Some Words from the

Calf and Achilles Experts

Craig Purdam
Consultant Sports Physiotherapist,
Adjunct Professor
University of Canberra / La Trobe University

The Calf-Achilles MTU is a complex system that appears to respond quite specifically to training stimuli such
as isometric, isotonic, eccentric, RFD, strength-endurance, stiffness enhancement or increases in fascicle
or optimal/functional length.
It should be cautioned that trainable changes in one domain are not necessarily transferrable to other
domains. However, accurately quantifying baselines and the degree of change is important in informing
specific rehabilitation aims, making a comprehensive assessment critical for optimal outcomes.

Sue Mayes Colin Griffin

Director of Artistic Health: PhD Lower-limb Rehabilitation
Australian Ballet / Specialist,
La Trobe University UPMC Sports Surgery
Clinic, Dublin

@S_Maysey @colingriffin colingriffin50k

Accurate and reliable isometric testing of lower I’ve been using VALD’s force plates for 7 years and
limb muscles is vital in The Australian Ballet’s the ForceFrame more recently. This technology
screening, monitoring and rehabilitation has significantly enhanced my practice by
to identify areas for development that can providing precise, time-efficient data on
enhance dancer performance, prevent injury lower-limb strength, as well as explosive and
and guide return-to-dance progressions.
reactive strength.
Real-time feedback and comparisons within
I also use the ForceFrame to assess foot strength
and between people have been valuable to
staff and dancers and help maintain motivation with 3 different protocols that I can easily adapt.
and adherence to exercise programs. The real-time feedback and dashboard reports
clearly highlight deficiencies and guide rehab,
Isometric testing is well-tolerated in-season
and as adverse outcomes such as DOMS are giving athletes a clear focus.
uncommon, dancers engage in testing and are Numbers don’t lie and the force traces often
more likely to perform maximal contractions.
leave clues!
The VALD equipment is easy to assemble and
portable, allowing us to continue accurately
testing even on tour.

2 | Practitioner’s Guide to the Calf & Achilles Complex

 Shane Kelly Ebonie Rio
Clinical Director: Senior Clinical Research Fellow &
The Royal Ballet Lecturer:
The Australian Ballet/ Notre Dame
/ La Trobe University,

@shanekellypt

The use of force plates is relatively new in a It is critical that we can accurately measure our
classical ballet setting. However, we have found clients' calf and Achilles progress accurately.
that the dancers have embraced the technology This allows us to work together to reach targets,
and the power of numbers is a language we all not just based on their other leg but comparable
share and buy into. ForceDecks have enabled us to data for their desired level of performance.
speak to the dancers in a way they have not heard
before.

"…the power of numbers

is a language we all share
and buy into."

Practitioner’s Guide to the Calf & Achilles Complex | 3

The Rising Impact
of Calf and Achilles Injury
The lower-leg, including all structures below the knee, has become a focus of attention in recent years
due to a noticeable rise in the impact of calf muscle and Achilles tendon injuries.

Days lost to injury

Hamstring Strain 2 000+

Muscle Injury 859
(Unspecified)

Calf Strain 710

Knee Injury 704
ACL Rupture 654
Adductor Strain 350
Ankle Sprain 259
Meniscus Tear 194

Total days lost to injury over the 2023/24 EPL Season

Calf muscle-tendon unit (MTU) injuries such as calf muscle strain injuries (CMSI) and
Achilles tendinopathy (AT) are among the top three contributors to time-loss injuries in the English
Premier League (EPL) and are a significant cause of missed time and recurrence in the Australian
Football League (AFL). These injuries have become persistent challenges for elite athletes in the
National Basketball Association (NBA), National Football League (NFL) and professional soccer.
High incidence and recurrence of calf MTU injury may result from measurable qualities like strength,
speed, and endurance. Tools such as force plates, dynamometers and timing gates can assess
injury risk based on these factors.

ForceDecks ForceFrame SmartSpeed DynaMo

Force plates Fixed-frame dynamometers Timing gates Handheld dynamometers

4 | Practitioner’s Guide to the Calf & Achilles Complex

 Time-Loss
Condition Incidence Recurrence
Return-to-Sport (RTS)

General Population: 24%

AT Athletes: 24% 20-44% 10 Days
Runners: 50%

Achilles Tendon 7-40 per 100,000 2.3% 11 Months

Rupture (ATR) training hours

Soleus: 25.1 Days

CMSI 3 per AFL team annually 16%
Gastrocnemius: 7.7 Days

Tracking metrics like peak force, RFD, impulse, and jump characteristics helps practitioners improve
calf and Achilles load capacity, reducing injury rates through targeted testing, training, and monitoring.

…practitioners improve calf and Achilles load capacity,

reducing injury rates through targeted testing, training,
and monitoring

Condition Measurable Modifiable Risk Factors

AT Plantar flexor strength, training schedule and gait abnormalities

ATR Insufficient strength, poor conditioning and athletic participation

CMSI Training age, foot and calf strength

Practitioner’s Guide to the Calf & Achilles Complex | 5

Calf Muscle Strain Injury (CMSI)
Calf injuries have often been viewed as relatively minor due to presentations of
dull soreness and subtle mechanisms of injury. However, this lack of noticeable symptoms may
contribute to their longer recurrence window compared to other strain injuries, such as hamstrings.
Because they often appear minor, these symptoms are not reliable guides for rehabilitation.
Practitioners can confidently guide care and monitor CMSIs by regularly measuring lower limb outputs
like plantar flexion peak force, ROM, strength, RFD, and reactive strength.

…symptoms are not reliable guides for rehabilitation.

Achilles Tendon Injury

ATR have increased recently in elite sport,
Achilles Tendon Ruptures

especially in leagues such as the NFL.

