How to manage soleus muscle strain or tear?

Management of Soleus Muscle Strain or Tear

For soleus muscle strains, initiate immediate functional treatment with relative rest, ice application, and early eccentric strengthening exercises combined with stretching, as this approach reduces pain, improves function, and facilitates faster return to sport compared to immobilization.

Initial Assessment and Injury Classification

When evaluating a suspected soleus injury, determine the specific anatomic site involved, as this directly predicts recovery time 1:

• Proximal medial musculotendinous junction (MTM): Most common site (25.5% of injuries), median recovery 29 days 1
• Proximal central musculotendinous junction (MTC): Worst prognosis, mean recovery 44.3 ± 23.0 days 1
• Proximal lateral musculotendinous junction (MTL): Best prognosis, mean recovery 19.2 ± 13.5 days 1
• Anterior myofascial (MFA): 21.8% of injuries 1
• Posterior myofascial (MFP): 21.8% of injuries 1

MRI is the gold standard imaging modality to confirm the diagnosis, localize the injury site, assess extent of edema and retraction, and rule out accessory soleus muscle pathology 1, 2, 3, 4.

Immediate Management (First 1-2 Weeks)

Begin functional treatment immediately rather than immobilization, as this approach leads to shorter recovery time and faster return to activity 5, 6:

• Relative rest: Avoid activities that reproduce pain, but maintain activities that don't worsen symptoms to prevent muscle atrophy 6, 7
• Ice application: Apply through a wet towel for 10-minute periods to reduce tissue metabolism and blunt inflammatory response 7
• NSAIDs: Use for acute pain control only, recognizing the underlying pathology is degenerative rather than inflammatory 6
• Gentle stretching: Begin hamstring and gastrocnemius-soleus stretching when tolerable 6, 7

Progressive Rehabilitation Phase (Weeks 2-6)

Eccentric strengthening exercises are the cornerstone of treatment and should be initiated as soon as pain allows 6, 7:

• Eccentric calf exercises: Perform daily, starting within patient capability and building up intensity over several months 5, 6
• Stretching program: Continue daily stretching of gastrocnemius-soleus complex, preferably after warm shower or moist heat application, holding each stretch 10-30 seconds 6, 7
• Deep transverse friction massage: Apply to reduce pain and promote healing 6, 7
• Biomechanical correction: Address overpronation or pes planus with shoe orthotics if contributing to injury 6

Key principles for exercise progression 5:

• "Small amounts often" (pacing approach)
• Link exercises to daily activities to make them habitual
• Start within capability but progressively increase dose over months

Advanced Phase and Return to Sport (Week 6+)

Sport-specific exercises with gradual return to activity should be guided by the specific injury site 1:

• Central aponeurosis injuries: Expect 44+ days recovery; be conservative with return to sport 1
• Lateral aponeurosis injuries: May return around 19 days if asymptomatic 1
• Age consideration: Older athletes require longer recovery (statistically significant correlation between age and recovery time) 1
• Retraction extent: Greater retraction correlates with longer recovery 1

Critical Pitfalls to Avoid

Never inject corticosteroids into or around the soleus muscle-tendon unit, as this increases rupture risk without improving long-term outcomes 6, 7.

Avoid complete immobilization, which leads to muscle atrophy and deconditioning without improving outcomes 6, 7.

Do not rely on passive modalities alone (ultrasound, electrotherapy, laser therapy) as primary treatment, since evidence shows no benefit for pain, edema, or function 5, 6.

Rule out accessory soleus muscle pathology in cases with atypical presentation (soft mass at rest, hard with contraction, lateral to Achilles tendon), as this requires different management 8, 2, 3. If accessory soleus muscle is symptomatic and significantly impairing function, complete surgical resection is preferred over fasciotomy 8.

Refractory Cases

If no improvement after 6-8 weeks of conservative treatment 6:

• Continue eccentric exercises and stretching
• Consider immobilization with fixed-ankle walker device
• Refer to sports medicine specialist or orthopedic surgeon
• Re-evaluate with MRI to assess healing and rule out complications