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Calf Strain in Athletes

Article in JBJS Reviews · March 2022

DOI: 10.2106/JBJS.RVW.21.00183

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Calf Strain in Athletes

Wendy M. Meek, BBA Abstract
» Calf strain is a common condition. In high-performance athletes, calf
Michael P. Kucharik, BS
strain contributes to a substantial absence from competition.
Christopher T. Eberlin, BS
» Player age and history of a calf strain or other leg injury are the
Sara A. Naessig, BS strongest risk factors for calf strain injury and reinjury.
Samuel S. Rudisill, BS
» Although the diagnosis is often clinical, magnetic resonance imaging
Scott D. Martin, MD and ultrasound are valuable to confirm the location of the strain and
the grade of injury.

Investigation performed at the » Nonoperative treatment is effective for most calf strain injuries.
Department of Orthopaedic Surgery, Operative management, although rarely indicated, may be appropriate
Sports Medicine Center, Massachusetts for severe cases with grade-III rupture or complications.
General Hospital, Mass General
Brigham, Boston, Massachusetts » Further investigation is necessary to elucidate the benefits of blood
flow restriction therapy, deep water running, lower-body positive
pressure therapy, platelet-rich plasma, and stem cell therapy for calf
strain rehabilitation.

C
alf muscle strain is one of seasonal injury incidence, defined as the
the most common muscle number of injuries per team per season, is
injuries in high-performance notable in tennis8-10 (0.3 to 0.8), calf
athletes and contributes to strains are not unique to tennis and have
substantial player downtime because of its since been reported in numerous other
high mean time to return to sport and professional and collegiate sports such as
occurrence during critical periods in the American football11,12 (seasonal injury
competitive season1-3. Published reports on incidence, 2.1 to 2.3), Australian foot-
lower-body muscle strain have provided ball 13,14 (1.8 to 2.9), basketball (1.2) 15,
frequent updates on the rehabilitation of and soccer (1.3 to 2.3) 16-20 (Table I).
high-profile muscle groups, such as the Calf injury is most prevalent among
hamstring muscles, and improvements to athletes 22 to 28 years of age, more fre-
calf strain management are seldom discussed quently affects men, and presents as a
despite the prevalence of these injuries in recurrent injury in approximately 19%
competitive sports. In this article, we discuss to 31% of cases 3,13,16,19-24. Rehabilita-
the diagnosis, treatment, outcomes, risk tion is generally conservative, with a recovery
factors, and prevention of calf muscle strain period that ranges from immediate return to
in athletes. play to multiple months of missed practice or
playing time2,3,12,13,19.
Epidemiology The risk of injury to the individual
First described in 1883, calf strain is also triceps surae muscles appears to be some-
known as “tennis leg” due to its frequent what sport-dependent. For example,
occurrence in that sport4-7. Although the isolated gastrocnemius strain is the

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JBJS REVIEWS 2022;10(3) :e21.00183 · http://dx.doi.org/10.2106/JBJS.RVW.21.00183 1

 | Calf Strain in Athletes

predominant calf strain injury in adapted for rapid contraction1,5,7,25. The otendinous junction7,28. The medial
American football, whereas isolated soleus, which contributes to plantar flex- head of the gastrocnemius is more
soleus strain is more common in Aus- ion, is dense in slow-twitch muscle fibers prone to injury than the lateral head,
tralian football (Table II)12,13,22. adapted for postural control1,2,26,27. possibly because the medial head
Moreover, gastrocnemius strain is asso- contributes more to muscle activity23.
ciated with high-intensity running, Pathophysiology Imaging studies have attributed a 2:
acceleration, and deceleration activities, Gastrocnemius Strain 1 ratio of tears to the medial head
whereas soleus strain is more likely to The classic pathogenesis of a gastroc- compared with the lateral head of the
occur during steady-state running nemius tear involves knee extension gastrocnemius30,31.
activities13. Differences between mus- with sudden ballistic foot movement
cles with respect to biomechanical func- from dorsiflexion to plantar flexion1,6, Soleus Strain
7,28,29
tion or muscle fiber profiles may . When the gastrocnemius is Soleus strain is an overuse condition
contribute to this observation13. The maximally stretched, the immediate from repetitive, passive dorsiflexion of
gastrocnemius, which flexes the leg at the contraction of the tensioned muscle the foot with the knee bent23,29. In
knee and plantar flexes the foot at the can abruptly rupture the medial head runners, this posture is observed while
ankle, is dense in fast-twitch muscle fibers of the gastrocnemius at the my- running uphill23,29. Because the

