Ankle or heel pain when doing calf raises: the Achilles, the step, a pinch at the back and cramp

What a calf raise asks of the ankle, and what no study has countedEmerging evidence

You rise onto the balls of your feet and lower again, and the big calf muscle (gastrocnemius) and the deeper soleus pull through the Achilles tendon on the heel bone. The load depends on how much of your body weight you lift and on how many legs. In one modelling study of 21 healthy men, the estimated Achilles force in a two-leg raise was about 6 times that of a seated raise, and on one leg about 13 times, roughly twice the two-leg load (our conversion from the study's figures). The authors suggest seated and two-leg raises as early steps. In 8 adults, the tendon's estimated load ran from half a body weight in a seated raise to about 7 body weights in a forward hop on one leg.

No study has counted ankle or heel pain caused by calf raises. So this map is built from what each condition is known to do, lab and modelling studies, trials of calf loading and NHS pages. Pain usually comes when a tendon or joint that is already a little sore meets more load than it is used to (our reading).

Sources 1, 2

Lowering, bent knees and the step: what the lab showsEmerging evidence

Lowering doesn't load the Achilles more than raising: peak tendon force didn't differ between the two phases in 7 and in 16 healthy adults, and in the 21 men the estimated stress was higher on the way up. Bending the knee to 45 degrees shifted calf muscle activity by only 4% to 5% in 48 adults, because the soleus pulls on the same tendon. In a modelling study of 16 people with Achilles pain and 16 without, the one-leg heel drop with the knee bent loaded the tendon most of the exercises tested, and people with tendon pain moved in ways that lowered the load; a one-person tendon model agreed. In people with Achilles pain, the soleus did about 61% of the calf's work.

So only sitting takes your body weight off the tendon. No study has measured tendon force off a step against on the floor, with added weight or at different speeds.

Sources 3, 4, 1, 5, 6, 7, 8

Why the step matters where the tendon meets the heelEmerging evidence

What a step changes is how far your ankle bends up as the heel drops. That bend presses the tendon against the back of the heel bone where it attaches: ultrasound studies show the tendon squeezed there as the heel lowers, and in insertional tendinopathy the bone presses on the tendon across more of the ankle's range. Squeezing (compression) is a recognised driver of tendon pain.

Pain within about 2 cm of the heel bone is insertional, 20% to 25% of Achilles cases; an NHS trust puts the middle of the tendon at 2 to 6 cm above the heel bone. Guidelines start insertional pain on a flat surface.

Sources 9, 10, 11, 12, 13, 14, 15

Where it hurts sorts the causesEmerging evidence

The NHS lists pain in the ankle and heel, with pain in the calf when standing on tiptoe, under Achilles tendonitis. An NHS trust says Achilles tendinopathy is most common between 30 and 60, and goes with a jump in activity, a new sport, weaker calves, long periods on your feet, diabetes, high cholesterol, inflammatory arthritis, a higher body weight and long-term steroids or some antibiotics.

A pinch deep at the back of the ankle at full tiptoe, tender in front of the tendon rather than in it, points to posterior impingement, which comes from repeated or forced full pointing: ballet, football and downhill running. A pinch at the front at the bottom of a step drop would be the front of the joint, which hurts at the end of the ankle's upward bend; that a step drop brings it on is our reading. Difficulty rising on tiptoe on one side is a key sign of the tibialis posterior tendon on the inner ankle. Nothing links the peroneal tendons on the outer ankle to calf raises, and their care starts without surgery. Calf strains are most likely with age and a past calf strain (10 studies, 5,397 athletes), and in elite Australian footballers 84.6% were in the soleus.

Sources 14, 16, 17, 18, 19, 13, 20, 21, 22, 23, 24

Cramp during calf raisesStrong evidence

The NHS lists putting too much strain on muscles during exercise among the causes of leg cramps, says a cramp lasts from a few seconds to 10 minutes and that the muscle may feel sore for up to 24 hours. A review's first recommendation is to stretch the cramping muscle gently until it lets go.

