Steve Miller – Calf Injury Rehabilitation – Injury Rehab Network Event

Steve Miller is a Physiotherapist who spent six seasons working in Premiership Rugby and was part of the Newcastle Falcons’ unbeaten Championship winning team. His other experiences include roles with Beach Volleyball during the London Olympics 2012 and Field Hockey at Glasgow’s Commonwealth Games 2014.

Steve’s presentation about calf injury rehabilitation was the latest event of the Injury Rehab Network. Over 230 people joined live for the presentation from Steve including lots of brilliant video content.

Steve is a guest lecturer at Newcastle University around his daily roles & responsibilities such as acute trauma/emergency medicine, injury assessment, treatment, rehabilitation, reintegration & injury reduction.

After graduating from Sheffield Hallam University with a First-Class BSc (Hons) in Physiotherapy in 2006, Steve worked within various NHS settings, working as a practitioner, and delivered clinical supervision and accelerated physiotherapy mentorship programmes.

Steve completed his Masters in Advanced Manipulative Physiotherapy in 2015 and is a member of the Musculoskeletal Association of Chartered Physiotherapists (MACP). He is acupuncture trained, has a keen interest in neurological contributors to symptoms and injury prevention.

Steve launched Grow Physio during the COVID-19 pandemic to offer an accessible e-learning platform to assist individuals: from students to advanced practitioners to build their practical clinical reasoning. He recognises there is a real challenge to deliver clinical placements and been inundated with requests for elite sport exposure.

He hopes Grow Physio will provide a real representation and valuable educational platform that shares his experiences, designed as a resource that he wishes had been available to him. The intention is to draw upon his expertise to provide a strong foundation that stimulates individuals to generate their own ideas, get creative and progress with consistent & positive outcomes.

In this session about calf injury rehabilitation, Steve discussed the rehabilitation differences for gastrocnemius and soleus injuries, with a particular focus on…

The aims, principles & planning of rehabilitation.
Injury predisposition: the training errors & variables.
Reduced tissue capacity loading options.
Progressive & functional loading.
Preparing athletes to run again.

The recording of the event is available here.

Calf Injury Rehabilitation

Steve’s presentation provided a unique visual insight into calf injury rehab including why calf injuries recur.

The presentation from Steve included timely interventions for sports rehabilitators to consider, a range of reduced capacity loading options and rehabilitation progressions.

Recurrence of Calf Injuries

Steve discussed how the recurrence of calf injuries can be linked to both underload and overload. Effective calf injury rehab needs to be heavy enough, long enough, specific enough and should consider lower limb muscle-tendon ‘stiffness’.

Reduced Capacity Options

Steve presented different reduced capacity options for calf rehab including wall/ ball presses and adapted rehab options.

Blood flow restriction/ occlusion (BFR) training could include seated calf raises or cycling on an exercise bike.

A swimming pool can be used to complete a range of reduced bodyweight loading exercises including raises and jogging. Athletes can use the side of the pool and different depths to adjust capacity.

Steve described how athletes with access to an Alter G treadmill can reduce % bodyweight for a range of strength exercises and dynamic drills. A Reformer/ Pilates machine can also be used to provide a controlled load.

Isometrics

Steve showed how weights machines can be used for squats and leg presses. Steve described clockface isometrics where athletes perform calf exercises and work through a range of different foot angles (around the clock) to ensure all areas of the calf muscles are activated.

Gait & Running Speed

Steve described how therapists can monitor gait speed during different phases of calf rehab. Therapists can track ground contact time and review various metrics to inform rehabilitation and review progress.

Treadmills and Load Builders

The use of exercise equipment and machines can help with calf rehabilitation and ensure the calf muscles are well activated. Steve described how rehab may include steady walking using an incline treadmill, the use of a cross-trainer and stairs/steppers.

Pain Acceptance

Pain is one of the greatest challenges faced by athletes and therapists. Steve described how a pain acceptance and monitoring model can be used to assess pain during, 1-2 hours after training and the following morning after training. Steve discussed how rehab should be repeatable and how there are differences in pain for gastrocnemius and soleus injuries.