TABLE I Incidence of Calf Strains in Professional and Collegiate Sports*

Seasonal Injury Injuries per 1,000 Study

Study Study Design Sample Incidence† Match Hours Duration

American football
Mack11 (2020) Descriptive Athletes from 32 National 2.1 NA 4 seasons (2015 to
epidemiology Football League teams 2019)
Werner12 (2017) Retrospective case Athletes from 1 National 2.3 NA 12 seasons (2003
series Football League team to 2015)
Australian football
Green13 (2020) Descriptive Athletes from 16 Australian 2.9 NA 4 seasons (2014 to
epidemiology Football League clubs 2017)
Orchard14 (2013) Descriptive 4,492 athletes from the 1.8 1.5 20 seasons (1992
epidemiology Australian Football League to 2012)
Basketball
McKay15 (2001) Prospective cohort 190 elite and recreational NA 1.2 2 seasons (1991 to
Australian basketball athletes 1992)
Soccer‡
Nilstad16 (2014) Prospective cohort 173 athletes from 12 elite 2.3 2.0 1 season (2009)
Norwegian soccer clubs
Hägglund17 (2013) Prospective cohort 1,401 athletes from 26 elite 1.3 NA 9 seasons (2001 to
European soccer clubs across 2010)
10 countries
Bengtsson18 (2013) Prospective cohort 621 athletes from 27 elite NA 1.1 11 seasons (2001
European soccer clubs across to 2012)
10 countries
Ekstrand19 (2011) Prospective cohort 2,299 athletes from 51 elite 2.0 NA 8 seasons (2001 to
European soccer clubs 2009)
Faude20 (2006) Prospective cohort 143 athletes from 12 German 1.6 NA 1 season (2003 to
national league soccer teams 2004)
Tennis
Dakic8 (2018) Prospective cohort 52 athletes from the NA 4.5 1 season (2015)
Australian Open
Colberg9 (2015) Prospective cohort 58 athletes from 4 collegiate 0.8 NA 1 season
tennis teams
Winge10 (1989) Prospective cohort 89 athletes from 13 elite 0.3 NA 1 season (1984)
Danish tennis teams

*NA 5 not available. †Seasonal injury incidence is defined as the number of calf strain injuries per team per season. ‡This sport is referred to as “football”
in most countries outside the United States.

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 Calf Strain in Athletes |

TABLE II Incidence of Gastrocnemius, Soleus, and Plantaris Strains in Professional Sports*

Gastrocnemius Soleus Plantaris

Study Study Design Sample Strain Strain Strain Other†

American football
Werner12 (2017) Retrospective Athletes from 1 National Football 20 (74.1%) 4 (14.8%) NA 3 (11.1%)
case series League team for 12 seasons
Australian football
Green13 (2020) Descriptive Athletes from 16 Australian Football 17 (11.8%) 126 (87.5%) 1 (0.7%) NA
epidemiology League clubs for 4 seasons
Waterworth22 (2017) Retrospective 63 athletes from the Australian 8 (12.7%) 32 (50.8%) NA 23 (36.5%)
case series Football League for 5 seasons

*NA 5 not available. †Other includes disruptions to the tibialis posterior, peroneus longus, or Achilles tendon, as well as concomitant tissue disruption
for which a primary tissue injury was not specified.

