Calf rehabilitation & low back rehabilitation

In part 1 of this short series (SIB July- Aug 2004) we looked at the principles that should guide your programme design for rehabilitation strength training with minimal equipment, and introduced a progressive exercise series for quadriceps rehabilitation. This month we are looking at the calf and low back. But first, a short recap of baseline principles.

Training principles

Intensity

Without weight stacks or graded free weights it is much harder to gauge the correct intensity of work, but it is essential that you can do this. The support professional needs to evaluate intensity for each exercise against the desired rehabilitation goal.

The term repetition maximum (rep max or RM) refers to the maximum number of times one can perform a movement at a specific weight. 1RM is the maximum weight that the individual can lift because they will only be able to lift it once before failure; for rehabilitation purposes, parameters within the 8-20RM range will provide appropriate intensity.

Remember, too, that with bodyweight- only exercises, the only way to change the load (and thereby progress the intensity) is to change either the position or the movement. This is why the range of movement performed is key to the difficulty of the exercise. In all the exercises outlined in this series, it is essential to maintain the range of movement as the difficulty of the exercises increases. If you standardise the range of motion for every exercise, each level becomes harder. Ease up on the range of motion and in effect you allow your client to ‘cheat’: the series does not work as a progression.

Volume and frequency

In general two to four sets of eight t0 20 reps is sufficient for each exercise. A rest of 60 to 90 seconds is recommended between sets; the patient should run out of effort in the final set if they are to achieve the ‘overload’ which produces training benefit. In some cases of early stage rehabilitation it will be appropriate to begin with only one set of an exercise.

Large muscle groups can be trained two to three times per week with at least 48 hours rest between sessions. Once a week may maintain strength but will not develop it. More than three sessions may not allow sufficient recovery tine.

Progression

For rehabilitation programmes I am in favour of first increasing volume, keeping the weight constant. Once the patient can competently perform a certain number of sets and reps, the load should be increased. This is a cautious and safe way to progress.

Table 1 below details how you can use the Rate of Perceived Exertion with your clients. RPE is a useful rehabilitation tool, giving subjective feedback that can help the therapist decide when and how to progress the programme. For full explanation of how to use the RPE tool, see Part 1 (SIB July-Aug).

Use your judgement alongside this tool to ensure you do not rush your patients. When increasing the load, keep in mind that tendon strength takes longer to develop than muscle strength.

Table 1: Rate of perceived exertion
RPE	Difficulty	Decision
<5	Too easy	Significantly increase the reps or the load
6-7	Quite easy	Increase reps, sets or load – progress to next level
8-9	Working well	Suitable level for rehabilitation training. Keep reps and loads the same
9.5-10	Max effort	Very difficult. Arguably too hard for rehabilitation, so reduce load, sets/reps or change the exercise

Specificity

It sounds obvious, but the goal of the rehabilitation programme is to enable the patient to be pain-free while they run, play sport, work or do the housework. The goal of rehabilitation is not to enable the patient simply to excel at a selection of exercises. The exercise prescription is the means to the end.

The exercises Group 2:

Calf muscles

Main muscles trained:

Gastrocnemius and soleus

Suitable for rehabilitation from:

Achilles tendinitis
medial tibial pain
plantar fasciitis

Two different variations of the standard calf raise are used to ensure optimum benefit to both gastrocnemius and soleus. The straight-knee version concentrates the training effect on the large gastrocnemius: this portion of the calf attaches above the knee and so is lengthened when the knee is straight. Longer muscles can produce more force. In the bentknee version, the effectiveness of the gastrocnemius is reduced with the shortened muscle position, thereby placing a greater work load on the shorter soleus. Both versions of the exercise are performed upon a step in order to achieve a full range of motion in the ankle joint.

Progression:

Begin with the double-leg versions at the start level of sets and reps. Progress to the target level sets and reps. Once this can be accomplished at RPE six to 7 out of 10 (see Table 1 above), move on to the single-leg versions, again at the start level. Once target is achieved, add load using the rucksack.

Table 2: Calf exercise series
Exercise	Start sets x reps	Target sets x reps
Calf raise, double legs, knee straight	2 x 10	3 x 20
Calf raise, double legs, knee bent	2 x 10	3 x 20
Calf raise, single leg, knee straight	2 x 10 each leg	3 x 20 each leg
Calf raise, single leg, knee bent	2 x 10 each leg	3 x 20 each leg
Calf raise, single leg + loaded rucksack, knee straight	3 x 20 each leg; 10kg rucksack	3 x 20 each leg; 40kg rucksack
Calf raise, single leg + loaded rucksack, knee bent	3 x 20 each leg; 10kg rucksack	3 x 20 each leg; 40kg rucksack

Technique and range of motion:

Please pay attention to the details, particularly those defining the required range of motion.

Calf raise, double, straight leg

Start position:

Stand with the balls of your feet on a step or stair.
Rear half of the feet are off the step.
Stand with your knees completely straight.
Stand upright with good posture: tummy in, chest out and shoulders back.
Place your fingers on a wall or stair rail for balance.
Do not lean or place your weight on to your hands as this will reduce the effectiveness on the calf muscles.

