strength Training for Runners, Part 5: Exercises

To finish up this series of posts on strength training, let’s cover a few examples of exercises that you can incorporate into your routine. Most of the videos focus on the lower body and trunk, though you should certainly work the upper body. With several of the lower body exercises, you can integrate in an upper body component to add an additional challenge. The Mountain Ridge Physical Therapy YouTube page contains several variations of these exercises, from basic to advanced versions. 

Quadriceps

Lunges, Bulgarian split squats, Squats, Step ups, Step downs, Plyometrics

Hamstrings

Squats, Hamstring curl with swiss ball, Hamstrings heel slide, Deadlift, Single leg deadlift, Plyometrics

Lateral gluteals

Side lying leg lift, Single leg pelvic drops, Airplane, Clamshell

Gluteus maximus

Lunges, Squats, Step ups, Single leg bridges, Double leg bridges, Glute thrusts, Plyometrics

Gastrocnemius/soleus

Calf raises, Plyometrics

Hip rotators

Single leg hip rotation

Abdominals

Front plank, Side plank, Anti-rotation walkout

Low and mid back extensors

Prone trunk extensions (Superman), Thoracic rotations, Front planks, Side planks

Please let me know if you have any questions at derek@mountainridgept.com. If you enjoy reading these articles and applying the information to your training, please “like” the Mountain Ridge Physical Therapy Facebook page.

Knee pain at the iliotibial band: What can you do about it?

Description: Iliotibial band syndrome, or ITBS, is one of the more common injuries affecting runners. And why is that? Probably because the same faulty motor patterns and muscle weaknesses tend to run rampant amongst many runners. ITBS tends to come on gradually, causing a lateral knee pain, though some runners are able to bring on the pain in a single run of greater distance or intensity than their typical. It is often another story of too much, too fast.

Anatomy: The muscles that attach to the ITB are from the hip and thigh region: gluteus maximus, vastus lateralis and tensor fascia latae. The far end of the ITB splits into several sections, which indicates it has a role in the function of many areas. Most commonly athletes will complain of pain where the ITB interacts closely with the lateral femoral condyle.

Cause: The primary function of the ITB is to stabilize the knee during walking and running gait. When some of the hip muscles are weak, the ITB can be relied upon too heavily for knee stability, thus stressing its lower attachment excessively.

Signs and symptoms: The far end of the ITB can flare up like a tendonitis does when initially becoming inflamed. There can be inflammation at the bursa that sits beneath the ITB as well. As a result, you might notice swelling and tenderness to touch at the outer knee where the ITB crosses. There can be a snapping or popping sensation at the lateral knee. The pain tends to take on a sharp and stabbing quality when there is demand placed on the leg but the general area may be achy after use. 

A common finding in many instances of ITB syndrome is hip muscle weakness, particularly of the gluteus medius and gluteus maximus muscles. There may be a decreased ability of the nervous system to activate and control those hip muscles while running, even if they are strong in testing.

An indicator of poor gluteus medius activation is an excessive dropping of the opposite side of the pelvis when the affected leg is in stance. One way you can check this is to stand in front of a mirror, hands on your hips, and then shifting yourself onto one leg. For instance, if you move onto the left leg and the right side of the pelvis clearly drops then you have a positive Trendelenburg's sign. Check both sides as it is common to have an asymmetry. In the video below I demonstrate both the active position and inactive position. The same excess of pelvic motion can occur in walking and running. 

Solutions: As with many of these injuries, there is no magic pill and no quick fix. Consistent but brief supplemental work is the reliable solution.

1. Some physicians may promote injecting the bursa region that lies between the femur and the end of the ITB. Corticosteroid injection should be a last resort as recurrence is very likely if the mechanical control of the hip and knee are not addressed. I have had patients where injection was used as a first line treatment. Guess what? The pain came back. At least this is a lower risk area to inject with corticosteroid as the risk of ITB rupture is minimal compared to an area like the Achilles tendon or posterior tibialis tendon. The side of the quadriceps is probably more likely to rupture. Remember, injections do not address the mechanical reasons the injury occurred in the first place.

