The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians

Key points

1. 01A systematic clinical examination distinguishing gastrocnemius from soleus involvement guides diagnosis, prognosis, and early management decisions.
2. 02Functional progression through six rehabilitation phases, from early therapeutic loading to full sport-specific reconditioning, was the consensus approach; pathology on imaging was considered secondary to clinical progress.
3. 03Premature return to running was identified as the leading cause of early recurrence; a slight delay to build adequate strength and plyometric capacity was endorsed.
4. 04Athlete monitoring throughout rehabilitation and after return to play is critical, as more than 50% of recurrent injuries occur during rehabilitation or soon after return to play.
5. 05No universal prevention program was identified; instead, a hierarchy of individualised load management, sport-specific exposure, and targeted strength and plyometric training was recommended.

How it was conducted

Design

Qualitative study using in-depth semi-structured interviews analysed with inductive thematic coding (constant comparative analysis, grounded theory principles)

Participants

20 expert clinicians (sports physiotherapists and clinician-researchers) from 9 countries, working in elite sport across football (soccer), Australian Football, rugby, athletics, Olympic sports, ballet, cricket, and collegiate sports

Recruitment

Purposive sampling from publicly available information and investigator networks; recruitment continued until data saturation

Data collection

Face-to-face (n=9) or video platform (n=11) interviews ranging 35 to 98 minutes; verbatim transcription

Analysis

Two coders (BG, TP) undertook independent familiarisation and thematic coding using NVivo v12.1.0; three primary categories: clinical evaluation, rehabilitation and return to play, and prevention

Primary outcomes

Practices and perspectives on assessment, management, and prevention of calf muscle strain injuries

What they found

• 20 of 26 invited experts completed interviews (3 not contactable, 3 opted out); interviews ranged 35 to 98 minutes.
• 50% of participants worked full time in elite sport; 65% had research experience, with 69.2% of those having completed a PhD.
• Soleus injuries were most prevalent in long-distance running, Australian Football, and football (soccer); gastrocnemius injuries were most prevalent in rugby, ballet, basketball, and sprinting.
• Experts preferred to wait 1-2 days before imaging in most cases; MRI was used in approximately 80% of cases but was not considered the primary prognostic guide.
• Return to play criteria included: self-reported pain VAS 0/10, palpation tenderness 0/10 over 0 cm length, single leg calf raise capacity of at least 30 repetitions with asymmetry no more than 10%, loaded strength meeting sport-specific benchmarks, and power asymmetry no more than 10%.
• Minimum loaded calf strength benchmarks for injury prevention varied by sport: sprinters and rugby players at least 2 x bodyweight (knee extended); Australian Football 1.0 to 1.5 x bodyweight; soccer 0.8 to 1.0 x bodyweight.
• Single leg calf raise benchmarks: at least 30 repetitions to fatigue with asymmetry no more than 10% for both return to play and prevention screening.
• Running early (at or before 4 days) following lower limb muscle strains in 70 Australian Football players (approximately 25% calf injuries) was associated with elevated risk of subsequent injury after return to play.
• Susceptibility to recurrent calf muscle strain injury remains elevated for approximately 4 months after return to play, longer than most other muscle strains.

Limitations

• Qualitative design: findings represent expert opinion rather than directly measured patient or athlete outcomes, and qualitative approaches carry inherent risks of interviewer and author-team bias.
• All participants were required to speak English, potentially limiting geographic and cultural diversity of perspectives.
• Participants had diverse clinical backgrounds and did not all have expertise in every topic area discussed, so some responses may reflect partial rather than comprehensive experience.
• No quantitative outcome data were collected, so effect sizes, recurrence rates, and comparative treatment efficacy cannot be determined from this study alone.

Why it matters

For patients

Athletes who sustain a calf muscle strain can expect that a thorough clinical examination, not just a scan, will guide their recovery, and that rushing back to running or sport carries a real recurrence risk that may lead to a longer overall absence.

For clinicians

Clinicians should use a structured six-phase rehabilitation model driven by functional milestones, prioritise soleus load tolerance before dynamic activities, and continue monitoring exposure and calf capacity for at least 2 months after return to play to reduce recurrence risk.

For readers

This paper provides a practical consensus-based framework for calf muscle strain injury management grounded in elite clinical experience, filling an evidence gap where few high-quality intervention trials exist.