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The Assessment, Management and Prevention of Calf Muscle Strain Open Access Injuries: A Qualitative Study of the Practices and Perspectives of 20 Expert Sports Clinicians

Green, B., McClelland, J.A., Semciw, A.I., Schache, A.G., McCall, A. and Pizzari, T., 2022. The Assessment, Management and Prevention of Calf Muscle Strain Injuries: A Qualitative Study of the Practices and Perspectives of 20 Expert Sports Clinicians. Sports medicine-open, 8(1), pp.1-28.

In today’s letter

• Overview of how to rehab a calf strain

• Professional takeaway = When returning an athlete to Running its important to be aware of the 6 rules to follow:

  1. Don’t run on consecutive days

  2. Avoiding early "plodding"

  3. Do not progress volume and intensity consecutively

  4. Scheduling off-field exercises post-running (not before)

  5. Shaping running progressions to match sport demands (not more)

  6. Avoiding sudden changes in conditions (footwear, surface)

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Aim of study

The aim of this study was to evaluate the current practices and perspectives of a select group of international experts regarding the assessment, management and prevention of calf muscle strains using in-depth semi-structured interviews

Background info

*Same as previous newsletter*

• The burden of calf muscle strain can result in significant >3 months time-loss, as reported in cases of American football, football, and Australian Football.

• Athletes face an increased susceptibility to recurrent calf muscle strains and other subsequent lower limb injuries, including hamstring strain, compounding the impact of the calf strain

• Despite it being a prevalent issue in various sports, there is a lack of research guiding clinicians on best practices for assessment, management, and prevention.

• In the absence of research on calf muscle strain diagnosis and management, sports medicine practitioners have relied on commentaries and book chapters, which represent a low level of evidence, to inform their clinical decision-making.

• Qualitative research, conducted rigorously to minimise bias, is a powerful tool to inform practice and future research. In-depth interviews in qualitative analyses allow exploration and evaluation of complex areas.

Methods

• Participants were identified purposefully using publicly available information, the networks of the investigators and identified experts, as well as a review of key research in the field

• Using a consensus approach among investigators, potential participants were sourced from different countries, sports and areas of specialisation to ensure diversity in the sample and to minimise the risk of bias

• As a mini- mum they had:

  (1) postgraduate qualifications in≥1 relevant discipline

  (2) > 5 years of clinical experience in elite sport and/or consulting elite athletes

Interview design

• In-depth interviews were selected as the method to delve into the practices and perspectives of experts involved in the assessment, management, and prevention of calf muscle strain

• The in-depth semi-structured design was employed to facilitate a thorough exploration of participant responses, allowing the recognition of emerging trends and themes.

• The interview guide, provided to participants in advance for approval, served as a framework during the interviews. This approach ensured that data collection covered all relevant topics from each participant, addressing the potential non-linear narrative characteristic of a semi-structured design.

Results

• Twenty participants were interviewed face- to-face (n=9) or using a meeting platform (n=11).

• All participants were primary contact practitioners and were engaged in clinical practice across nine countries: Australia, the USA, the UK, Ireland, Norway, Sweden, Spain, New Zealand and India.

• Participants were primarily involved in managing adult elite (i.e. professional) athletes

• Of the 65% who had research experience, most (69.2%) had completed a PhD

Rehabilitation and Return to Play Decision Making

Overview of Management

• Rehabilitation process shifts from a primarily medical focus to emphasising performance and injury prevention post Return to Play as progress is seen.

• Expert highlight the contextual nature of optimal management, recognising the significant impact of athlete-specific traits and external factors.

• The rehabilitation process involved systematically advancing exercises and load through six distinct management phases.(Image below)

• Successful management, as collectively perceived, hinged on three key outcomes:

  1. Return to play ASAP

  2. Restoration of athlete performance to previous levels

  3. The absence of adverse events such as recurrence of calf strain or subsequent injuries.

Early Loading and Foundation

• Early loading was viewed by experts as a therapeutic approach, accelarating the resolution of basic signs, symptoms, and impairments associated with calf strains.

• Exercise selection and load parameters exhibited variability among experts, primarily influenced by injury severity and the specific muscle affected.

