Calf Muscle Injuries in Youth Soccer: Causes and Treatment
Gerry Delahunt is a sports physiotherapist residing in England. He has worked with professional teams throughout his career and is providing his wide range of knowledge to Football.com in order to help youth soccer players, coaches and parents learn more about soccer injuries.
Muscle injuries are commonplace in soccer and are frequently sustained in training and playing. These can occur either through direct contact or non-contact mechanisms.
The management of non-contact muscle injuries such as those sustained by a sharp pull-up while running, for example, needs to be differentiated from direct contact injuries that normally result from a kick by an opponent or collision with another player.
It is important to make this early differentiation between the two types of injury mechanisms, because although the initial treatment is the same - rest, ice, compression, elevation - there are different signs to look out for and complications that can easily occur.
In this article, however, we will look at the non-contact muscle injuries; and specifically non-contact muscle injuries to the calf.
Understanding Muscle Injuries
When dealing with muscle injuries it’s important to have a knowledge of the different kinds of injury that players can sustain. A simple muscle strain is defined as the tearing of a few fibers. This happens when the force of muscular contraction exceeds the capability of the muscle to resist the force and inevitably something has to give.
With muscular strains, the injury usually happens at the weakest point. In the calf group, which is formed by the combination of the soleus, gastrocnemius, and plantaris muscles, the weakest point lies in the lower calf where the soleus and gastrocnemius muscles merge to form the Achilles Tendon. This area is known in medical terms as the musculo- tendinous junction; and because tendons have a lesser blood supply than muscles, they don’t heal as quickly.
The function of a tendon is to join muscle to bone, and tendons are formed of a different constitution. This difference in tissue make-up means that an injury to the musculo-tendinous junction of the calf won’t heal as quickly as the muscle fibers in the main body of the calf will; but will be usually be quicker than an injury to the Achilles Tendon itself.
Recurrent calf muscle strains can be difficult for a soccer player, and an average calf strain often results in a four to six week absence from the game. Calf strains can be sustained through sharp, sudden movements or by overuse leading to metabolic fatigue.
The classic sign of a footballer struggling with fatigue is somebody playing with the socks rolled down to the ankles. This is because the body is trying to get more nutrients to the muscles, and tight socks restrict the circulation and make it feel as though the muscle is wanting to ‘cramp-up’. This is often followed by a painful muscular spasm that forces the player to have to stop and stretch. Sometimes the intensity of this spasm makes it impossible for the player to relieve this individually and often requires a team mate or trainer /coach to deliver a passive stretch to ease the muscular tension. Cramps can be painful; and the associated spasm can be quite intense.
When this happens, care is needed because muscular cramp can often lead to a strain; since tired or fatigued muscles are more likely to be injured; particularly in the later stages of the game (Reilly et al, 2008).
Although muscular cramps can be temporarily relieved by stretching, they invariably return a few moments later. By that stage though, the body’s energy sources are almost depleted, and if someone tries to play on despite severe muscular cramps then a strain is almost certain to result.
The Importance of Calf Muscles in Soccer
In soccer, the injuries are often specific to the nature of the game. The calf muscles are the running muscles; the ones that keep players on the go throughout the entire duration of the game but are among the first to tire or fatigue. We will discuss the difference between true fatigue and tired muscles in a later article, though, but for the moment let’s regard the calf muscles as being important for just getting around the field.
The calf group is made up of three muscles, often referred to as the ‘Triceps Surae’, and comprise of the gastrocnemius, which is the superficial and often bulky area of the calf situated in the upper half of the lower leg; and the soleus muscle, which lies deeper and originates behind the fibers of the gastrocnemius. A third muscle comprises the trio, known as the plantaris muscle, and this is a deeper muscle running along the posterior aspect of the tibia.
As we said earlier, these muscles blend to become the Achilles tendon, which attaches to the heel bone, or calcaneus. Together, the Triceps Surae are the muscles involved in providing the movement to the ankle joint by pointing the foot downwards; thus lifting the heel off the ground to propel the body forward in the running action.
Individually, the soleus muscle is important for ankle mobility, while the gastrocnemius affects mainly the knee.