mechanism for soleus rupture is associ- retraction1,6,7,23,28. In addition, mild to nemius and soleus occur in 17% of
ated with overuse, a soleus injury is severe ecchymosis can appear at the rup- cases1,27. Moreover, defects in the tri-
subacute, with a gradual and cumulative ture site23,28. ceps surae can present with symptoms
effect, although acute strain can mani- In contrast to gastrocnemius similar to those of thrombophlebitis,
fest in fatigued athletes23,32. strains, soleus strains are typically suba- posterior compartment syndrome,
cute and present with muscle tension popliteal artery entrapment syndrome, a
Plantaris Strain and tightness, gradual pain development torn Achilles tendon, or a ruptured
Although relatively rare, an isolated over the course of days to weeks, and Baker’s cyst6,7,28. Tenderness in the
rupture of the plantaris muscle can occur mild swelling and disability1. Palpation medial gastrocnemius belly can be nor-
at the proximal muscle belly or the may identify tenderness deep within the mal and is common even in uninjured
midportion of the-plantaris tendon5,29. lateral calf and distal to the gastrocne- athletes34. Posterior leg pain can also be
The pathogenesis is similar to that of a mius muscle bellies1,23. Soleus muscle referred from defects in other muscles,
gastrocnemius tear and involves knee contraction can be evaluated with the such as the popliteus, peroneus longus,
extension with ballistic foot plantar flex- knee in maximal flexion, in which case and other deep posterior compartment
ion23. Athletes with isolated lesions can the soleus becomes the primary con- or lateral compartment muscles. Physi-
retain a full range of motion without tributor to plantar flexion. Imaging is cal examination and imaging are useful
reduction in strength29. However, a recommended to identify potential to confirm the differential diagnosis and
plantaris injury is more often diagnosed concomitant ruptures of both the gas- inform the best treatment strategy.
concomitant with traumatic knee injury, trocnemius and the soleus1,27.
such as lesions of the anterior cruciate lig- An isolated plantaris strain is rare Physical Examination
ament or the posterolateral corner5. and can be clinically indistinguishable Palpation, strength testing, and passive
from a gastrocnemius strain, requiring flexion and extension of the knee and
Presentation imaging for a definitive diagnosis1. ankle joints are effective methods to
An acute strain of the gastrocnemius can Plantaris rupture can present with an identify areas of tenderness, tightness,
present with an audible pop at the onset audible pop at the onset of the injury, swelling, and, in more severe cases, sub-
of the injury, followed by dull to severe and athletes with isolated lesions may cutaneous gaps or masses1,6,7,23,28. Ten-
pain and swelling in the posterior lower retain a full range of motion without derness in the medial gastrocnemius belly
limb within 24 hours1,6,28. The pain can reduction in strength23,29. More often, or the musculotendinous junction indi-
be latent at the time of the injury, mani- plantaris strain is concomitant with cates gastrocnemius strain, the most
festing only after the athlete tries to stand, traumatic lesions of the knee, such as common calf injury, and tenderness distal
walk, or plantar flex the foot28,33. Indi- those involving the anterior cruciate and lateral to the gastrocnemius implicates
viduals are often unable to perform a heel ligament or posterolateral corner5. the soleus1,23. A palpable defect indicates a
raise on the affected side because of possible muscle retraction with complete
compromised plantar flexion6. Palpation Differential Diagnosis fiber disruption. Palpable contractions
may identify tenderness at the muscle Within the triceps surae, ruptures are that are spasmodic and involuntary indi-
insertion into the Achilles tendon or, in possible in the medial or lateral gastroc- cate muscle cramps35.
more severe cases, a subcutaneous defect nemius, soleus, or plantaris muscles, and As previously mentioned, athletes
in the medial gastrocnemius from muscle concomitant injuries of the gastroc- with gastrocnemius defects are often