Often, ATRs occur without prior pain or
symptoms, further increasing the need for
per Season

objective monitoring strategies to detect non-

painful changes in force or ROM that may identify
individuals at risk for ATR.
Conversely, AT is widely prevalent in elite sports.
Approximately 50% of running athletes will
experience AT during their careers.
Many athletes continue to compete despite
AT, leading to prolonged symptoms and a
recurrence rate of nearly 30%. Therefore, NFL Season
regular monitoring of objective markers like
reactive strength and peak force is essential
to assess readiness, manage symptoms and
mitigate recurrence.

6 | Practitioner’s Guide to the Calf & Achilles Complex

What Will You Get from
This Guide?
This guide provides a comprehensive approach to calf MTU injury assessment and management,
emphasizing the importance of precise measurement using advanced tools like force plates
and dynamometers. You’ll learn how to apply specific tests, interpret key metrics and tailor your
assessments to the unique
demands of your athletes
or patients.

This guide focuses on improving lower leg

function with a consistent and effective approach.
It covers measurement techniques, targeted
interventions, and strategies to reduce injury risk
and enhance performance.
Readers will have the confidence and knowledge
to apply elite assessment strategies to
any population.

Practitioner’s Guide to the Calf & Achilles Complex | 7

Contents

Background..................................................................................................... 9

Methods of Calf MTU Assessment ............................................................... 16

Management................................................................................................. 25

Case Study.................................................................................................... 33

What’s Next? ................................................................................................. 36

In this document, we will cover a wide range of topics

and answer some common questions, including:

Tip: Click any heading to jump to section

Best Methods How to Select Relevant

to Assess the Calf MTU Assessment Tools Technologies

Calf Endurance
How to Manage and Strength Training
Developing Strength
Calf MTU Injury

Technology Intergration in Ingury Prevention Strength

vs.
Early Rehabilitation Performance Enhancement Domains

8 | Practitioner’s Guide to the Calf & Achilles Complex

Background
Lower Leg Anatomy and Biomechanics
To effectively assess lower-leg performance, practitioners must understand the basic function of the
calf MTU and structural characteristics that enable this function.

The Calf Muscle-Tendon Unit (MTU)

The combination of structures in the lower leg (soleus,
gastrocnemius and achilles tendon) that contribute to and
enhance ankle plantar flexion. Also referred to as the triceps
surae complex (TSC) or as the plantar flexor complex (PFC).

Gastrocnemius
Soleus
Achilles Tendon

The calf MTU plays an important role in athletic movements, contributing roughly 35-40% of total
lower-body work across both horizontal and vertical dynamic tasks such as running, sprinting, cutting
and jumping.
This contribution to sport-specific tasks allows the calf MTU to support other muscle groups during
various sporting demands.

The Calf Assists All Major Lower Body Muscle Groups

Practitioner’s Guide to the Calf & Achilles Complex | 9

Back to Contents
The Ankle is Integral to Vertical and Horizontal Propulsion
Vertical Horizontal
Jump Power Jump Power

Kotsifaki et al., 2021

The calf MTU supports these actions largely through its reliance on the stretch-shortening cycle (SSC),
enabling it to handle high tensile loads efficiently while minimizing energy-intensive contractions,
such as eccentrics. The most demanding tasks, like jumps and accelerations, can place over
12x bodyweight (BW) through the calf MTU.

The length-tension relationship of the calf MTU has a large influence on force readings when assessing
plantar flexion strength. This relationship will often dictate which testing positions are best for the
patient or athlete.
Understanding the high tensile load demands of the calf MTU and its contribution to sporting activities
demonstrates the importance of quality load assessment of this complex.

10 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Assessment Tools & Technology
Advancements in technology have significantly enhanced the precision and effectiveness of calf and
Achilles rehabilitation. Technology adds value through six main pillars:

Quantify MTU function

with objective data

Comparisons Asymmetry
and Norms data comparing
limb outputs

Facilitate
Biofeedback to
recovery with
improve loading
optimized loading

Monitoring progress through

testing and training

…the most demanding tasks, like jumps and accelerations,

can place over 12x bodyweight through the calf MTU.

Practitioner’s Guide to the Calf & Achilles Complex | 11

Back to Contents
Technology for
Calf and Achilles Management
Force Plates: Force plates offer valuable insights into weight-bearing distribution, proprioception
and balance. Along with common high-load isometric and jump assessments, force plates enable
assessments such as quiet stand, single-leg stand and range of stability.
Metrics from these tests help practitioners monitor load tolerance and address balance impairments
that may be present. Biofeedback features allow athletes to visualize their performance in real-time,
promoting engagement and early weight-bearing.
Examples of force plate technology include VALD’s ForceDecks range (ForceDecks Mini,
ForceDecks Lite and ForceDecks Max).

FORCEDECKS

Expert Tip:
Using a block or wedge
under the heel can limit force
production by the calf MTU,
allowing for safer end-range
strengthening with less strain
on the tissue during the early
stages of rehabilitation.

Dylan Carmody
Physical Therapist, VALD CSM

Fixed-Frame Dynamometers (FFDs): FFDs provide accessible and accurate assessments of isometric
strength for the calf MTU. These tools allow practitioners to implement customizable, low-load
isometric training programs to preserve strength and muscle mass while minimizing tissue stress.
Examples of FFDs include VALD’s ForceFrame and NordBord systems.

NORDBORD
FORCEFRAME FOLD
Expert Tip:
High-load isometric and eccentric
training of unaffected muscles, like
the quadriceps, glutes, and ham-
strings, can boost rehab outcomes.
Implementing technologies like
ForceFrame and NordBord enhance
athlete engagement and provide key
data for calf MTU rehabilitation.

