Knee Pain: Why You Should Be Doing Calf Rehab With Every Patient

Posted By: Andy Barker

One of the most common struggles New Grad therapists talk to me about regarding knee pain, is that patients often are doing well, until…

They go back to higher-level activities like the gym, running or sport.

Once activity levels are increased their pain returns and they feel like they are back to square one.

This is a common pattern New Grad’s talk to about and leaves them and their patients feeling frustrated and sometimes lacking confidence and questioning whether they will ever be able to return pain-free to those higher-level activities.

I had a client this week on an online appointment who had had a 3-year history of on-off knee pain.

He was a keen runner but had lost all hope that he would ever be able to get back to running as he had been working hard for over 3 years, resting, doing all his rehab and everything he was told to do, but it wasn’t working.

He would get injured, rest his knee, then get back into his rehab, build himself back up and for a little while he would be ok.

But when he stepped up the miles on the road or tried to run a little faster then his symptoms would quickly return.

However, after 3 sessions he is already very close to a return to running and I am confident that he will NOT break down again.

Most of his ‘knee’ rehab has in fact been ‘calf’ rehab.

Once you understand the importance of the calf and its role in knee biomechanics then you will understand why this has been so effective and why you also be considering using calf rehab with every knee pain patient you see.

Knee Biomechanics: The Role Of The Calf

Firstly, it is important to understand the role the calf has with knee function.

The calf is not just an ankle muscle.

The gastrocnemius attaches to the femur and as such is a two-joint muscle, working at both the ankle and the knee.

It contributes to ankle plantar-flexion and works as a knee flexor.

If we look at walking the gastroc will be working to plantar-flex the ankle during toe off.

At the same time the knee will be extending.

We spoke above how the gastroc is a knee flexor so you might think that during toe-off the gastroc at the knee wouldn’t be doing too much.

However, it plays a really important role in its action to control knee extension.

The gastroc will be working eccentrically as the knee extends to control this movement.

Poor control of this motion is often seen in patients with knee pain as their knee snaps back in walking, running and other movements like a squat or lunge.

Hamstring & Calf Working Together

We know muscles don’t just work in isolation and the calf is no different.

At the knee, the gastroc muscle will overlap with the distal hamstrings and both these muscles contribute to knee flexion.

Their ability to work together is key, to provide stability to the back of the knee and allow the knee to function well.

If these muscles are not doing there job well then other structures will have to take up the slack and work harder.

In knee pain patients this is usually the quad muscles.

The quads overworking puts additional load through the front of the knee and gives rise to problems at the patella or quad tendon, patella-femoral joint, fat pad and other anterior knee issues, the most common site of knee pain.

The patient I mentioned earlier had this issue.

His calf was underworking, and his quads were overworking.

By giving him calf exercises we were able to take his knee pain away immediately and have been able to progress his rehab quickly and without problem.

Had we have given him traditional knee rehab we would have likely been overloading tissues that were already overworking.

This is a common pattern with knee pain patients and is the reason why many knee pain patients do not make the progress you think they should with traditional knee rehab.

NOT A Calf Raise In Sight

We didn’t however use any traditional calf exercises like calf raises or donkey raises.

Whilst we identified this patient had a calf issue and we know these muscles are important to provide stability to the knee and can reduce loading through other overworked areas of the knee, it is not quite as easy as just giving calf or hamstring strengthening exercises.

The key is activating the right muscles and using these muscles in positions they are used in real life.

We did this using a standing calf drill during this first session and a wall calf drill during his second session that mimicked his walking and running position.

By putting him in this position we are giving him no option but to use the right muscles for the right job.

Secondly, it allowed an easy transition from rehab into function.

He was recruiting the right muscles during his rehab exercises which then he can use during the rest of his day, for example when walking.

This results in a quicker improvement in symptoms, function and progress with his rehab.

Where possible we always want patients to rehab in positions that are as close to their desired goal, in this example running, as possible.

This may sound new to you but if it is something that you find interesting, you will get great value in my upcoming New Grad Physio Lower Limb Course

This is a LIVE online course.

On the course I will be covering the ankle, knee, hip and lower back.

The content will help you to be able to make sense of your patient assessments and use case studies to show how to take information from your subjective and objective assessments so you know exactly what treatment and rehab exercise to give to your patients.

You will learn how to better assess gait and how to use simple standing movement tests to identify what is causing your patients pain, NOT just where their pain is.

I’ll show you how to better ‘muscle test’ your patients so you can highlight issues like the calf issue my patient had above, and then what you need to do and the exact exercises you should then prescribe to fix these issues.

You will see my ‘6 Step Rehab planner.’

This is the exact system that I use for every patient I see with a lower limb or lower back injury, regardless of whether I am working with a middle aged sedentary patient in my private practice or an elite athlete at the top of their game.

To book your ticket or to find out more details visit

Any questions please let me know…

The New Grad Physio Mentor