MARCH 2022 · VOLUME 10, ISSUE 3 · e21.00183 3

 | Calf Strain in Athletes

unable to perform a heel raise on the may have financial and strategic conse- diagnosis for partial-thickness and full-
affected side because of compromised quences for professional teams1,6. Mus- thickness calf strains and is useful for
plantar flexion6. Muscle contraction can culoskeletal ultrasound and magnetic evaluating edema, hemorrhage, hema-
be evaluated with the knee in maximal resonance imaging (MRI) are appropri- toma, and thrombophlebitis7,28. Dop-
extension, which isolates the contribu- ate imaging modalities in the context of pler ultrasound can readily detect deep
tion of the gastrocnemius to plantar calf strain injury and have the additional vein thrombosis, which is sometimes
flexion1. Conversely, the soleus can be benefit of detecting intramuscular fluid
concomitant with gastrocnemius
evaluated with the knee bent from 90° to collection, which is associated with de-
strain7,28. Ultrasound is particularly
maximal flexion, which makes it the layed return to play1,6,7,12,28.
convenient for its short imaging time,
primary contributor to plantar flexion1. MRI is an accurate and reliable
method for examining muscle fiber dynamic visualization, and easy com-
Thus, close attention to knee posture
can improve the accuracy of strength integrity and continuity. It can differen- parison with the contralateral, unin-
tests and inform the diagnosis. tiate gastrocnemius strain from other jured leg38. However, there are no
Achilles tendon pathology is also a soft-tissue injuries, such as soleus strain or guidelines that define specific ultra-
concern for clinicians. Achilles tendon Achilles tendon pathology, and can eval- sound characteristics as indications for
rupture is best evaluated with the Sim- uate the integrity of surrounding con- return to play in professional sports.
monds triad, which includes the nective tissue2,7,28,32. Connective tissue
Simmonds-Thompson calf squeeze test, defects are often associated with longer Grades
the Matles angle-of-declination test, and rehabilitation time than muscle tears Calf strain is graded on the basis of physical
palpation for tendon defects near the alone, and studies have identified addi- and imaging parameters (Table III). A
insertion into the calcaneus1,36. A com- tional MRI characteristics as indicators grade-I (mild) strain is associated with
parative study showed that positive for return to play, making MRI useful for micro-tears in muscle fibers that cause
results on at least 2 of the 3 tests provided the continual evaluation of recovery for mild pain or soreness but minimal reduc-
confirmation of Achilles tendon rupture professional athletes2,12,13,22,28,32. tion in strength and range of motion1. A
in all cases, which indicates high sensi- Moreover, fluid-sensitive MRI can reveal grade-II (moderate) strain corresponds to a
tivity for the Simmonds triad36. edema, hemorrhage, and hematoma7.
partial muscle tear that causes appreciable
Ultrasound is often considered for
reduction in strength and range of motion.
Imaging its affordability, accessibility, and conve-
Athletes with partial tears are sometimes
Although the diagnosis of calf strain is nience1,7,29,37,38. Although no direct
often based on clinical findings, imaging comparison of ultrasound and MRI unable to walk and often have pain and
is valuable to confirm the location of the diagnostic accuracy is available for calf swelling from edema or hemorrhage1. A
strain and the grade of the injury1,7. This strain, a comparison of the imaging grade-III (severe) strain signifies complete
information guides the choice and modalities in the evaluation of hamstring rupture, which presents with severe pain
duration of rehabilitation and influences strain found no significant difference39. and disability, loss of muscle function, and
return-to-play considerations, which Ultrasound can provide a differential extensive edema and hemorrhage1.

TABLE III Grades of Injury in Calf Strains and Recovery Times1,2,42

Grade Presentation Pathology Management Recovery*

0 Tenderness or swelling with no Edema or fluid adjacent Conservative 0 to 2 weeks

reduction in strength or range of to intact muscle fiber
motion
I (mild) Mild pain, tenderness, and Micro-tears with ,10% Conservative 1 to 4 weeks
swelling; minimal reduction in muscle fiber disruption
strength and range of motion
II (moderate) Moderate pain, tenderness, and Partial tear with 10% to Conservative 2 to 5 weeks
swelling; reduction in strength 50% muscle fiber
and range of motion disruption
III (severe) Severe pain and disability with Complete tear with Conservative 5 to 10 weeks for conservative
complete loss of muscle function; .50% muscle fiber or operative treatment or 24 weeks for
palpable subcutaneous defect disruption operative treatment

*Recovery times are sport-dependent.