“you might find that isometric loading at certain angles, or at certain muscle–tendon unit lengths, is less symptomatic in the early phase of rehab. So therefore that’s the loading you do,” Expert 18

• Experts advocated for the inclusion of single-leg calf raise exercises as soon as tolerated, aiming to restore foundational muscle capacity.

“We’ve got to be single leg heel raising, really, straight away. So we can go from an isometric, which is usually only for a day just to get their confidence. I don’t waste time with bilateral, I think they just cheat, so I would rather them just do an isometric, mid-range, or a comfortable range, and then small range isotonics, then full range as soon as they can, even if they can only do 2. I’d much rather them do that than do 100 bilateral,” (Expert 19).

• Prescribing multiple loading sessions per day and progressively loading through the full range of motion or muscle-tendon unit length were seen as strategies to accelerate functional progression and mitigate post-injury issues like atrophy and inhibition.

• Consideration of directional work, whether horizontal or lateral, emerged as a crucial factor for experts rehabilitating athletes in sports involving acceleration and cutting, such as rugby, or when the injury implicated these mechanisms.

We get them strong in terminal, inner range, plantar flexion. We do that almost like a motor exercise, where again, we get them into the ‘leaning tower’ position, with their good leg resting on a small stool, to get them balanced, we will then get them come up into terminal, inner range plan- tar flexion, and then get them to lift off the front leg while maintaining that 45 degree lean, or whatever angle it is,” (Expert 7)

• Indicators of suboptimal recruitment and function included the "sickle sign" involving progressive inversion and adduction, "clawing the toes" denoting excessive reliance on deep flexors, and diminished eccentric control.

• In cases of 'problem calves,' characterised by severe or recurrent calf strains, extended time to running, or impairments from past foot and ankle injuries, retraining balance and proprioceptive function through foot intrinsics and deep lower leg muscle exercises were deemed particularly beneficial.

  

Loaded Strengthening

• Smith machine and seated calf raise machine exercises were commonly initiated for loaded strengthening, introduced by experts following the demonstration of a baseline in single leg calf raise capacity.

We use the Smith Machine a lot, with weights or weight vests. We progress from a flat surface to stand on an incline to increase the range of motion with those kinds of exercise too” (Expert 10).

• Loaded strengthening parameters were systematically advanced by experts to align with the specific demands of different sports. This involved emphasising strength-endurance for activities like football and Australian Football, characterised by prolonged running, and prioritising maximum force generation for shorter bursts, as seen in rugby and sprinting.

• Critiques from several experts highlighted a perceived deficiency in conventional strengthening after calf strain, particularly in sports requiring rapid acceleration and cutting, attributing it to a failure in addressing horizontal and lateral capacity

  

Loaded Power, Plyometrics and Ballistic Exercises

• Following the achievement of initial strength milestones, the introduction of dynamic exercises aimed to gradually reintegrate movements utilising the stretch-shortening cycle (SSC) for the calf muscle-tendon unit (MTU).

“The first bit is about volume and the ability to contract and to work. The sec- ond is about that rate of force development or spring, because in the end it comes back to that rate of loading rather than the total force,” (Expert 9)

• Experts typically initiated the prescription of dynamic exercises with a focus on predominantly vertical actions, progressing to activities with increased horizontal movement, lengthening demands, and stiffness requirements.

• Two key categories of dynamic exercises were emphasised by experts:

  (1) repeated SSCs over small length-excursions, linked to rhythmic MTU action (e.g., single-leg pogos)

  (2) single or multiple SSCs over larger length excursions, associated with accelerative MTU action (e.g., single-leg countermovement jump, forward hopping).

• While basic plyometrics were generally well-tolerated soon after calf strain, experts identified that 'problem calves' necessitated a more comprehensive approach, culminating in advanced exercises incorporating inclines, stairs, and varied surfaces.

“Do their plyometrics up on an incline... they can also do their jumping and drills up them too. Like the ‘rudiments’, the broad jumps...” (Expert 1)

Locomotion

• Testing readiness for running after a calf strain was considered crucial by experts, given the substantial workload the calf muscles endure during running.