Gabriel Manoel FORCEFRAME MAX

Physical Therapist, VALD CSM

12 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Handheld Dynamometers (HHDs):
Portable HHDs offer an alternative for assessing muscle strength and monitoring progress. However,
consistency in testing protocols is crucial to minimize inter-tester variability.
VALD’s DynaMo range (DynaMo Lite, DynaMo Plus and DynaMo Max) provides both handheld and
fixed-point options for comprehensive and tensile strength testing.

DYNAMO PLUS

DYNAMO LITE
DYNAMO MAX

ROM Assessment: Accurate ROM assessment is essential for setting early rehabilitation goals. Tools
such as inclinometers, inertial sensors and camera-based technologies ensure consistency in tracking
progress.
VALD’s DynaMo and HumanTrak systems enable reliable and efficient ROM screening for both single-
joint and multi-joint assessments.

By integrating these
technologies into early-phase
management, practitioners
can optimize loading, monitor
progress and maintain muscle
function from day one, ensuring
a more precise and effective
rehabilitation process for
lower-leg injuries.

Practitioner’s Guide to the Calf & Achilles Complex | 13

Back to Contents
Lower Leg Injury Basics
Calf MTU injuries often occur during a false step, where an athlete quickly extends their leg backward
to generate momentum from a static start. This results in a large eccentric load placed on the calf
MTU, exceeding the capacity of either a sarcomere, leading to CMSI or the Achilles tendon, leading
to ATR.
While chronic conditions, such as AT, don’t have direct mechanisms of injury, there are biomechanical
factors that are associated with athletes with AT and CMSI.

While chronic conditions, such as AT, do not have direct

mechanisms of injury, there are biomechanical factors that
are associated with athletes with AT and CMSI.

Excessive
Ankle Eversion

Lateral Pelvic Drop

False Step
(“Plyo Step”)

Anterior
Pelvic Tilt

Bramah, 2021 | Becker, 2017 | Dixon, 2009

14 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Calf MTU injuries have a longer recurrence window than other soft tissue injuries, making return-to-
play decisions difficult without objective criteria. However, not all objective measurements of plantar
flexion are created equal.
Handheld (only) dynamometers, for example, have limited capabilities for assessing calf MTU
function, as their typical capacities can be as little as one-quarter of typical forces registered in fixed
system isometric plantar flexion strength tests.
For this reason, FFDs and force plates are traditionally better suited to calf testing, although high-
capacity HHDs (such as DynaMo Max) are also suitable.

FFDs and force plates are traditionally better suited to calf

testing, although high-capacity HHDs are also suitable.

However, there is a gap in understanding how technology can optimize lower-leg rehabilitation.
The following examples provide practical strategies for technology-based testing tailored to these
injury challenges.

Muscle:
Calf muscle injuries are complex due to the
variable role of muscle damage in injury and
return-to-play decisions. A criteria-based
rehabilitation approach, supported by objective
data from validated measurement systems,
ensures accurate tracking of athlete readiness.
Number of Days to RTP

Tendon:
Tendon injuries and flare-ups can be influenced
by surface changes in training and competition. Overlap in
Return-to-Play
Monitoring metrics such as reactive strength (RTP)between all
4 grades
index (RSI) or plantar flexion peak force can
help identify early strength deficits that often
Injury Grade
precede symptoms in soft tissue injuries.

Training: While high-speed running dominates hamstring injury prevention, moderate and slow-speed
running results in greater ground contact times with similar calf MTU loading. This leads to the calf
complex experiencing greater total impulse (force x time). Exposure to these running speeds may
help reduce injury risk, emphasizing the need for a comprehensive, data-driven approach to lower-leg
injury management.

Practitioner’s Guide to the Calf & Achilles Complex | 15

Back to Contents
Methods of Calf
MTU Assessment
A tiered assessment system guides the profiling process for calf MTU rehabilitation and performance.
This approach ensures baseline qualities like peak force, endurance and power are assessed and
managed before progressing to advanced locomotive and reactive strength assessments.
If an individual lacks the necessary foundational characteristics, moving prematurely to higher
tiers of assessment may lead to excessive soreness in training or an increased risk of setbacks
during rehabilitation.

A tiered assessment system guides the profiling process for

calf MTU rehabilitation and performance

Tier 1: Isolated High-Load Assessment

Peak isometric force assessment is the most common lower-leg force test. Strong athletes can
produce over 2,000N (200kg/450lbs) of force in a seated assessment and over 3,000N (300kg/660lbs)
in a standing assessment. Therefore, practitioners should use measurement technology with high-load
capacity and sampling rates to ensure accurate, reliable results.
Systems like ForceDecks, DynaMo Max and ForceFrame offer load capacities of approximately
"20,000N (2,040kg/4,500lbs)""10,000N (1,020kg/2,250lbs)""2,500N (250kg/550lbs), respectively.
ForceDecks and DynaMo Max have sampling rates of 1,000Hz and 1,200Hz to accurately measure RFD
qualities as well.

16 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
 Expert Tip:
Quality Common Metric(s) Assessed
Proper cueing is essential during isometric testing. Cues
like "push as hard as possible" might not accurately reflect
an athlete's true RFD capacities. Ensure that your cues
align with the specific quality you aim to assess, such as Maximal Strength Peak force
maximal strength (e.g., "Push hard") or explosive strength
(e.g., "Push fast").
Force at 100ms
Ryan McLaughlin Explosive Strength or
Sport Scientist, VALD BDM Time to 80% peak force

Tier 2: Isolated Endurance Assessment

Plantar flexion force endurance testing is necessary for athletes in sports requiring sustained or
repetitive lower-limb loading, such as long-distance running, soccer and rugby.
Traditional endurance assessments, often based on subjective measures like repetitions to fatigue,
demand close supervision to ensure accuracy. Advancements like ForceFrame Training Mode address
these limitations by providing objective data on isometric endurance performance, evaluating the calf
MTUs ability to sustain submaximal force over time.