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 Calf Strain in Athletes |

Management moist heat application are generally con- bandage to immobilize the repaired
Nonoperative management is effective traindicated in the acute phase as these muscle and ambulation with crutches.
for most calf strain injuries. Treatment techniques increase the risk of hemor- The patient is non-weight-bearing for the
generally consists of rest, ice, compres- rhage1,7. first 4 to 6 weeks and then weight-bearing
sion, elevation, and nonsteroidal anti- with progression to physical therapy40.
inflammatory drugs (NSAIDs) in the Subacute Phase Recovery from the surgical procedure is
acute phase, followed by appropriate In the subacute phase, the body repairs gradual over the course of 6 months42.
stretches and exercise in the subacute the soft-tissue damage and forms scar
phase1,6,7,23,28. A delayed progression tissue. Treatment is designed to restore Other Therapies
from the acute phase to the subacute mobility, prevent muscle atrophy or Additional therapies for muscle reha-
phase should trigger reevaluation for contracture, and guide tissue regenera- bilitation include blood flow restriction
intramuscular hematoma or extensive tion to optimize functional improve- therapy (BFRT), deep water running,
tissue damage40. Operative treatment, ment28. Rehabilitation includes passive LBPPT, and nascent therapies such as
although rarely indicated, may be and active stretches, soft-tissue tech- platelet-rich plasma, and, to a limited
considered in more severe cases with niques, muscle strengthening, and pro- extent, stem cell therapy.
complete grade-III rupture or complica- prioception exercises for 2 weeks, BFRT involves light resistance
tions1,6,7,28,41. Another common event followed by general and sport-specific training with the use of a restriction band
in athletes is exercise-induced muscle reconditioning exercises1,6,7,28. proximally on the extremity to occlude
cramps, which can be alleviated with Stretching elongates the intramuscular venous blood outflow while maintaining
passive stretches of the calf muscle35. scar tissue in preparation for strength- arterial blood inflow. Light resistance
The utility and evidence for blood flow ening exercises, and altering the degree training exerts mechanical stress on the
restriction therapy, deep water run- of knee flexion can isolate the gastroc- muscles, and the use of a restriction band
ning, lower-body positive-pressure nemius and soleus during stretches1,28. induces tissue hypoxia and stimulates
therapy (LBPPT), platelet-rich Soft-tissue techniques such as low-level anaerobic metabolism43-45. Research has
plasma, and stem cell therapy are laser therapy, therapeutic ultrasound, demonstrated that BFRT can increase
discussed as well. electrical stimulation, and friction mas- muscle strength, hypertrophy, and angi-
sage are also appropriate1,7. As range of ogenesis compared with unrestricted
Acute Phase motion improves and pain subsides, light resistance training, but less muscle is