• The clinical decision-making process regarding running readiness focused on three primary elements:

  1. Strength assessment

  2. Hopping capacity evaluation

  3. The absence of other clinical signs and symptoms.

• A prevailing notion was that a more comprehensive buildup before running could enhance outcomes without necessarily prolonging Return to Play timelines, effectively mitigating the risk of recurrence.

• Early after calf strain, experts prescribed low-load locomotive reconditioning exercises like stair ascents to facilitate rehabilitation.

“We use stair walks in our transition from walking to running. We are lucky enough to have five flights of stairs. We might have them walk up the stairs and then catch the lift down to mask them from the eccentric load,” (Expert 12)

• In the lead-up to running, rehabilitation incorporated run drilling and technique exercises.

Gradually, I’ll work through some full drills, track drills. So you work through ‘A’ drills, ‘B’ drills, skips, marches, lunge walks, you know those sorts of things. With a bit of resistance, I will do a bit of resisted stuff in the first instance. And then gradually I’ll start them off running, and I will tend to run them, we tend to say a limit of about 5 m per second on their running for the first week,”

• Experts outlined 6 'rules of thumb' for running rehabilitation after calf strain

  1. Don’t run on consecutive days

  2. Avoiding early "plodding"

  3. Not progressing volume and intensity consecutively

  4. Scheduling off-field exercises post-running

  5. Shaping running progressions to match sport demands

  6. Avoiding sudden changes in conditions.

     

• Prolonged, slow continuous running, referred to as "plodding," was generally discouraged during early running rehabilitation, especially for calf strains involving the soleus, as it was associated with an increased risk of recurrence.

• The last thing we tick off is the endurance...it is all very nice ticking off the sprinting and the high-speeds, building their confidence. But at some stage in the match, and in training, they are going to have to cover 12-13 km, and a lot of that is jogging. But it is the last thing we ‘tick off’, as opposed to the hamstrings and the quads, which is the first thing we ‘tick off ’,” (Expert 5)

  “In those first few sessions I am still not going to get them going out sprinting. Because you’re still going to get very high forces and it is very energy storage and release with the higher-level running,” (Expert 12).

• Locomotive reconditioning, bridging gym-based exercises and field-based activities, was crucial, as neglecting to restore function at higher loading rates was perceived as a contributor to failed management

  
  We almost go to a different paradigm of loading quantification. The big thing is, it is partly about the tension, but then it’s the rate of force application, and this is something that is not used in anything at the moment. Except for maybe a bit in bone loading. I think it’s something that, as clinicians, we need to expand our paradigm,” (Expert 13).

Reaching an Optimal Return to Play Decision

• Optimal Return to Play decisions, according to experts, are achieved through consensus among stakeholders, guided by a central question.

“What is the acceptable level of risk that the player returns at this time?”

• A clinical checklist (image above) derived from valuable information identified by experts, serves as a helpful tool to assess readiness for return to play

• Throughout the return to play phase, experts primarily rely on exposure to sports-specific activities to guide their decisions

You need to make a decision about: “Well, this guy plays this sort of role, he’s an explosive marking forward, and what does this player do in a game? And how many times do I want to see that at training, those sorts of activities, before I’m happy to know that he’s done that, he hasn’t reacted adversely to it...” That’s the sort of thing that we’d work through. But, at a bare minimum, guys have got to get themselves through at least one main training session where they’ve done everything, and they’ve done all their position-specific activities, and have been fine. They haven’t been apprehensive about anything in that session. Their GPS data mimics what you would normally expect to see from that type of session. And yeah, they’ve pulled up fine the next day. But sometimes you might broaden that more and say: “No. I don’t want just one training session. I want to see 2 or 3 because it’s a more extended injury.” Or they’re coming back the second time around after an exacerbation of an initial injury. Or maybe they’re a player that’s just had a lot of trouble from time to time. But for a simple calf injury that’s taken 2 or 3 weeks to settle down, well you’re not going to make them train for 2 or 3 weeks before they play, especially if they’re an important player. Otherwise you’re going to be out of a job pretty soon. But we’re not putting them through isokinetic dynamometry. We’re not re-imaging guys. I don’t use formal questionnaires with calf injuries...” (Expert 18).

Thank you for reading this weeks edition!

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