Practitioner’s Guide to the Calf & Achilles Complex | 17

Back to Contents
 Expert Tip:
When using ForceFrame training mode, you can
quickly adjust the training zone in real time to
higher or lower depending on the individual's
output on that given day.

Ryan McLaughlin
Sport Scientist, VALD BDM

Training mode not only highlights deficiencies in the calf MTU but also in synergist muscles, offering
actionable insights into performance limitations while minimizing fatigue.

Plantar Flexion Training Mode

Outputs Heel Raise Endurance Test
(ForceFrame)

Type of
Isometric Isotonic
Loading

Saved presets for consistent, Requires supervision for

Execution autonomous execution accurate outputs

Average time in zone

Metrics Average variance Repetitions to fatigue
Average impulse

Training mode not only highlights deficiencies in the

calf MTU but also in synergist muscles, offering actionable
insights into performance limitations while minimizing fatigue.

18 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Tier 3: Compound Dynamic Assessment
The calf MTU plays a key role in dynamic, multi-joint movements, relying on quasi-isometric actions
and the SSC to produce power during activities like jumping, cutting and sprinting.
Measuring SSC tasks creates better clarity in assessing the compound function of the calf MTU during
dynamic activities. Tools like force plates and timing gates, such as ForceDecks and SmartSpeed,
provide valuable data on high-force and high-speed activities, supporting lower-leg injury rehabilitation.

Jump Assessments
Pick One Pick One
Compound Tests

Dynamic Assessments
Evaluation of the calf MTUs ability to produce Laterality Unilateral (Single Leg) Bilateral (Double Leg)
power during dynamic, multi-joint movements
by measuring tasks that rely on quasi-isometric
actions and the SSC, such as jumping Metric
Performance Asymmetry Strategy
Selection
and hopping.

The following assessments and metrics are geared towards the specific function of the calf MTU in
each activity. For more information on dynamic force plate assessments, check out the
Practitioner’s Intermediate Guide to Force Plates.

Test Quality Performance Asymmetry Strategy

Metric Metric Metric

Counter Move- Peak Power / Phase 2 (P2) Countermove-

Slow SSC
ment Jump (CMJ) BM Impulse ment Depth

Concentric P2:Phase 1 (P1)

Squat Jump (SJ) Explosive Jump Height P2 Impulse
Strength Impulse

Single-leg Jump Slow Displacement at Concentric Dura-

Jump Height*
(SLJ) Unilateral SSC Takeoff* tion*

Fast Contact Time

Hop Test (HT) SSC (Repeated)
RSI Fatigue (%) Active Stiffness
Fatigue (%)

Peak Drop Land-

Drop Jump (DJ) Fast SSC RSI Contact Time
ing Force
* Single-leg assessments require asymmetry comparisons, regardless of underlying performance or strategy quality

Practitioner’s Guide to the Calf & Achilles Complex | 19

Back to Contents
Locomotor Assessments
As a primary contributor to horizontal power in running at slow speeds, fast speeds and change of
direction (COD) activities, objective locomotor assessment for calf MTU function is a helpful end-stage
tool to determine Return-to-Play readiness for many individuals.
Timing gate assessments can be used to compare athlete performance to benchmarks or pre-injury
data to best inform a safe Return-to-Play.

Timing gate assessments can be used to

compare athlete performance to benchmarks
or pre-injury data to best inform a safe Return-to-Play.

Calf Performance Correlations Interval Drills:

Greater calf, ankle and Customizable repeated sprint ability
foot strength is related to (RSA) test.
performance in acceleration,
Fixed duration (set time allotted between
maximum velocity sprinting,
the beginning of each test) and
marathon running and COD
fixed recovery (set time allotted
times.
between the end of one test and
Once isolated performance the beginning of the next) allow
qualities have been restored in practitioners to customize work-
a calf MTU rehab, locomotor to-rest intervals and intensity
assessments are helpful to thresholds to best match their
ensure athletes have returned to athletes’ sport.
their prior level of performance in
sport-related tasks.

Curvilinear Speed: Cut Drills:

An athlete’s ability to Cut drills test
maximally accelerate and the athlete’s
sprint along an arc. response to
directional
Often executed as one-way
signals – random
timing drills. These drills
or pre-set by
simply measure the time
the practitioner
between initial and final
– during their
beam breaks (multiple
speed and agility
gates can be added to
training.
provide split times as well.)
Drills often mimic a
cutting or side-step
maneuver, representing
the visualization and exploitation of a gap from a
defensive or offensive opponent.

20 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Tier 4: Accessory Assessments
Rehabilitation provides an opportunitity to improve and restore capacities from other regions to make a
more well-rounded athlete and decrease potential injury risk.
Below are assessments practitioners may consider assessing as calf MTU synergists and accessory
assessments and benchmarks.

Synergist Function with

Muscle Group Benchmark Metric
Calf MTU
Acceleration, deceleration and COD
Knee Extensors performance
>3.0Nm/kg BW (Isometric)

>1.5Nm/kg BW (Isometric) or
Knee stability in sprinting and knee
Knee Flexors flexor agonist
NordBord nordic < 10% asymmetry
and >350N

Synergist in
Hip Extensors high-speed acceleration
>3.0Nm/kg BW (Isometric) *

Greater calf strength reduces hip-

Hip Flexors flexor demand in running
>1.6Nm/kg BW (Isometric) *

Pelvic drop is seen in AT

and hip abduction is related 4.0N/kg
Hip Abductors to calf performance in Supine, hip and knee at 90°
sidestep-cutting maneuvers

Ankle Invertors and Ensures multidirectional Eversion: 24Nm

Evertors ankle strength Inversion: 14Nm
* Tested in supine, 60° of hip flexion, 90° of knee flexion

Common ratios comparing standing plantar flexion MVIC and a standing Knee Iso-Push range
between 0.7-0.8.
Ratios below 0.7 may call for more calf training, while those above 0.8 may require increased
quadriceps work for better load sharing during high-intensity activities.