In the acute phase, treatment is designed to strength training can progressively recruited compared with unrestricted
protect the injured tissue by reducing incorporate isometric, isotonic, and heavy resistance training43-48. Although
activity, managing pain, and preventing dynamic exercises as tolerated without the biological mechanism is unknown, in
hemorrhage or other complications1,7,23. pain1,7,28,40,42. Finally, general and theory, the combination of mechanical
This is accomplished with rest, ice, com- sport-specific reconditioning helps to and metabolic stress is thought to facili-
pression, elevation, and NSAIDs1,6,7,23,28. restore strength and agility7,28. tate cellular signaling pathways that lead
In the first 24 to 72 hours, activities should to protein synthesis, fast-twitch muscle
be limited to allow the injured leg to be Operative Management fiber recruitment, and stimulation of
rested in an elevated position and NSAID The mainstay of treatment is nonoper- myogenic stem cells43-45. Because heavy
use should be carefully managed to prevent ative. Operative management, although resistance training is often contra-
bleeding from antiplatelet effects1,6,7. rarely indicated, may be considered in indicated in the early stages of recovery,
Alternatively, acetaminophen and cele- the most severe cases with complete BFRT may be useful as a progressive
coxib, which do not interfere with platelet grade-III ruptures, contractures, fibro- rehabilitation method to promote the
function, may be used for pain manage- sis, substantial hematoma, acute com- regeneration and healing of muscle43,44.
ment1. Cryotherapy, ice packs, compres- partment syndrome, or myositis Hydrotherapy techniques such as
sion bandages, and neoprene sleeves may ossificans1,6,7,28,40,41. In cases of com- deep water running can be considered
be used to manage symptoms and to plete muscle rupture, the inability to for muscle rehabilitation. Aquatic exer-
facilitate early ambulation1,6,7,23,34. High stand on the metatarsal heads of the leg cise has been practiced since the Romans
compression bandages that exert 20 to with a calf strain has been described as an first described the use of hydrotherapy to
30 mm Hg of pressure have been recom- indication for a surgical procedure41. manage orthopaedic conditions49.
mended in published reports, and some Cheng et al. published a surgical tech- Hydrotherapy uses the buoyancy, vis-
evidence has suggested that compression nique for complete gastrocnemius rup- cosity, and hydrostatic pressure of water
bandage use can improve recovery by up to ture41. Surgical intervention reconstructs to counterbalance gravity and provide
7 days6,23. Crutches, boots, or heel lifts anatomical structures and removes resistance and compression50,51. Deep
may be used to protect the injured area and fibrous scar tissue41. Postoperative man- water running is one technique for
control pain1,7,23. Soft-tissue massage and agement includes use of a compression weight-supported aerobic training, in

