Steve Phillips – Calf Muscle Injuries – Injury Rehab Network Event

The second Injury Rehab Network event of July 2023 with BASRaT featured Steve Phillips, Physiotherapist. The online event took place on the evening of 31st July with 300 sports rehabilitation professionals in attendance.

Steve’s presentation considered the assessment, management, and prevention of calf muscle injuries. He is a Physiotherapist with significant experience in professional football.

The recording of Steve’s presentation is available to watch here

Steve Phillips – Head of Performance, Crewe Alexandra FC

Steve Phillips began his career working in the NHS as a rotational physio at Salford Royal Hospital. He then moved into professional football as Salford City’s Head Physiotherapist. There he won back-to-back promotions, most recently in a play-off final at Wembley.

Steve then moved to Crewe Alexandra FC, where he has spent four seasons, also achieving a promotion to League 1 during this period. He is currently their Head of Performance, overseeing the Sports Science and Medical departments.

Steve is soon to start a new role as Physiotherapist at Everton FC, where he will work with the women’s team. He has recently finished his MSc in Advanced Physiotherapy at the University of Salford.

Steve has a special interest in sports injuries and has set up his own clinic in Manchester alongside his work at Crewe.

Calf Muscle Strain Injuries: Assessment, Management and Prevention

Steve’s presentation, “Calf Muscle Strain Injuries: Assessment, Management and Prevention”, discussed the differences between Gastroc and Soleus injuries and how to manage them in a sporting setting. It started with a recap of calf muscle anatomy and the features of the gastrocnemius and soleus muscles.

Muscle Injury Physiology

Steve described the physiology of a muscle injury with the following stages of tissue repair:

1. Bleed (4-6 hours) – followed by clotting
2. Inflammation (onset 0-3 days, resolve over 2-3 weeks)
3. Proliferation (onset 24 hours, max 2-3 weeks)
4. Tissue repair (first week to several months)
5. Tissue remodelling (weeks and up to 9 months +)

Subjective Assessment

He considered the subjective assessment of calf muscle injuries, where practitioners should identify the primary muscle involved. Steve discussed differences in Soleus and Gastroc injuries for consideration during a subjective assessment, including:

• History of onset
• Mechanism of injury
• Symptoms
• Symptom location
• Symptom severity
• Previous injury
• Potential predisposing factors

Objective Assessment

Steve again described the differences between the Soleus and Gastroc muscles for the objective assessment of calf muscle injuries. An objective assessment should focus on the following:

• Observation
• Palpation
• Stretch tolerance
• Isolated strength
• Other body regions
• Dynamic capacity
• Locomotive capacity

Principles for Calf Injury Rehab

Steve discussed twelve principles for calf injury rehab with the aim of priming the muscle for the demands required.  The first step is to normalise walking. Rehab should then progress to calf loading, activation exercises, strengthening of uninjured muscles and single-leg exercises.

Loaded Power, Plyometric and Ballistic Progression

Steve considered power and plyometric training for calf injury rehabilitation. Once load tolerance has been shown, practitioners can begin dynamic stretch-shortening cycle (SSC) exercises. The objectives are to increase the volume of exercise and rate of force development (RFD) using loaded and unloaded exercise to restore elastic function.

Steve discussed how calf capacity must be high before commencing running and that running volume and intensity should be increased independently. Acceleration and exposure to the injury stimulus can be addressed during the end stage for return to play.

Criteria Based Return Rather than Time-Based

For calf injury rehabilitation, Steve discussed the importance of criteria to inform progression to slow running and then to high-speed running.

Injury Prevention

Steve discussed how testing is key for injury prevention and that practitioners should work with athletes to address deficits and any previous injury history. He described skipping as a great way to train the muscle-tendon unit. Outcome measures should be specific to the sport and position played. Performance data such as GPS can be combined with injury history information to inform injury prevention programmes.

Steve considered how a history of reduced exposure increases the risk of injury. It may take a month after returning to play before an athlete returns to normal loads. It is, therefore, important to use workload protection during this period.

References

Steve referenced the following journal articles, which informed his presentation and are recommended reading for practitioners:

• Muscular Strategy Shift in Human Running
• Return to Play and Recurrence After Calf Muscle Strain Injuries
• Calf Muscle Strain Injuries in Elite Australian Football Players
• The Assessment, Management and Prevention of Calf Muscle Strain Injuries
• Regeneration of Injured Skeletal Muscle After the Injury
• Muscle Injuries: Optimising Recovery

Q&A

Steve kindly answered questions put forward by the practitioners who attended the session.

Q1. With a Prakash tear, would you recommend to re-scan prior to return to play?
A1. Not if the athlete is hitting all outcome measure pain-free.

Q2. If practitioners don’t have access to force plates, which tests would you recommend?
A2. Would recommend using normative data and comparing it to baseline. A hop-to-jump test is good.

Q3. Is it possible to do early loading after an acute injury?
A3. Advise 48 hours rest with cold/ compression therapy the begin light isometric loading.

Q4. What are the last points to focus on for return to play for calf muscle injuries?
A4. Steady-state running is the final stage for soleus injuries. For gastroc injuries, accelerations and explosive jumps should form the final stage of rehabilitation.

Q5. Should rehab focus on single leg max before impact exercises?
A5. Yes, use the baseline to assess and focus on one rep max.

Q6. Is it advisable to also check ankle dorsiflexion as part of calf rehabilitation?
A6. Yes, but a full range of movement should be achieved through calf raises anyway.

Q7. Are there any special tests for calf strains?
A7. Tests are just functional, and the injury can be isolated depending on the knee position.

Q8. Can calf pain radiate to the knee?
A8. It can through nerve compression with severe tears.

Q9. Are there any differences between women and men for calf injuries and rehab?
A9. There aren’t any specific differences, but it’s important to be aware of the menstrual cycle. The goals are the same for both women and men.

Q10. Can an optigate be used for assessment/ measurement?
A10. Ground contact time is a good measure, and an optigate would be a good addition.

Q11. Can foam rolling be used to help with scar tissue alignment?
A11. Early loading and manual therapy are best to assist with the alignment of scar tissue. A foam roller is probably too large, but a small ball may be effective.

Q12. Are interior tibialis exercises recommended?
A12. Yes, it’s important to train the smaller muscles around the foot and ankle.

Q13. Is a different approach required where an athlete has suffered multiple calf muscle injuries?
A13. It is advisable to delay the return to play to ensure the athlete is ready to accept the load. Practitioners should keep tabs on athletes with multiple injuries and consider increasing the load slowly.

Q14. How should soleus tightness be treated in comparison to a tear?
A14. Advise to treat it as a tear initially and review progress accordingly.

Q15. What are your thoughts on ice and the potential for delayed tissue healing?
A15. I recommend the use of ice to help reduce inflammation and pain in the early/ immediate stages after an injury. Some of the benefits may be psychological, as it gives the athlete something to focus on in the early stages.

Q16. Which baseline tests would you recommend for calf injury rehabilitation?
A16. Jump and hop tests are good. Single efforts and capacity tests also provide a good measure.

Q17. How would you advise to load the calf complex effectively?
A17. Work on the anterior chain and posterior chain. Work together with the strength and conditioning department.

Q18. Do you use ultrasound for calf injury rehabilitation?
A18. No but diagnostic ultrasound can be used to support assessment of a calf injury.

Q19. Is a neural assessment recommended for a calf injury?
A19. Nerve problems are unlikely, so a neural assessment isn’t essential but could be done as an extra outcome measure.

Q20. Do you use kinesiology tape for calf injuries?
A20. Yes, where requested by the player and where they have used it before to assist with confidence and a feeling of security.

Presentation Recording

The recording Steve’s presentation is available to watch here

Follow Steve Phillips

Instagram @ste_physio

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