Practitioner’s Guide to the Calf & Achilles Complex | 21

Back to Contents
Applying Assessment Methods
Tools like ForceDecks, ForceFrame and DynaMo provide objective data to identify calf MTU
deficits, streamline return-to-play and optimize performance outcomes. By leveraging these insights,
practitioners can seamlessly integrate injury prevention and performance enhancement into
care strategies.

Screening for Injury

Modern injury screens rely on objective technology to assess risk factors like reduced plantar flexion
MVIC, associated with conditions such as AT and CMSI.

Simple assessments – like seated plantar

flexion MVIC jump testing and hop testing
– offer insights into isolated and integrated
lower-limb function.
Comparing against population benchmarks
provides a starting point for determining
potential injury risk in uninjured populations.

Expert Tip:
For athletes with a history of calf MTU injury, returning
to pre-injury strength levels is the minimum standard.
In these scenarios, practitioners should aim to build
surplus performance qualities to counter the high risk of
recurrence.

Matt Witt
Physical Therapist, VALD BDM

22 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Benchmarking for Performance
Performance benchmarking uses quick, targeted assessments to profile individuals or groups
and inform training plans. Metrics like seated plantar flexion peak force, CMJ P2 concentric
impulse asymmetry, DJ RSI and peak landing force offer actionable insights. Additionally, dynamic
assessments, such as sidestep-cutting drills with timing gates, can effectively evaluate calf MTU
function in sport-specific contexts, enhancing training and performance strategies.

Team Average
Injured Side
Uninjured Side

Practitioner’s Guide to the Calf & Achilles Complex | 23

Back to Contents
Strength Domains
Measurements of maximum strength, explosiveness and reactive strength capture specific
abilities, categorized as individuals’ “strength domains.” Understanding these domains in calf MTU
rehabilitation is important for comprehensive assessment and reducing redundant data in complex
injury management.
Geneau et al. (2024) identified four strength domains relevant to sports performance and
rehabilitation, applicable to the entire body.
• Dynamic Timing: Measured through tasks • Dynamic Force: Captured through loaded
like the CMJ, where metrics that assess dynamic and explosive movements, this
jump strategy may be critically important. force relates to an athlete’s ability to
• Reactive Strength: Involves the SSC, produce fast and moderate-speed forces.
highlighting an athlete’s ability to • Isometric Strength: Often measured via
transition quickly between eccentric and MVIC, this provides a snapshot of maximal
concentric phases. strength capacity.

Domain ForceDecks Assessment Related Metrics

Concentric Impulse
Dynamic Timing CMJ
(P1 and P2)

DJ
Reactive Strength RSI
(30cm/12in and 45cm/18in)

Loaded CMJ
Dynamic Force Jump Height
(+20kg/44lb, +40kg/88lb, +60kg/132lb)

Isometric Seated Plantar Flexion MVIC or Force at 200ms

Strength Ankle Iso-Push Net Peak Force

24 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Management
The calf MTU contributes to nearly every ambulatory activity, both sporting and recreational. Fully
restoring and rehabilitating this area is crucial to prevent compensatory patterns that could lead to
re-injury or new injuries.

Early Phase Management

Early phases of calf MTU rehabilitation share similarities with other injuries:

• Prevent further structural damage;

• Minimize negative effects of the healing process (decreased ROM, weakness and atrophy);

• Create an effective therapeutic loading environment; and

• Educate stakeholders on expectations for the rehabilitation process.

By integrating technology early on, practitioners can track progress and adjust a greater level of detail,
further optimizing the rehabilitation process.

Technology in Early Rehabilitation

Technologies like ForceDecks and ForceFrame are not reserved for elite athletes’ performance training
or late-stage return-to-play. These tools are just as impactful during the early phases of rehabilitation.
From biofeedback with ForceDecks to reliable ROM assessments with DynaMo and HumanTrak.
Technology allows practitioners to load efficiently and effectively within safe guidelines for tissue
healing, optimizing the early-stage recovery process. Here are some early loading and assessment
strategies to accelerate recovery from calf MTU injuries:

Balance Testing and Training

Quiet stand, single-leg stand and range of stability
assessments are valuable for practitioners to
measure and address any proprioceptive or balance
impairments present. Low-Load Isometric Training
Customizable training programs allow
practitioners to safely begin loading the injured
tissue, minimizing strength and hypertrophy loss
within athlete tolerance and medical clearance.

ROM Tracking
Technologies like DynaMo and HumanTrak enable
simple and reliable ROM assessment. Practitioners
can ensure early ROM goals are being met with
consistent assessment. Accessory Muscle Training
Large synergists like the quadriceps, hamstrings and
glutes, along with ankle invertors and evertors, are key.
High-load isometric training for these accessory muscles
can boost strength, buy-in and athlete engagement by
keeping intensity high in unrestricted tissues.