Surfing the Rehab Curve

Steve used a surfing analogy to describe the traditional rehab curve focused on velocity and force. Steve highlighted how a different approach and different rehab is required for soleus injuries and gastrocnemius injuries. The force output is significantly different between the two muscles.

Using the wave analogy, Steve recommended that therapists should pick their wave with options including isometric exercises, loaded jumps, sled marches/ runs, plyometrics and hill sprints.

Calf Loading

Steve presented a range of options for calf loading. Starting with traditional eccentric loading programmes which may build from calf raises, to the addition of increasing step sizes as rehab progresses.

The Soleus muscle can be worked through Swiss ball wall raises, with a seated hamstring machine and may progress to dynamic lifting with a step. Steve described how gym equipment such as a seated hamstring machine can be adapted for calf rehab exercises. Steve’s videos showed how a sled may be used for isometrics including prowler walks and pulls.

As rehab progresses simple exercises such as wall sprinters may be varied to load the calf muscles and tendons. Steve showed how glute activation can be achieved with step and Swiss ball exercises. Single leg exposure can be activated with calf raises using a plyometric box and bar.

Steve discussed how a Swiss ball can be used for rolling/ rocked calf raises and with quicker exchanges for sprinter variations. In late-stage rehab this can progress to increased forward propulsion and the introduction of multiplane demands, incorporating sport-specific warm-ups.

Summary

To summarise, Steve gave a recap on the key points about calf rehab including:

How early loading may have positive implications for return to play.
To modify activities to ensure an active recovery.
Therapists should focus on tendon stiffness and reduce body weight, as necessary.
Education and dispelling of misbeliefs are important.
Failed rehab should consider time under tension and whether rehab has been heavy enough to replicate training and competition.

Q&A

Steve’s kindly answered several questions following his presentation:

Question 1 – What is your advice for the prevention of calf injuries?
Answer – Where possible, screening is the best way to prevent calf injuries and to identify any athletes that may need additional support and focused training to reduce the risk of injury. Screening could include a knee to wall test and strength exercises such as extended calf raises and prowler pushes. Calf activation sessions can form part of the whole team warm-up and training activities.

Question 2 – In the assessment of calf injuries how do you differentiate between the soleus and gastrocnemius?
Answer – It is important to use clinical reasoning skills and to consider the athlete’s history. The soleus often grumbles whilst there may be sharp/ shooting pain with gastrocnemius injuries. Manual assessment can be used with pressure applied by the thumb to identify areas of pain. Functional testing can also be useful.

Question 3 – Can a mini trampoline or other unstable surface be used for calf rehab exercises?
Answer – Yes it can be useful as it provides an early form of impact.

Question 4 – How can blood flow restriction (BFR) be used for calf injury rehab?
Answer – This is a large topic with lots of emerging research. To be considered in further depth at a future event.

Question 5 – Why do many calf rehab exercises focus on time under tension?
Answer – For progression to more dynamic exercises such as footwork drills where athletes can work on reducing their ground contact time.

Learn More

Steve passes on his thanks for attending and the positive feedback so far. He currently has full access to all his courses to form a Virtual Pro Sport ‘Placement’, available to watch for just £1 for 30 days access or just £99 for 12 months at growphysio.com/online-courses & Sports Taping Masterclasses at taping.growphysio.com discounted to help out during the pandemic.

Please do not forget to watch Grow Physio’s Mid-Late Stage Calf Rehabilitation, which covers preparation, how to integrate plyometrics, running drills, change of direction, return to play markers that use real case studies to demonstrate the process.

Check out his Instagram @Grow.Physio for more educational tips and he encourages you to get in touch if you have any questions or would like any CPD learning opportunities with your teams/students.

Follow

Follow Steve and find out more about Grow Physio at the links below:

https://growphysio.com/

Instagram @Grow.Physio

Facebook @GrowPhysioSportsInjuries

Twitter @growphysio

LinkedIn Steve Miller/Grow Physio

Recording

The recording of Steve’s presentation is available to view here.

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