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Botulinum Toxin-A: exercises calf muscles fact sheet

Botulinum Toxin-A: exercises following injection into calf muscles

About the calf muscle

The calf muscle is made up of two muscles. The gastrocnemius is the big calf muscle that can be seen on the outside of the lower leg. It starts behind the knee on the thigh bone and connects to the achilles tendon which attaches to the heel. It can affect the position of the knee and the ankle because it crosses both joints. The second muscle, the soleus is not visible when looking at the body from the outside as it lies underneath the gastrocnemius on the back of the lower leg.

The gastrocnemius raises your heel to help you go up on tip toes. The soleus acts in a similar way, working when your knee is bent.

Signs your child has a tight calf

  • Tip toe walking (difficulty getting the heel down)
  • Toe dragging or catching on the floor when walking
  • Difficulty putting on their AFO or discomfort/pain while wearing the AFO
  • Frequent falls or difficulty walking due to poor balance
  • Pain or discomfort in their foot or ankle
  • Increased difficulty with physical skills such as jumping, hopping, kicking a ball
  • Difficulty walking or running and getting tired quickly

Calf muscles are commonly injected with Botulinum Toxin-A injections and the following exercises will help to make the most of this treatment.

Serial casting

Serial casting of the calf muscles is often done after BoNT-A injections. The muscle is relaxed and this provides a good opportunity to stretch it for a prolonged period. The physiotherapist will assess your child’s calf muscle length and walking pattern to evaluate whether casting may help your child.

Serial casting involves placing one or both of your child’s lower leg (below knee, including the ankle) into a cast from one to four weeks. The time each individual cast is on can vary from 4-7 days, depending on the amount of muscle tightness and stiffness. After this time, the cast is removed, your child’s foot is assessed and another cast may be applied if needed to gain more length in the calf muscle.


Why stretching is important

Your child may have shortened calf muscles because of spasticity, limited movement or long term muscle tightness.

Spasticity is caused by the brain sending too many messages to the muscles telling it to tighten. Tight calf muscles make it difficult to place the foot flat on the floor. To stretch your calf muscle, you should have a straight knee and your ankle must dorsiflex (bend upward), bringing your feet up towards the shin bone.

The goal is to achieve a foot that can contact the ground with the heel first when walking or be maintained in a good position when sitting.

How to stretch

Short stretches of 20-30 seconds help to mobilise the calf muscle. To lengthen a muscle, they need to be stretched in a position for long periods of time, between two and six hours in total every day (using a variety of positions, splints and AFOs).

Stretch positions can be held while watching TV, or playing games on the floor. Stretches can be done at regular times in the day e.g. first thing in the morning and/or before bed.

Stretching exercises

Slope board

Standing on a slope board is an excellent way to stretch the calf muscles. Stand with knees straight and heels flat on the slope board and try to keep the toes pointing outwards slightly. If your child has leg wraps, these can be worn during this exercise.

Standing on the slope board for approximately 30 minutes once or twice a day will give them a good stretch. Reaching for objects at different heights when on the slope board is also good as it helps with weight shift and trunk muscle strengthening.

Stair stretches

Stand on the bottom step with your child’s ball of the foot on the edge of the step with the heels off the edge. Ask them to hold on to the rails or the wall. Make sure your child’s toes are pointing forwards. Keeping their knees straight, ask them to drop their heel towards the floor. Hold for 20-30 seconds. Repeat 5-10 times.

Wall stretch / lunge

Ask your child to stand in a stride position (1 leg in front, 1 leg behind) facing a wall. Lean hands into the wall keeping trunk and back leg straight and the front leg bent. To stretch the back leg, the heel should be down and toes pointing forward. Hold the stretch for 20-30 seconds and repeat 5-10 times.

Your physiotherapist will advise you if your child needs to wear their AFO for calf stretches.

Other activities to assist stretching

  • Swimming
  • Kicking
  • Sit to stand
  • Squatting (toes facing forwards, heels down)
  • Walking up hills or driveways
  • Wearing AFOs
  • Walking backwards
  • Heel stomping

Strengthening calf muscles

Why strengthening is important

All children with a diagnosis of cerebral palsy have some degree of muscle weakness. Strengthening exercises help to reduce underlying weakness in children with spasticity. Therapy will help to improve your child’s strength and improve functional abilities. However, to see genuine and long lasting improvements, your child’s therapy program must be supported in the home environment as well.

Your therapists will assist you by providing home exercise programs and activities, individualised for your child.

How to strengthen calf muscles

Any activity that involves pushing off with your toes works your calves. This may include pushing a skateboard, walking, running, climbing, hopping, walking through sand, jumping, dancing and swimming (especially freestyle kicking or use of flippers).

Strengthening exercises

Standing calf raises (gastrocnemius)

  • Ask your child to stand on a bottom step with their heel off the edge.
  • Slowly raise up on to the ball of the foot. Hold for 3-10 seconds.
  • Your child’s physiotherapist will tell you how many times to do this exercise.

Seated calf raises (soleus)

  • Ask your child to sit on a chair and raise up onto their toes. This is a gentle exercise that will strengthen the soleus muscles. Resting a weight or heavy book on the knees will increase the resistance.

Contact us

Queensland Paediatric Rehabilitation Service
Queensland Children’s Hospital
Level 6, 501 Stanley Street, South Brisbane 4101
t: 07 3068 2950
t: 07 3068 1111 (general enquiries)
f: 07 3068 3909

In an emergency, always call 000.

If it’s not an emergency but you have any concerns, contact 13 Health (13 43 2584). Qualified staff will give you advice on who to talk to and how quickly you should do it. You can phone 24 hours a day, seven days a week.

Resource No: FS196. Developed by the Queensland Paediatric Rehabilitation Service, Children’s Health Queensland. Updated: August 2015. All information contained in this sheet has been supplied by qualified professionals as a guideline for care only. Seek medical advice, as appropriate, for concerns regarding your child’s health.