Movement:

Lower your heels until you feel a small stretch in your calf/Achilles.
Slowly – for a count of two – push up on to your toes.
Push all the way up, evenly, placing weight through both your big and little toe joints. This helps you to plantarflex the ankle with good alignment.
Maintain good posture throughout the movement.
Slowly lower down – for a count of three – until you feel the stretch; then continue.

Calf raise, double, bent leg

Start position:

Stand with the balls of your feet on a step or stair.
Rear half of the feet are off the step.
Do a ‘knee squat’ bending down until your knees are about 40 degrees flexed.
Hold the knee squat position with your knees slightly ahead of your toes and hips above your heels.
Set your upper body upright with good posture: tummy in, chest out and shoulders back.
Place your fingers on a wall or stair-rail for balance.
Do not lean or place your weight on to your hands as this will reduce the effectiveness on the calf muscles.

Movement:

As for straight leg, except:
It is essential to maintain the knee squat position throughout.
If you allow the knee to extend as you push up on to the toes you will significantly reduce the effectiveness of the exercise.
Use your quads to brace the knee squat position at 40 degrees.

Calf raise, double, bent leg

Calf raise, single, straight leg

Start position:

Stand with the ball of one foot on the step/stair.
Stand with your knee completely straight.
Bend your other knee so your leg does not get in the way.
Stand upright with good posture using ‘fingertip’ balance as above.
Set pelvis using your core muscles.
Ensure pelvis is level and that you do not lean or place weight on one hand.

Movement:

As for double-leg, except:
As you push up on to the toes, ensure you do not ‘hitch’ the hip.
It is even more essential that you do not lean or place weight on to your hands.

Calf raise, single, bent leg

Start position:

Stand with the ball of one foot on the step/stair.
Perform a single knee squat as described above.
Hold the 40-degree knee bend position.
Bend your other knee so your leg does not get in the way.
Stand upright with good posture, using ‘fingertip’ balance.
Set pelvis using your core muscles.
Ensure pelvis is level.

Movement:

As for double leg, except:
As you push up on to the toes, ensure you do not ‘hitch’ the hip.
It is even more essential that you do not lean or place weight on to your hands.
Remember – no cheating by extending your knee. Calf raise, single plus load
Perform the exercise with a rucksack on your back.
Bottles of water, sandbags or weights in the rucksack increase the load on the calf muscles.
10kg in the rucksack will be a significant increase in body weight.
Progress by adding 10kg up to 40kg total load.
If you do have access to a barbell, feel free to use this instead!
With the increased load, pay extra attention to pelvis, ensuring it remains level throughout.

Group 3: Back extensors

Main muscles trained:

Erector spinae group
plus assisting muscle groups:
Multifidis
transverse abdominis
obliques

Suitable for rehabilitation from:

Low back pain
Back injury

These exercises are chosen to begin with gentle loading and do not involve hyperextension of the spine, which limits the lumbar compression forces. The ‘superman’ exercise is low load and only trains one side of erector spinae at a time, hence the need to hold the position for a duration to provide sufficient training effect.

The back-raise exercise involves greater load on the muscles, but the swiss ball allows the range of movement to run from flexed to neutral extension. This makes it superior to the dorsal raise exercise performed on the floor which hyperextends the spine (involving high compression forces). The progression focuses solely upon developing strength endurance, as this is most relevant for rehabilitation purposes.

Progression:

Start with the first exercise and progress from the start level to the target level of sets and reps. Once this can be accomplished at RPE of 6 to 7 out of 10 (see Table 1 above), move up to the next exercise, and so on.

Table 3: Back exercise series
Exercise	Start sets x reps	Target sets x reps
Superman, leg only	2 x 10 each leg, holding each rep for 5 seconds	3 x 10 each leg, holding each rep for 10 seconds
Superman, arm and leg	3 x 10 each side, holding each rep for 10 seconds	3 x 20 each side, holding each rep for 10 seconds
Swiss Ball back raise (stop at extension)	3 x 10	3 x 20
Swiss Ball back raise, superman arms (stop at extension)	3 x 10	3 x 20

Superman, leg only

Start position:

Kneel upon all fours, hands below shoulders and knees below hips.
Adjust your lumbar spine to neutral position.
Ensure your upper back is also extended, chest out and shoulders back.
Set your core muscles, bracing your abdominal and obliques.
Stay relaxed and keep breathing.

Movement:

Slowly slide one leg backwards, extending the knee and lifting the foot slightly.
As you extend the leg back use your core muscles to maintain neutral lumbar and level pelvis.
Do not lift the leg above the horizontal.
Do not extend the lumbar spine.
Hold the leg extended for the required number of seconds.

Superman, arm and leg

Start position:

As for previous exercise.

Movement:

Slowly slide one leg backwards, extending the knee and lifting the foot slightly.
At the same time slide your hand forwards, lifting the arm.
As you extend the leg back and arm up, use your core muscles to maintain neutral lumbar and level pelvis.
Hold the extended position for the required number of seconds.

Superman, arm and leg

Back raise, Swiss ball

Start position:

Lie face down with your hips on a Swiss ball.
Use an appropriate ball size for your height. You should be able to place your feet on the floor with a slight knee bend and feel balanced with your hips on the top of the ball.
Place your hands by your head.
Allow your spine to flex around the ball.

Movement: