What is the recommended rehabilitation protocol for a soleus (gastrocnemius and soleus muscle) injury?

Soleus Injury Rehabilitation Protocol

The recommended rehabilitation protocol for a soleus muscle injury should include early functional treatment with progressive loading, starting with pain-free activities and gradually increasing intensity based on the specific location and severity of the injury. 1

Initial Assessment and Classification

• Injury Location Assessment: MRI evaluation to determine the specific site of injury

  • Central aponeurosis injuries: Worst prognosis (mean recovery ~44 days)
  • Lateral aponeurosis injuries: Best prognosis (mean recovery ~19 days)
  • Medial aponeurosis and myofascial injuries: Intermediate recovery times 2

• Pain and Functional Assessment:

  • Assess bony tenderness
  • Evaluate pain during walking
  • Test functional movements that replicate running requirements 1

Phase 1: Acute Management (Days 1-7)

• Pain Management:

  • Cryotherapy (ice) for 10-minute periods to reduce acute pain and swelling 3
  • NSAIDs (oral or topical) for pain relief 3

• Early Mobilization:

  • Begin immediate functional treatment rather than immobilization 1
  • Initiate pain-free walking as soon as possible
  • Avoid complete rest which can lead to muscle atrophy 4

• Initial Exercises:

  • Gentle isometric contractions of the soleus muscle
  • Pain-free ankle range of motion exercises
  • Light stretching (avoid overstretching) 4

Phase 2: Early Rehabilitation (Weeks 1-2)

• Progressive Loading:

  • Initiate low-load strengthening exercises
  • Begin with seated calf raises (isolates soleus)
  • Progress to bilateral standing heel raises as tolerated
  • Focus on proper biomechanics to avoid compensation patterns 1

• Stretching Protocol:

  • Daily stretching sessions (10 stretches of 60 seconds followed by 30 seconds rest) 4
  • Focus on gentle, progressive stretching of the soleus muscle 3

• Functional Activities:

  • Pain-free walking with proper gait mechanics
  • Pool-based exercises (reduced weight-bearing) 1

Phase 3: Mid-stage Rehabilitation (Weeks 2-4)

• Progressive Strengthening:

  • Implement intermittent mid-intensity exercise protocol rather than continuous low-intensity exercise 5
  • Progress to single-leg heel raises
  • Add resistance with weights or resistance bands
  • Incorporate eccentric training (lowering phase of heel raises) 3

• Neuromuscular Training:

  • Balance exercises on stable then unstable surfaces
  • Proprioceptive training with eyes open, then closed 1

• Functional Progression:

  • Stationary cycling
  • Elliptical training
  • Pain-free aqua jogging 1

Phase 4: Advanced Rehabilitation (Weeks 4-6)

• Sport-Specific Training:

  • Progress to plyometric exercises (only when pain-free)
  • Implement agility drills
  • Begin sport-specific movement patterns 1

• Running Progression (if applicable):

  • Start on level surfaces (treadmill or track)
  • Begin at 30-50% of usual pace
  • Increase distance before increasing speed
  • Progress running volume by no more than 10% per week 1

Return to Sport/Activity Criteria

• Complete resolution of pain during and after activity
• Full range of motion compared to uninjured side
• Strength symmetry >90% compared to uninjured side
• Successful completion of sport-specific functional tests 1
• Ability to perform repeated single-leg hopping without pain 1

Recovery Timeline Considerations

• Expected recovery time varies by injury location:

  • Central aponeurosis: 6-8 weeks
  • Lateral aponeurosis: 3-4 weeks
  • Medial aponeurosis: 4-6 weeks
  • Myofascial injuries: 3-5 weeks 2

• Age is a significant factor affecting recovery time (longer recovery with increased age) 2

• Extent of muscle retraction correlates with longer recovery times 2

Common Pitfalls and Caveats

• Avoid Premature Return: Returning to full activity too soon is a major cause of reinjury
• Avoid Prolonged Immobilization: Can lead to muscle atrophy and decreased collagen organization 4
• Monitor Pain: Pain during rehabilitation should not exceed 3/10; if higher, reduce intensity 1
• Address Biomechanics: Correct any biomechanical issues that may have contributed to the initial injury 1
• Progressive Loading: Ensure gradual progression of load rather than sudden increases in intensity 1

By following this structured, progressive rehabilitation protocol that emphasizes early functional treatment, appropriate pain management, and gradual return to activity based on objective criteria, patients with soleus injuries can achieve optimal recovery and minimize the risk of reinjury.