Dehydration and salt loss aren't supported as causes: the evidence for them is anecdotes, small case series and one small study, and four cohort studies don't support them. Across 9 studies (11,274 people), a past cramp raised the odds of another about 4 times, and fluid intake showed no consistent link.

Sources 25, 26, 27, 28

What a scan shows, and when it mattersEmerging evidence

An NHS trust says Achilles tendinopathy is diagnosed from where it hurts, how it behaves and what makes it better or worse, and that ultrasound or magnetic resonance imaging (MRI) scans are usually not needed.

Read reports with care. An os trigonum is in about 9% of feet (41 studies, 36,612 feet), and in 76 elite dancers and athletes training at full load, an extra bone or bony spur at the back of the ankle showed on MRI in 61.8% and fluid behind the joint in 90.8%. After a snap, a fall or with a swollen calf, the warning signs come first: if a doctor thinks you have a blood clot (deep vein thrombosis, DVT), the NHS says you should be referred for an ultrasound scan within 24 hours.

Sources 14, 29, 30, 17, 31

How it usually goesEmerging evidence

No study follows pain from calf raises. In mid-tendon Achilles pain, improvement starts from about 2 weeks of loading and most of the gain comes by 12 weeks (31 groups of people). An NHS trust says most people notice some improvement within 8 to 12 weeks, but full recovery can take several months, and NHS inform says several months or more. Five years after a heel drop programme, 39.7% of 58 tendons were pain-free and 48.3% had needed other treatment.

Posterior impingement often settles with changed training and physiotherapy: in 26 elite footballers, physiotherapy then an injection settled 18. Cramp passes in minutes. No one can promise a date.

Sources 32, 14, 33, 34, 35, 25

Calf raises are the treatment for Achilles painStrong evidence

Across 29 trials, calf exercise beat wait-and-see by about 20 points on a 100-point Achilles questionnaire at 3 months, more than the smallest change that matters (15), though most trials were at high risk of bias and certainty was low. Heavy slow calf raises matched heel drops off a step at 12 and 52 weeks in 58 people, and people finished more of their sessions (92% against 78%). Heavy heel drops were no better than other calf exercise (7 trials).

Two well-known programmes did equally well at a year in 40 recreational athletes: Alfredson's (3 sets of 15 with the knee straight and 3 with it bent, twice a day for 12 weeks, working into pain) and Silbernagel's (3 sets of 15 once a day, from two legs to one and from the floor to a step). The Dutch guideline advises progressive calf strengthening for at least 12 weeks.

Sources 36, 37, 38, 39, 15, 40, 41, 34

Pain where the tendon meets the heel: keep raises off the step edgeEmerging evidence

Heel drops below a step did well in 89% of 101 tendons sore in the middle but only 32% of 31 sore at the heel bone. Lowering only to floor level, 3 sets of 15 twice a day for 12 weeks, satisfied 67% of 34 tendons in a pilot with no comparison group. A smaller range lowered pain from 5.4 to 3.0 out of 10 at 3 months in 16 people. These are small series, not trials.

Experts rated how far the ankle bends the most important setting for insertional pain. The Dutch guideline, an NHS trust and the Silbernagel protocol all start it on a flat surface, and the protocol suggests a small lift under the heel (about 1.3 to 2.5 cm) to cut the bend.

Sources 42, 43, 44, 45, 15, 13, 14

Keep going under a pain limit: carrying on did no harmStrong evidence

In 38 people with Achilles pain, those who kept running and jumping under a pain-monitoring model did as well at 12 months as those who stopped for 6 weeks. In one trial's version, pain during activity mustn't pass 5 out of 10 and should settle within 24 hours, and in 127 people on that programme, tolerable pain below 5 out of 10 wasn't harmful to recovery. Adding injections or other treatments to exercise isn't clearly better than exercise alone (68 trials).

Sources 46, 39, 47, 48

Posterior impingement: change the pointing first, specialist care if it failsEmerging evidence

Changed training and physiotherapy come first, though no trial has tested them, and conservative care was reported for only 33 dancers' ankles, too few to judge. In 26 elite footballers, physiotherapy then an ultrasound-guided steroid injection settled 18, back training in about 5 weeks on average. When rehab fails, surgery satisfies most people (89% good to excellent in 376 dancers' ankles), and keyhole surgery got people back a little sooner than open surgery (about 9 against 11 weeks) with fewer complications.

