Yep. This is why a GOOD (emphasize) PT is worth their weight in gold. They can also guide your return by safely testing your injury status and progressing your recovery/return to activity accordingly with appropriate exercises for what stage you are at and what the calf can take on at each follow-up.
Your posts are interesting...
Because frequent re-occurrence of this particular injury is what put me out of running.
I am also a PT... and while maybe not a good one... I had access to treatments and modalities...and exercise programs... but none of it kept this from happening every year or two... which would put me out of running for a couple of months. Towards the end it was happening frequently and I switched to full time cycling.
I say all this to say that I am pretty convinced that I had... and most people who can't shake this.... have Posterior Compartment Syndrome as opposed to a standard calf strain or tear.
This was decades ago for me... but I would recommend these days that if a person keeps getting this... that they consider a fasciotomy of the posterior compartment.
Data indicates that it is only about 50-60% successful in runners... But it isn't a dangerous or complicated surgery.
PT is fine if it works... but if it doesn't... that is what I would recommend.
I find your post interesting as well regarding posterior compartment syndrome being in the differential dx. There should be some pretty stark differences in how the two conditions present, however. The calf heart attack starts as a sudden, sharp, relatively localized zing that continues to be painful at the injury site afterwards for at least a couple of days but maybe a bit longer depending on the severity, whereas an exertional compartment syndrome is not focal and symptoms gradually build up over a short period while running, then completely resolve relatively shortly after cessation of activity, with swelling gradually resolving shortly thereafter as well, whereas with the calf strain, swelling persists and feels tight/full in the posterior compartment for a good 24-48 hrs or more, severity dependent. ECS will also typically have neurovascular symptoms that develop and extend into the foot during the activity due to pressure on the nerves and blood vessels adjacent to the compartment but resolve shortly thereafter when swelling deminishes.
I used to get these about twice a year and it would keep me from running well for weeks and months. I tried PT a couple of times which didn't work well for me. I did deep tissue massage therapy and that worked for a time. I've been doing chiropractic care twice a month for the last decade or so and that really helped. The chiro I go to thinks that the nerves were misfiring causing my calf to seize up. I also had a pretty severe Ieft shoulder droop that he fixed up. I haven't had one in a long time. I don't wear compression socks any longer for runs. I don't do a ton of stretching. I recently started getting acupuncture as well. It seems to keep things good for me and loosens up my ankles. I'm turning 60 this year so anything I can do to keep running, I'm willing to try.
I don't usually post at all, but I wanted to help the OP and others: I struggled with calf heart attacks for several years, dozens of times, exactly as described by the OP.
I tried all sorts of stretches and strengthening exercises, changes in running form, and calf sleeves. They all seemed to help slightly.
But the one thing that actually solved the issue for me was daily ice baths. I bought a plastic tub from the hardware store, big enough to submerge both calves entirely, just below the knee. Fill it with ice water and soak for 12-15 minutes each day. This is not just recovery, but prevention. Do it before you get your next calf heart attack.
I dealt with this on and off for at least five years. It was so frustrating I almost quit running altogether. In my case, the only thing that solved it was weekly PT with dry needling and electric stim. After about three months of needling I was fine and haven't had an issue with it in 6+ years.
This issue with my chronic calf issues were the shoes I was wearing at work.
I previously had been running 100 mile weeks (high of 132) including many races, track, road, and 36 marathons and never had issues with my calves, with 2 exceptions.
When I went out for track in 10th grade, I was doing well and started to do calf raises at home. Then when I went to track practice my calves were so tight and painful that I was not able to run at all for several days. I stopped doing them then won the league 880 finals which was a big event for me.
The second time was in my mid 50s. I was running 70 miles a week, and my calves would seize up in the middle of runs and I'd have to walk home, sometimes several miles and it was quite frustrating. I figured the problem was my shoes, and it was.
I cut out the heels of the shoes, glued in 1/4" slabs of wood, let them dry and then started running in those. They were awesome. Within a few days I went out for a 10 mile run and blazed right through at a relatively good pace. I kept wearing them and had no more issues with my calves. The problem was the shoes, and the solution was firm heels.
The heels did make a clack clack sound from the wood, but other then that they were fine.
Wouldn't it have been more simple to insert an insole with built-in heel pad? You can also put in cork heel inserts under the insole for firmness.