Practitioner’s Guide to the Calf & Achilles Complex | 25

Back to Contents
Middle Phase Management
The middle phases of rehabilitation often feel slow and tedious for individuals recovering from injury.
Although the calf MTU may no longer be painful and individuals may start to feel “back to normal,”
cautious progression is advised.
Technology offers an objective way to show clients their true progress and keep them engaged
during this stage. While the specifics may vary by athlete and injury, middle-phase rehabilitation
typically includes:

• Calf strength and endurance training

• Locomotive and early plyometric drills
• Running reconditioning

Calf Strength and

Endurance Training
High force demands are placed on the calf MTU
even at slow running speeds, therefore, restoring peak force production to benchmark levels is best
before returning to run.
Peak force asymmetry is helpful, but absolute performance should be compared to robust datasets
like VALD’s Norms as well. O'Neill et al. (2019) found that even the unaffected calf in individuals with
Achilles tendinopathy (AT) produces significantly less peak force than age-matched controls.
Mid-phase rehabilitation should also emphasize loaded and bodyweight heel raise endurance. Accurate
heel raise benchmarking requires strict adherence to execution standards:

• Begin at a 10° dorsiflexion deficit

• Maintain heel height for each rep
• Maintain a 1010 tempo
• Keep knee fully extended
• Limit upper extremity support

Plantar flexion peak force assessments immediately after a maximal heel raise test may provide
indicator of fatigue response in those returning from calf injury. Sara et al. (2021) identified up to 20%
peak force deficits post-endurance testing, providing a benchmark to distinguish normal and abnormal
responses to fatigue during calf MTU rehabilitation.

…in those returning from calf injury…

Sara et al. (2021) identified up to 20% peak force deficits
post-endurance testing

26 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Locomotive and Early Plyometric Loading Drills
Returning to running is a key milestone in lower-extremity rehabilitation. Ankle horizontal power –
critical for running, jumping and cutting – is a primary focus during this phase.
For practitioners without access to advanced technology, traditional strength training drills can still
provide valuable insights and effectively target horizontal loading:

• Penguin walks • Step-ups

• Frontal plane push-offs • Forward pogos

• Sled or prowler pushes • Single and continuous bounds

Integrating exercises like penguin walks, marches, dribbles and heavy sled work effectively targets
the calf MTU with running-specific loads. When paired with objective assessments such as jumping,
hop tests, isometrics and single-leg jumping, practitioners can uncover critical deficits often missed in
traditional evaluations.
This comprehensive approach ensures clients are better prepared for an optimized return-to-run and
return-to-play process.

Return-to-Run Decision-Making

Achieve Accepted Strength Threshold

• Seated Plantar Flexion MVIC

• Run-Specific Ankle ISO-Push

• Loaded Strength Assessments

Tolerant of Repeat Hopping

• 10-5 Hop Test

• 60s Hop Test

• Countermovement Rebound ump

Absence of Other Clinical

Signs and Symptoms

• Weight bearing
dorsiflexion assessment

• Pain with Walking

Image adapted from Green et al. (2022)

Ready to Begin Running

Practitioner’s Guide to the Calf & Achilles Complex | 27

Back to Contents
Running Reconditioning
Restoring qualities like peak force and strength endurance is essential when returning to running, as the
soleus experiences about 85% of a healthy athlete’s peak force during running. Due to these high-
loads, the running reconditioning process for calf MTU injuries differs from typical protocols.

Key guidelines for calf MTU reconditioning include:

Image adapted from Green et al. (2022)

Research suggests volumes and intensities may

be effective for early run conditioning, but clinical
judgment and athlete feedback remain critical for
individualized programming.

Modern speed technologies such as SmartSpeed

offer real-time training data such as average
speed and split times, allowing practitioners
to monitor performance at each stage of the
reconditioning process.

28 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Late Phase Management
Late-phase management focuses on fully restoring the physical qualities essential for sport – such
as peak force, RFD and reactive strength – while also integrating those qualities into the dynamic and
variable movements required in sport.
In late-stage sessions, return-to-play practitioners likely have a few key qualities to restore:
• Unilateral plyometrics and reactive strength

• Sprint restoration and repeat sprint ability

• Peak force endurance and recovery

Unilateral Plyometrics and Reactive Strength

Unlike other lower body structures, the calf MTU relies on fast-twitch isometric contractions,
emphasizing reactive strength in sporting contexts.
Given that many athletes have a preferred jumping limb, relying solely on limb symmetry during
unilateral reactive strength assessments can be misleading. Instead, establishing benchmarks and
thresholds based on age-matched normative data (e.g., VALD’s Norms) for metrics like RSI, peak
power and peak drive-off force provides a clearer picture of performance-related readiness.

Metric Spotlight: Displacement at Takeoff Asymmetry

Description and Insights:

With proper execution of the SLJ assessment, comparing the
displacement at takeoff asymmetry can provide insights into
“toe-off” mechanics between limbs. Greater displacement
may indicate a better use of plantar flexor power during
the jump.

Tracking these values over time,

along with calf MTU capacity
measures like peak force or RFD,
helps practitioners evaluate reactive
strength gains.
This approach clarifies whether
improvements reflect true capacity
increases or compensatory
strategies from muscles like
the quadriceps. Sample regression plot of plantar flexion peak force (Y-axis) and single-leg RSI (X-axis) with
"good" correlation.

Practitioner’s Guide to the Calf & Achilles Complex | 29

Back to Contents
Return to Sprinting and Repeated Sprint Ability
Restoring an athlete’s top speed and repeat sprint abilities is crucial for returning to pre-injury
performance levels.
Top speed refers to the maximum velocity achieved during maximal effort sprints, which is vital in
sports like track and field. However, many coaches also prioritize Repeated Sprint Ability (RSA) – the
capacity to perform short sprints (2.5-5s) with brief rest periods (10-60s).

Maximum Maximum
Velocity Soccer Velocity Tennis
Change of Acceleration
Soccer is a highly reactive and Change of Acceleration
Tennis is a fast-paced sport,
Direction Direction
dynamic sport with high volumes constrained by a small court size.
of curvilinear running, endurance This requires athletes to have elite
and change of direction tasks with a acceleration, deceleration and
Deceleration Curvilinear
large field that allows for maximum Deceleration Curvilinear
change of direction capabilities.
Speed velocity breakaway plays. Speed Tennis has low speed endurance
demands and it almost never
Speed Speed
Endurance Endurance requires maximum velocity.