Sources 18, 19, 35, 49

Heel raises for plantar heel pain: mixed resultsMixed evidence

In 48 people, heel raises with a towel under the toes every other day improved foot function more than stretching at 3 months, but not at 1, 6 or 12 months. In 180 people, adding the same training to advice and a heel cup made no clear difference. A guide built on 51 trials puts taping, stretching the sole and advice at the core. So the towel raise is worth trying for heel pain within the pain rule, not a cure.

Sources 50, 51, 52, 17, 53

Stretching, heel lifts and cramp drinks: smaller than claimedEmerging evidence

An NHS trust says strengthening matters more than stretching for Achilles pain, and that stretching can irritate the tendon near the heel. Heel lifts and insoles may ease symptoms, but there is a lack of high-quality evidence, and they go alongside exercise, not instead; in the lab, a lift does cut the squeeze at the attachment. Regular calf stretches may reduce cramps but may not stop them, the NHS says. For cramp, one small study found small amounts of pickle juice eased induced cramps faster, an effect not explained by its salt, and quinine and tonic water shouldn't be used for exercise cramp.

Sources 14, 9, 25, 26

Your calf raise for now (written steps)

Our 3D figure can't show how far your heel drops or how high it rises. These steps come from an NHS trust leaflet, NHS inform, the Silbernagel programme, the Dutch guideline and lab studies; where a step is our suggestion, it says so. No trial has tested a change to the calf raise for pain.

• 1. How low: heels only to the floor, or to just below the level of the step for pain in the middle of the tendon (an NHS trust). With pain where the tendon meets the heel, keep every raise on the floor, or stand on a small lift under the heel (about 1.3 to 2.5 cm) to cut the bend (the Silbernagel programme).
• 2. How high: only as high as stays free of a pinch deep at the back of the ankle (our posterior impingement guide). Rise over the big and second toes rather than rolling out onto the little toes (our calf raise technique guide).
• 3. Legs and knees: two legs before one, and seated before standing; a seated raise loads the tendon far less (a modelling study). A bent knee works the soleus but doesn't rest the tendon (lab studies).
• 4. Speed: slow, about 2 to 3 seconds up and down, with no bounce at the bottom (our suggestion).
• 5. Still holds: about halfway up, 30 to 45 seconds, 4 or 5 times, once or twice a day, on days the moving raise hurts (an NHS trust).
• 6. Weight: add it only once 3 sets of 15 pass the pain rule, about 5 kg at a time (the Silbernagel programme as one trial used it).
• 7. Volume: fewer sets for now, and no calf raise challenges or sets to failure (our suggestion).
• 8. The rest of your day: keep walking; if running hurts a lot, walk or cycle instead for a while, and break up long periods on your feet (an NHS trust; NHS inform says Achilles pain doesn't improve with rest).

Sources 14, 13, 15, 1, 5, 39, 33

Back to running, jumping, dance and the gym (written steps)

No study has tested how calf raises and sport come back after this pain, so these steps are our suggestion unless a source is named.

• 1. Running: walk-jog intervals on alternate days once hops pass the pain rule, with hills and speed last. Carrying on under the pain rule did no harm in a trial.
• 2. Jumping sports and classes: skipping and hops before jumps, and box jumps and plyometrics last.
• 3. Dance: relevé and pointe only as high as stays free of a pinch, with pointe last, as our posterior impingement guide's return-to-ballet steps say.
• 4. The gym: machine and Smith calf raises come back in stage 3, at about half your old weight, through a full but pinch-free range.
• 5. Shoes: avoid backs that press on a sore heel; a small heel lift may ease pain at the heel bone, though the evidence is thin (an NHS trust).
• 6. Keep two calf sessions a week once you're better: the Dutch guideline advises carrying on with calf exercise after recovery.

Sources 46, 15, 14