2. The very first and simplest issue to address is the presence of any weak muscles at the lateral side and back of the hip. These muscles need to be activated easily and consistently by the nervous system. So many people have weak muscles around their hips, trunk, and pelvis so don't assume you are an exception. It is a daily occurrence for me to see these issues in the clinic. 

Athletes need a baseline level of strength and the ability to effectively recruit these muscles while running to prevent the pelvis and hips from destabilizing. Poor strength or activation may allow the thigh to collapse inward or rotate inward along with an unleveling of the pelvis. It’s also important to consider the endurance of these muscles because the strength will undoubtedly be decreased a few miles into a run or fatiguing workout.

As a side note, I have seen so many patients that were correctly told to perform exercises like a side lying straight leg raise only to discover they are doing it in a manner that works the wrong muscles because no one checked their technique. Their form was incorrect and doing these exercises incorrectly can actually contribute to the problem. Not only are the wrong muscles used (eg. tensor fascia latae), they are creating a dominance in areas that further inhibit the function of the correct muscles (eg. gluteus maximus).

Here's the routine that I do on a weekly basis. 

3. As the awareness, endurance, and strength are all starting to increase, it is necessary to challenge the nervous system’s ability to stabilize the hips and pelvis. Single leg balancing activities are a great program component to do this. The individual must recognize where the pelvis achieves a stable position in order for this to be effective. This can progress to single leg hopping and jumping activities while keeping the pelvis stable.

4. There has been some controversy over whether athletes should foam roll their ITB, which I discussed previously here. Don’t bother trying to stretch your ITB unless you like to waste time and potentially worsen the problem. Most ITB stretches simply stretch the hip muscles that are already weak, which is absolutely counterproductive. And the ITB’s connective tissue is extraordinarily strong so you aren’t going to stretch it.

image courtesy 220triathlon.com

5. Running technique changes can be effective to normalize demands on the hip muscles and move in a less painful range of motion. The knee needs to maintain a high level of bend during swing. If you have a tendency to overstride far forward of the body’s center of mass then you will place greater demand on the gluteus medius muscle as soon as the foot makes contact, setting yourself up for failure. You may only need to increase your cadence 4-6 steps per minute and think of nothing else. There’s more information on cadence changes in my shin splint article here. The relationship of the ITB to the femur bone beneath it also changes as the knee is bent and straightened so changing the technique can change that relationship. In some runners there can be a benefit to running quickly for 20-30 seconds and then walking to vary the mechanical position of the ITB to the femur.

Poor right hip abductor engagement

6. If you have been unable to exercise secondary to ITB pain, make sure you take full recovery days between the days that you do start to exercise. These off days are great to emphasize the strengthening, balance, maintenance, and so on. For running that first time back, short and consistent is the name of the game. Better to run one mile each on three or four days than three to four miles at once. Depending on the number of days you have taken off, a mile isn’t an unreasonable distance to start at and that may also require a walk/run program. 

Please let me know if you have any questions at derek@mountainridgept.com. 

Footwork Friday - Why am I developing black toenails?

Many runners develop black toenails, especially after longer runs. This is a very specific type of bruising known as a "subungual hematoma." It has often been believed that this is caused by the shoe's toe box size restricting the toes to so much that direct trauma and bruising develops. This isn't always the case, and The Gait Guys suggest that there is another cause in one of their older blog posts.

Many runners tend to curl their toes downward in an effort to grip the inner surface of their shoe. In addition to black toenails, another sign of this habit is the presence of a callus on the very tip of the toe. Curling your toes downward requires heavy use of the flexor digitorum longus and/or flexor hallucis longus muscles. Using these muscles is a way to gain stability within the shoe, but it is not a good habit. Regardless of the presence of black toenails, this should be avoided because these muscles are not built to produce larger amounts of power or engage in constant stability control.

The area under a toenail has a large blood vessel supply close to the nail bed, so bruising occurs more easily with any vessel damage. Gripping downward combined with a small forward/backward movement of the shoe causes a shearing force through the skin and fatty tissue of the toes. That repetitive pressure with this shearing force against the insole is thought to be enough trauma to disrupt the blood vessels. The solution? Don't grip the shoe with your toes.