The gastrocnemius is considered a high-risk muscle for injury due to it’s action as a two-joint muscle; affecting movements of the knee in addition to those of the ankle (Brukner and Khan, 2012). The gastrocnemius muscle divides into two heads, medial and lateral, and injuries are common; typically presenting with unilateral pain, normally in the medial head of the muscle, or at the musculo-tendinous junction (Bryan Dixon, 2009). Academics agree that the plantaris muscle is rarely involved in calf strains (Armfield et al, 2006).
The Types of Calf Injuries
The calf muscles are frequently injured in older players and adults, but less so in the younger population. Calf strains commonly occur in growing adolescents.
As the running muscles, these are involved in just about every lower limb activity in soccer. This includes providing dynamic stability to the ankle joint, and assisting in the power required to jump and challenge for a high ball, especially on landing. Injuries to the calf muscles are reported to occur broadly across the different positions in football and can strike at any time.
Like most injuries, calf muscle strains can occur as the result of a sharp pull up while running for example, or by a gradual niggle that slowly develops into something worse. Calf strains were reported to comprise 3.6% of all injuries recorded in a 5 year study of soccer players by Armfield et al, (2006).
Injuries sustained through gradual development are often the most difficult to deal with. The injury will have had at some point a single, specific trigger leading to the pain but frequently this will be overlooked and the player will continue to train and play. This is particularly true of minor injuries which may not be considered as being serious enough to impact on training and playing, but all the while are slowly worsening until it gets to the point where the player is simply unable to continue.
By the time it gets to this stage the damage will have been well and truly done, and what originally began as a partial tearing of a few muscle fibers may well have morphed into a fully-blown Grade 2 muscle strain in a matter of weeks.
Injuries to muscles and ligaments are graded according to their severity.
Understanding How Injuries Are Graded
A Grade 1 muscle strain is simply the tearing of a few muscle fibers and will heal relatively quickly.
Grade 1 injuries are generally more of an irritation than an actual injury problem as such, and rarely take longer than 10 to 14 days to heal. The danger with Grade 1 minor injuries is that the tendency to return early to play isn’t usually based on science or recovery rates, the player returns to play simply because he or she reports that they “feel fine”. This is particularly true when Grade 1 injuries are sustained by youth and adolescent players.
“Kids are quick healers!” is the usual response from eager parents and coaches, keen to get their youngsters back into the game before they are ready to properly return. This in turn can lead to a recurrence of the original injury, except that second-time around these take a lot longer to heal; and so instead of a standard 10 day injury you are now looking at a three-week injury.
If your player has rushed back to play after only 7 days and the injury hasn’t healed properly, that becomes the point where the clock starts ticking again. If this happens on a few occasions, you can soon find that your player is missing for six or seven weeks with what should have been a relatively minor 10 day injury had this been managed correctly in the first place.
Grade 2 injuries involve more than a few muscle fibers and take on average anything between two and six to eight weeks.
Depending on the extent of the injury, however, this can be considerably longer. The injury grading system for musculo-ligamentous injuries is really only a guide and as you can imagine, injuries fitting into the Grade 2 category will vary from very mild Grade 2 injuries which are little more than sub-acute Grade 1 injuries, to severe Grade 2 strains with the greater percentage of the muscle fibers torn than not. At this end of the scale these Grade 2 injuries are in essence bordering on being Grade 3 complete ruptures.
It follows then, that the recovery period for injuries categorized as Grade 2 will be variable; and this explains why in so many cases different players with the same (theoretical) injury grading will vary so much in their response to treatment in terms of training days lost and absence from the team.
In healing terms, the body doesn’t replace like with like, therefore damaged muscle fibers are repaired using a form of scarring; which makes the likelihood of further injury a strong possibility if the healing process is disturbed too soon.
Hagglund et al (2006) indicated that the biggest risk of recurrent or repeated injury comes from having sustained a previous injury to the same structure; so if you try to come back to play too soon then you are simply increasing your chances of sustaining a similar injury in the future (Orchard et al, 2005).
Although the research on recurrent injuries applies to all injuries, this is particularly true in the case of muscle damage. Healing needs to be complete in order for the injured tissue to be strong enough to withstand the demands placed on the body. After the acute stage where ice and rest are the priorities, treatment generally consists of heat applications, gentle massage and stretching, plus specific exercises to strengthen the muscle.