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 | Calf Strain in Athletes

which the body is partially submerged in unloaded during exercise57. The reduc- stem cell therapy has demonstrated
water. The upward buoyant force, tion in muscle activation is similar to accelerated muscle recovery with
which is equal to the weight of water that that achieved with deep water running at improved angiogenesis and reduced scar
the body displaces, acts in opposition to a matched stride frequency59. Further- tissue formation69,70. Stem cell therapy
the downward force of gravity50-53. more, modifications that decrease the has been investigated in a limited num-
Thus, submersion up to various body treadmill speed and/or incline also lessen ber of clinical trials and primarily for the
parts offloads body weight: by 40% up gastrocnemius and soleus muscle acti- treatment of muscular dystrophies and
to the hip, by 50% up to the waist, by vation56. For this protective reason, incontinence disorders69,71. In these
60% up to the sternum, or by 85% up to published reports have suggested clinical trials, patients who received
the shoulders50-53. The depth of LBPPT as an option for patients com- transplantation or intra-arterial infusion
immersion can be controlled using the mencing a rehabilitation program and as of progenitor cells such as mesenchymal
slope of the pool, flotation equipment, an alternative to hydrotherapy56,57. stromal cells, mesoangioblasts, or myo-
or hydrotherapy treadmills that encapsu- Platelet-rich plasma is an autolo- blasts cultured from muscle satellite cells
late users in aquatic cabins made of glass50. gous, platelet-rich blood product had outcomes that ranged from no dif-
Deep water running has 2 forms: a high- obtained from the centrifugation of ference in muscle histology and/or
knee style (high-knee deep water running) whole blood. Platelets are purported to functionality to improvements in these
with stair-stepping movements, and a release growth factors and cytokines that measures69,71. The differences across
cross-country style (cross-country deep facilitate the regeneration and healing of published reports are partly attributable
water running) with kinematics similar to muscle tissues60-63. Presently, 1 study to variations in study methodology,
treadmill running51. Both high-knee deep has examined platelet-rich plasma small patient samples, and an incom-
water running and cross-country deep treatment in the calf muscles. In a ret- plete understanding of the biological
water running have been observed to rospective evaluation of patient out- mechanisms stimulated by stem cell
reduce gastrocnemius activation in com- comes, Borrione et al. reported that early therapy. Future research may provide
parison with treadmill running54,55. An ultrasound-guided platelet-rich plasma more evidence for the use of stem cell
environment that reduces muscle activa- treatment of grade-II and III gastrocne- therapy in muscle rehabilitation.
tion allows for active recovery with a mius strain reduced pain, discomfort,
decreased risk of reinjury50,51. and recovery time compared with the Return to Play
LBPPT has emerged as a popular standard conservative treatment63. Most calf strains recover well under
alternative to hydrotherapy and other However, the patient sample was limited conservative treatment; the muscle
weight-supported rehabilitation to recreational sport athletes older in age develops a small fibrous scar without
methods. Lower-body positive-pressure than elite athletes engaged in competi- pharmacological or surgical interven-
treadmills, such as the AlterG, allow for tive sports63. Level-I studies investigat- tions28,40. Full recovery is indicated by
weight-supported exercise in which ing platelet-rich plasma application in symptom relief and the return of
users can designate the percentage of other muscle groups have shown strength, flexibility, and range of motion
their body weight to be borne by the inconsistent evidence60-62; in the case of comparable with those of the contralat-
treadmill in addition to adjustments for the hamstring muscles, A Hamid et al.64 eral side1,34. Early diagnosis and treat-
speed and incline56-58. Users wear neo- reported that platelet-rich plasma facili- ment of muscle strain can ameliorate the
prene shorts that secure to a positive air tated a faster recovery with a shorter time severity and duration of the injury, and
pressure chamber of the treadmill. The to return to play, and Reurink et al.65 limited evidence has suggested that
differential air pressure of the chamber and Hamilton et al.66 observed no sig- treatment within 48 hours of an injury
produces a variable force that lifts users, nificant differences in the time to return facilitates earlier return to play1,28,34,40.
thereby decreasing the impact of gravi- to play or the reinjury rate between Although return to play is often medi-
tational forces and body weight during platelet-rich plasma and control cohorts. ated by sports-specific considerations, a
exercise56. Published reports on LBPPT Thus, additional investigation is neces- general benchmark to begin sports re-
have associated it with improved muscle sary to elucidate the benefits of platelet- conditioning is ambulation without
functionality and posture in patients rich plasma for muscle rehabilitation. pain6,7,72. Premature exertion can delay
with muscular dystrophy and earlier The therapeutic implications of recovery, can cause incomplete healing,
postoperative return to sport in ath- stem cell therapy are still preliminary but and can increase the risk of reinjury1,13.
letes58. Although LBPPT has not been demonstrate some potential for muscle
studied in the context of muscle strain, rehabilitation. Stem cell therapy aims to MRI Correlation
LBPPT has demonstrated a linear restore the structural integrity and MRI is useful to evaluate professional
reduction of gastrocnemius and soleus functionality of skeletal tissue by stim- return to play2,12,13,22,28,32. Certain
muscle activation in healthy individuals ulating muscle fiber development and imaging characteristics, such as the
in relation to the amount of body weight vascularization67-69. In animal models, severity and the site of the injury, are