Shorter runs usually aren't enough repetition to harm the vessels, but longer runs will. Especially as we fatigue we  rely more heavily on muscles that aren't fatigued as much during shorter runs. Trail running could cause a greater problem because the trail surfaces are unstable and the runner will more frequently seek stability by gripping with the toes. Also, there is a greater likelihood of steeper inclines and declines that will cause more sheer force of the foot against the insole.

Although there isn't existing research to back up this idea yet, it makes good sense. Next time you are running, think about what your toes are doing. If you are gripping the inside of your shoe then STOP IT!

Let me know if you have any questions at mountainridgept@gmail.com. 

Balance and proprioception: overlooked training for runners and athletes with knee pain and other leg overuse injuries

After reading the title you’re probably wondering a few different things:

1. “What does balance have to do with being a good athlete?”
2. “What the heck is proprioception?”
3. “What’s for lunch today?”

These issues come up time and time again when I work with injured athletes from many different sports. I’ll address the first two questions and you are on your own for that last one.

Let’s review some anatomy first. There are specialized nerves in your joints, ligaments, muscles and tendons that help sense position and movement of your body. That sense is referred to as proprioception. Without these and other specialized nervous system parts you couldn’t close your eyes and know how your body is positioned at any instant. And you couldn’t stand up or walk in a stable manner. Clearly you don’t absolutely need vision to know where your body is or you would be watching your feet while you walk or run, right? By sensing position, these special nerves are also part of what keeps us stable so we aren’t just stumbling around like a drunk college student on Friday night. But many of us, even some of the best athletes, have poor proprioceptive awareness. For so many of us these proprioceptive pathways aren’t challenged often, and then the “use it or lose it” principle kicks in. Especially as we age, we begin to lose the efficiency of these specialized nerves. As these nerves degrade we can’t precisely place each leg with athletic movement. This decreased precision leads to poorer biomechanics that can be related to overuse injuries. Also, a previous or current sprain at the knee or ankle ligaments will negatively impact your positional awareness and movement precision because of the damage that a sprain will do to these special nerve endings. All in all, aging, previous injury and a lack of training stimuli are going to degrade the quality of your movement precision.

Do you think you have good balance and stability? Let’s find out in a couple simple steps. Try these in your bare feet.

1. Stand on one leg as long as you can without touching anything and count slowly. How many seconds can you last on each one? Less than 30 seconds? In that case you’ve got a lot of hard work to do. More than 30 seconds? Well that’s a good start but we’re only getting started.
2. Now stand on one leg as long as you can with your eyes closed. I bet most of you aren’t going to brag about this one. If you don’t make it to 30 seconds on one leg with your eyes closed then there’s likely to be some room for improvement in this aspect of your training.
3. If you have some kind of superhero balance, try standing on one leg, keeping the eyes closed and tilt your head backward or turn your head to each side. This is really hard and will likely stop all but the best balancers.

So what are you doing to train this aspect of your abilities? I imagine several folks are going to say “nothing” because they didn’t know it was important. For what is essentially very little effort, I’d suggest working on your balance, stability, and proprioception to improve your running and prevent injury. Here are a couple ideas to address this area:

1. Stand on one leg with your eyes closed. Sound familiar? If you are able to stand steadily on one leg with your eyes closed on a flat floor then stand on an unstable surface like a folded towel or pillow with your  eyes closed. Or, you could try moving your head as mentioned earlier. Aim for 30 seconds of the most difficult, but achievable, level. Switch sides.
2. Single leg Russian dead lift. One of my favorite exercises. In a standing position pivot your trunk forward from the hip of the weight-bearing leg. The other leg raises up behind you for every same degree the trunk goes downward. Don’t round your back. Repeat 8-15 times until the hamstrings and buttock muscles tire. Switch sides. You can do this with and without weight. 
3. Single leg step down. Stand on a single leg on the edge of a step. Drop down very slightly by bending the weight-bearing leg, keeping your weight back on your heel. Return to the start position. Don’t let your bending knee travel too far forward beyond the front of your foot. Think about keeping your buttock back. Repeat 8-15 times, at least until your hip muscles and quadriceps are getting tired. Switch sides. You can also do this with and without weight. 

Let me know how you do with these activities at mountainridgept@gmail.com. Easy? Hard? These skills become particularly important for runners and other athletes with overuse related knee pain, ankle pain and foot pain.