Soccer places a high demand on the muscle tissues due to the requirements of the game, therefore in the later stage of injury treatment the emphasis changes to active exercise with a focus on strengthening and stretching.
Grade 3 muscle injuries constitute a complete rupture of the muscle and can sometimes require surgical repair.
Often a severe Grade 2 calf tear involving a significant percentage of muscle fibers can be confused with a Grade 3 tear; since the symptoms are often the same. In older adolescents, the feeling of a sharp pull in the calf muscle often resembles being kicked from behind. This normally occurs when suddenly changing direction and / or increasing or decreasing speed on the field. The same feeling can occur when jumping for a high ball or even in landing afterwards.
Muscle tears are all influenced by forces and angles; and if the forces acting on the muscles are out of proportion with the angles of the joints this leads to an increased injury risk. Similarly, quickly stopping, starting or changing pace can have the same effects. Muscular injuries of this type are impossible to prevent; but the risk of sustaining avoidable injuries can be lowered though the correct techniques of warming-up beforehand and cooling-down after a game or training session. This will also be addressed in a future article.
Treating Calf Injuries
Most calf injuries are sustained through running, and as we said at the beginning of the article, vary between sharp, sudden ‘pulls’ and a gradual onset of stiffness and / or discomfort which leads to a muscular strain. The treatment of either kind is essentially the same.
The importance of early cold applications are essential to any soft-tissue muscle injury, since ice reduces pain through having a sedative effect on nerve endings and also reduces swelling. When a muscle tears, it bleeds into the adjacent tissues; and the early application of ice helps to limit this in the early, important, stages of injury treatment.
By restricting the damage to the muscle through the colder temperatures, the increased flow of blood to the injured area can be limited through early applications of ice-packs which will help to minimize swelling.
It’s important at this stage not to increase the blood flow to the affected area by applying any form of heat, or by introducing any form of massage treatment until the acute phase has passed; usually after about 4 - 7 days but this is often variable. A minor Grade 2 muscle strain will have passed the acute stage after only a few days, while a severe muscle injury will naturally take a few days longer. In the case of the latter, it can take up to and including 7 – 10 days for the acute stage to comfortably pass.
As we’ve mentioned in previous articles, the acute stage is often the most vital in terms of immediate injury management since this is where the application of correct treatment principles can really make a difference. If you can withdraw your player from the field as soon as he or she indicates that an injury has been sustained, and then follow that up immediately with applications of ice and a cold compress (ideally with the limb in elevation), then you are well on the way towards a complete recovery.
However, although calf injuries with a specific injury mechanism such as a sharp pull-up while running for example, are usually what they appear to be; unexplained calf pain without specific cause or incident can be a warning sign that a serious underlying condition might be present.
In this case an examination by a physician is essential; since the symptoms mimicking a calf muscle strain may be hiding a more serious pathology of a medical nature as opposed to a straight-forward injury.
Pain arising from a deep vein thrombosis (DVT) will be felt by applying a passive stretch to the calf muscles and may present with symptoms similar to a muscular strain, therefore DVT should be excluded by a physician without delay. Additionally, thrombophlebitis, cellulitis, osteomyelitis, and intermittent claudication can all be underlying and more serious causes of unexplained calf pain. If in any doubt, it’s better to have these checked by a medical doctor as soon as possible in order to be safe.
Calf muscle strains are more common in the youth and adolescent age groups in soccer, but younger children can and do sustain simple muscle strains as well.
In all cases, obtaining an accurate and early diagnosis is essential; not only in respect of the injury sustained but also to exclude the possibility of the presence of other more serious and less straight-forward pathologies than a simple muscle strain.
It should be stressed that this applies not only to muscle strains of the calf, however, since complications can occur following most injuries, whether sustained through soccer or otherwise. Although complications are relatively rare, the need for medical opinion and advice should always be sought in order to eliminate the potential for underlying medical conditions presenting as musculo-skeletal injuries.
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Bryan Dixon J (2009). Gastrocmenius v soleus strain: How to differentiate and deal with calf muscle injuries. Current Reviews in Musculoskeletal Medicine. Vol. 2 (2); 74 – 77.
Hagglund M, Walden M, Ekstrand J (2006). Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. British Journal of Sports Medicine. Vol.40, 767 – 772.
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