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 Calf Strain in Athletes |

associated with a longer recovery time. ever, the degree of tissue damage in re- son, the benefits of stretching alone are
Higher grades of tissue injury generally injuries compared with the index injuries unclear. However, dynamic and sport-
require longer rehabilitation (Table III). is subject to debate. Studies of hamstring specific pre-participation drills may be able
Concomitant connective tissue disrup- strain have shown greater muscle damage to restore stretch-induced performance
tion has been associated with longer time in reinjuries than in index injuries, which loss when coupled with a stretching rou-
to return to play in elite runners and may explain the prolonged recovery time tine appropriately tailored for the player
Australian football, soccer, rugby, and in reinjuries74. However, conflicting evi- position77. Because the strongest risk fac-
hockey athletes with calf strain2,13. dence of similar muscle damage between tors for calf strain are unmodifiable, the
Connective tissues such as tendons, reinjuries and the index injuries also prevention of calf strain is best accom-
aponeuroses, and epimysium are inte- exists74. An appropriate rehabilitation plished with pre-participation stretching
gral to muscle support and function but timeline may consider other contextual
and warm-up exercises that increase
heal more slowly than muscle when factors as well, such as sport-specific
flexibility and agility in the tissues most at
disrupted2,22. Injury location may also demands, player position, seasonality,
risk for injury34,77.
play a role in recovery time. Although and athlete psychology24.
gastrocnemius and soleus strains have
Risk Factors Conclusions
similar recovery times, the location of
Calf muscle strain is a common condi-
the tear within the tissue and the pres- Player age and history of a calf strain or
ence of aponeurotic disruption may other leg injury are the strongest risk tion. In high-performance athletes, calf
influence overall recovery2,24. Soleus factors for calf strain in elite athletes, and strain contributes to missed practice or
strains in which the musculotendinous player characteristics such as height, playing time in many professional and
junction or tendon are implicated cor- weight, sex, and side dominance are collegiate sports. Timely diagnosis and
respond to more missed games22. In unlikely to be associated with calf muscle treatment can improve outcomes and can
addition, ruptures in the central apo- injury3,13,16,17,19,20,75. A possible facilitate earlier return to sport. Although
neurosis recover more slowly than those explanation is that age-related tissue the diagnosis can be made by clinical
in the lateral or medial aponeurosis and changes involve progressive declines in examination, MRI and ultrasound are
myofascial sites24,32,73. In gastrocnemius skeletal muscle quality and function, the both appropriate imaging modalities to
strains, tears in the anterior aponeurosis consequences of which include neuro- confirm calf strain. MRI may additionally
and distal myotendinous junction corre- muscular maladaptations that restrict be useful in the evaluation of recovery
late with higher-grade injuries, which muscle force and rate of contraction3. In time as return-to-play decisions often
require longer rehabilitation2. some cases, the rehabilitated tissue has have financial and strategic consequences
suboptimal functionality compared with for professional teams. Conservative
Other Considerations the contralateral, uninjured side76. treatment is effective for most calf strain
Other considerations for return-to-play Because optimal tissue functionality is injuries. Operative management, although
decisions include the manner and his- protective, this suggests that a previous rarely indicated, may be appropriate in
tory of the injury. A study of elite Aus- muscle injury can be a risk factor for a severe cases with grade-III ruptures or
tralian football players showed that calf future injury. Prior injuries in the calf, complications. Player age and history of a
strains from running activities corre- hamstrings, quadriceps, adductors, and
calf strain or other leg injury are the stron-
sponded to longer recovery periods than knee have been identified as risk factors
gest risk factors for calf strain injury and
calf strains from non-running activities, for a subsequent calf injury3,16. More
reinjury. Athletes are encouraged to practice
irrespective of the muscle injured13. limited evidence has shown that increased
pre-participation stretching and warm-up
Running activities such as high-intensity body mass index and preseason activity
exercises to maintain flexibility and agility
and steady-state running, acceleration, are risk factors for calf strain3,16.
for prevention of calf muscle injury.
deceleration, or sudden change of direc-
tion may be associated with more tissue Prevention
disruption of the muscle-tendon unit13. Studies have indicated that pre- Source of Funding
Player reinjuries are another concern for participation stretching improves range of The Conine Family Fund for Joint
sports managers as calf strain is a recurrent motion and muscle compliancy, which Preservation provided funding for this
injury in approximately 19% to 31% of may be protective against muscle strain77. study.
cases3,21,24. Reinjuries are associated with Although stretching promotes muscle
Wendy M. Meek, BBA1,
longer rehabilitation times and often performance in elastic movements such
Michael P. Kucharik, BS1,
involve older, more experienced as hops or leaps, it is associated with
Christopher T. Eberlin, BS1,
players13. Premature return to play decreased muscle power in predominantly Sara A. Naessig, BS1,
increases the risk of reinjury as tissues concentric contractions such as steady- Samuel S. Rudisill, BS1,
have not completely healed1,13. How- state cycling or jogging77,78. For this rea- Scott D. Martin, MD1

MARCH 2022 · VOLUME 10, ISSUE 3 · e21.00183 7

 | Calf Strain in Athletes

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