Maximum Maximum
Velocity Baseball Velocity Track
Change of Acceleration
Baseball is a slightly less reactive Change of Acceleration
Track sprinting is incredibly velocity
Direction Direction
sport compared to soccer or and acceleration dominant with very
basketball due to slower pace and little need for change of direction
general sport demands. It has a or deceleration capacities, speed
Deceleration Curvilinear
high demand for curvilinear running, Deceleration Curvilinear
endurance and volume of curvilinear
Speed acceleration and maximum velocity Speed running is event-dependent.
with occasional change of direction
Speed Speed
Endurance demands during fielding. Endurance

Maximum
Velocity Basketball
Maximum
Velocity
Hockey
Due to the sporting environment
Change of Basketball is a reactive sport with Change of (ice), hockey has unique
Acceleration Acceleration
Direction Direction
moderate volumes of curvilinear demands that focus on skate
running, high demands for acceleration, change of direction
acceleration, deceleration and and deceleration requirements to
Deceleration change of direction tasks due to it’s Deceleration optimize performance. Curvilinear
Curvilinear Curvilinear
Speed smaller court size compared to a Speed running, maximum velocity and
soccer field. speed endurance often take a
Speed Speed
Endurance Endurance
secondary role.

RSA is typically tested using timing gates, such as SmartSpeed, with interval drills designed to assess
and improve this ability. At least two gates are required for athletes to sprint between repeatedly.

20 Meters
(21.87 Yards)

Recovery:
• Fixed Duration (or)
• Fixed Time

30 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
The distance between timing gates is typically set at 20m (or 20yd) but can be customized. Intervals
are set in two common formats:
• Fixed Recovery: The athlete rests for a set • Fixed Duration: Each interval, including
time starting immediately after completing the sprint and rest, fits within a fixed time
a sprint. For example, a 20s rest begins as frame. For example, in a 30s interval, if the
soon as they pass through the gate. sprint takes 10s, the athlete has 20s to rest
before the next sprint.

This flexibility allows practitioners to tailor drills to the specific demands of the athlete’s sport, position
and individual needs.

This flexibility allows practitioners to tailor drills to the

specific demands of the athlete’s sport, position and
individual needs.

Peak Force and Endurance Recovery Monitoring

Current evidence on calf MTU injuries, such as AT and CMSI, highlight the importance of maintaining
peak force and heel raise endurance throughout rehabilitation and Return-to-Play. These metrics
can be combined with pain and soreness reports to monitor an athlete’s tolerance to prior sessions
or competitions.

Peak Force Recovery Endurance Recovery

Pre-Injury

Rehabilitation

Return-to-Play

Return-to-Play

Post-Injury Rehabilitation
Pre-Injury

Pain and fatigue inhibit force production; therefore, individuals may show reduced performance in post-
practice or post-match assessments.
Although specific recovery benchmarks for calf MTU are lacking, large deficits exceeding 20% in peak
force or endurance (e.g., number of repetitions) during early return-to-sport phases may indicate poor
fatigue resistance.
This could heighten the risk of reinjury, as soleus strains – the most common CMSI – often occur in
the second half of matches, suggesting a fatigue-related mechanism.

Practitioner’s Guide to the Calf & Achilles Complex | 31

Back to Contents
Case Study

Team Sport – CMSI

Lila Sage is a collegiate basketball player who

has been playing through considerable left calf
discomfort, which she reports as “6/10 painful
soreness in the second half and after games.”
This issue has progressed over the last 6 days
after an extended practice of acceleration,
deceleration and COD drills.
After a brief screen Lila shows a 21% asymmetry
in P2 concentric impulse from CMJs and SJs.
This information, in combination with significant
increases in pain and soreness, triggers the team
to evaluate and treat Lila’s left calf pain. Lila's
athletic trainers suspect a soleus muscle strain.

Phase 1: Early Load and Remodeling

After testing Lila's maximal pain-free plantar flexion strength on ForceFrame, she begins training mode,
set at 80% of her maximal tolerance (400N) for 5 reps of 4-second holds, repeated 3 times to promote
load tolerance and tissue remodeling.
She continues to perform high-load isometric
training for her quadriceps and glutes on
ForceFrame and performs eccentric training of
her hamstrings on NordBord Training mode
throughout rehabilitation. She is allowed to
practice ‘spot-up’ shooting, free throws and ball-
handling during this phase.

Phase 2: Maximal Force and

Strength Endurance
After three days of performing the prescribed
training mode, Lila reports reduced pain and
progresses to heavier isometric loads. Lila
produces 1.2 x BW net force during the Ankle
Iso-Push on ForceDecks (compared to 2.1xBW on
her right).

32 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
As a test of strength endurance, Lila's trainer prescribes a maximum effort bout of single-leg heel
raises, immediately followed by a maximal effort Ankle Iso-Push to compare her maximal effort force
production under fatigue to her "fresh" performance. After performing 13 heel raises on her left and
24 on her right, Lila registers a 0.85 x BW (30% deficit) ankle Iso-Push on her left and 1.85 x BW (12%
deficit) on her right.
Lila is encouraged to work on both isometric endurance training through Training Mode and heel raise
endurance while progressing through side-shuffling and predicted defensive drills on the court.

Phase 3: Plyometric Loading

3 days after her strength endurance assessment (12 days post-injury), Lila begins short ground
contact, low-amplitude pogos to improve plyometric capacity in her calf. ForceDecks hop testing
reveals a 17% average drive-off force asymmetry. This encourages Lila’s team to continue focusing on
rapid isometric force production during rehabilitation.
As Lila progresses through her plyometric training, her confidence and symmetry improve.
Lila is cleared to begin performing 50% effort accelerations to the rim and perform uncontested layups
as part of on-court training.

Phase 4: Locomotive Reconditioning and Return-to-Play Monitoring

After seated and standing peak forces have returned to within 10% of her right calf, Lila is cleared by her
training staff to go through the last stage of her return-to-sport assessment: acceleration and maximal
speed testing with SmartSpeed.
Lila passes her ¾-court sprint test with a time of 3.5s, reporting 0/10 pain and no residual soreness
throughout the day.
As Lila returns to full practice and minutes-restricted gameplay, she agrees to undergo 2x weekly jump
testing and 1x weekly plantar flexion strength testing to monitor her performance with increasing work
demands.

Injury Onset Clinical and Functional Progression Medical to Performance Model Shift Injury Prevention

Foundational lower limb function

Loaded Strengthening

Loaded Power, Plyometrics and Ballistics

Locomotion

ATHLETE MONITORING

Acute Injury Early Rehab Intermediate Rehab Return to Training Return-to-Play Post Return-to-Play
• Prevent • Actively resolve • Sustained resolution • Reintegrate full • Return to elite stan- • Mitigate risk of
further damage symptoms of clinical signs with training loads over > dard of performance adverse events during
and impairments progressing intensity 1 session during practice and the ‘high-risk’ window
• Leverage technology play with no adverse
for effective therapeu- • Redevelop function • Return to running • Prioritize sports events at RTP • Transition to ongoing
tic loading early (e.g., and capacity through related calf qualities injury prevention
Training Mode) maximal strength and • Progressive rate of (strength, endurance, • Balance exposure model involving
strength endurance loading while building power, plyometrics) between on-field individualized athlete
• Normalize gait volume and intensity (sport-related) and profiling, monitoring
(if relevant) • Progress basic loco- of plyometrics and • Reintegrate running off-field (gym or thera- and loading for
motion (stair climbs loaded strengthening fitness, volume py-related) activities optimized outcomes.
• Educate and inform and walking) and intensity of
stakeholders on running activities.
criteria based • Address other mod-
progressionsendur- ifiable factors in calf
ance demands and it MTU rehabilitation
almost never requires
maximum velocity.

Graphic modified from Green et. al, 2022

Practitioner’s Guide to the Calf & Achilles Complex | 33

Back to Contents
User Spotlight
Royal Ballet: Profiling with ForceDecks
The Royal Ballet, one of the world’s largest ballet companies, employs
over 100 dancers and stages roughly 140 performances annually at the
Shane Royal Opera House during its 10-month season.
Kelly
Like many sports, classical ballet carries a significant risk of injury. To
support their dancers, the Royal Ballet has a dedicated healthcare team,
Ballet Healthcare, which employs advanced injury and illness management strategies typically seen in
elite sports.
Classical ballet, a highly choreographed art form dating back to the 17th century, demands a blend
of strength, explosive power, muscular endurance and neuromuscular control. Among its most
demanding skills is jumping, identified as a leading cause of injury in professional ballet.
Research shows that during a 75-minute ballet class, male dancers average 153 jumps, while females
average 119. Workloads can reach 500-600 jumps daily for male dancers. To monitor performance and
injury risk, the Royal Ballet regularly profiles its dancers using tests such as CMJ, single leg CMJ and
the 10:5 Hop Test.
Since 2020, the Ballet Healthcare team has used ForceDecks for jump profiling, allowing them to
establish reliable company norms and better understand dancers’ capacity to meet ballet’s physical
demands. With limited research on normative jump data in ballet, the Royal Ballet’s use of ForceDecks
offers valuable insights into advancing the art form.

Normative CMJ scores Normative Single-leg CMJ scores

for males and females at from the Royal Ballet
the Royal Ballet

34 | Practitioner’s Guide to the Calf & Achilles Complex

Back to Contents
Normative 10:5 performance from dancers of the Royal Ballet

Royal Ballet uses custom dashboards to monitor all of their key performance metrics.

Key metrics we profile are jump height, landing forces and LSI for the CMJ and RSI and limb symmetry
index for the 10:5. We have decided as a team to keep the metrics simple, as they have proved over
time to be reliable and detailed enough to inform practice.
We use this data to inform dancers of their athletic and artistic development as they progress through
their careers. We also use this data in a rehabilitation setting where we can use their baseline profiling
data to provide us with rehabilitation goals and indicate readiness to train.
The use of force plates is relatively new in a classical ballet setting. However, we have found that the
dancers have embraced the technology and the power of numbers is a language we all share and buy
into. ForceDecks have enabled us to speak to the dancers in a way they have not heard before.

Special thanks to:

Gregor Rosenkranz,
Senior Strength and Conditioning Coach, Ballet Healthcare,
The Royal Ballet, London

Royal Ballet dancer performing CMJ assessment with ForceDecks

Practitioner’s Guide to the Calf & Achilles Complex | 35

Back to Contents
What’s Next?
VALD’s Practitioner’s Series offers in-depth insights for performance and health practitioners
to improve their knowledge in technology-assisted training, testing and integration of
modern technologies into practice. For more reading and information, check out the VALD
Practitioner’s Intermediate Guide to Force Plates, Practitioner’s Guide to Speed and Isometrics.

However, VALD is far from the only resource for performance, health and technology knowledge. Check
out some of the phenomenal practitioners that are pushing our industry forward:

Practitioners Worth Following

Seth O’Neill Alex Natera
Lecturer, University of Leicester Performance Science Manager

Colin Griffin
Dylan Carmody
Rehabilitation Specialist at UPMC Sports Surgery
Physical Therapist, VALD CSM
Clinic / UPMC Institute for Health, Ireland

Rich Willy Be sure to check out:

University of Montana / Montana Running Lab

VALD Webinars
36 | Practitioner’s Guide to the Calf & Achilles Complex
Back to Contents