[Physio Discussed] Calf injuries: from assessment to return to running with Brad Beer and Dr Brady Green

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How should we be profiling physical capacity following a calf muscle strain injury?
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And what are the key strength and reactive qualities we need to restore before returning someone to running?
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And how much attention should clinicians actually be paying to footwear during calf rehab and return to running?
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Today we cover all of this and more as we take a deep dive into calf muscle strain injuries.
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To do this, we're joined by Brad Beer and Dr.
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Brady Green.
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Brad is an APA-titled sports and exercise physiotherapist and principal physiotherapist at Pogo Physio.
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He brings extensive clinical experience in the assessment, rehab, and return to performance of running and sporting injuries, with a particular interest in translating complex rehab principles into practical clinical decision making.
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Brady is a physiotherapist and researcher whose work has extensively explored calf muscle strain injuries, bringing together the latest research with its application in clinical and sporty environments.
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His research has helped advance our understanding of calf injury risk factors, prognosis, rehabilitation, and recurrence, particularly within high performance sport.
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Together, we explore the intersection between research and clinical practice, from diagnosis and profiling physical impairments through strength and plyometric rehabilitation to return-to-running decision-making, footwear, and imaging.
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You're going to get so much out of today's episode.
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I'm Sarah Yule, and this is Physio Disgust.
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Well, Brady and Brad, welcome and thank you so much for joining us today.
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I'm really excited about this podcast.
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Thank you very much for having me.
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Yeah, likewise, Sarah, it's uh a professional honor to be on the Physio Network platform.
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It's been the the original and still such great content that comes out.
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I'm a regular listener to this day.
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Thank you.
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What a shining introduction.
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Well, let's launch into it.
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Brady, perhaps we can start with you.
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If we look at the current state of the literature around calf muscle strain injuries, what do we understand considerably better now than what we did perhaps five or 10 years ago?
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Yeah, really good starting point.
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I think we're starting to make some ground regarding understanding pathology, understanding potential return-to-play time frames with particular injury types and also potential recurrent susceptibility regarding pathology.
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But the work isn't done just yet, and we've got plenty more to sort of tease out within those areas.
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I think also in recent times, there's been some really good work within profiling physical capacities, diagnosing particular impairments of the calf muscle tendon unit.
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And that's certainly been a strength, I think, in the research direction that has hopefully helped clinicians guide their practice.
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And no doubt we'll chat about the ins and outs of that particular area.
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But similar to pathology and anatomical location, the work isn't done.
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And I think we'll have some more exciting work within that space as well.
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Fantastic.
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And Brad, I'm sure you've got plenty to add here as well.
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Well, Sarah, I'm a full-time clinician, and I've been treating many calf muscle strain injuries in the last decade in clinic.
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But one thing, Sarah, I find very challenging about this presentation is just how blind we seem to fly in a clinical setting with regards to some of the emerging literature and then applying that into the day-to-day bread and butter clinic with athletes that aren't being monitored in a professional sports setting 24-7.
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So my comments probably aren't really literature-based, but more experiential-based at the coal face as a full-time practitioner.
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And my own practice has evolved, largely led by the work of Brady and his team, who have informed us, as Brady just mentioned, around return to play time frames, pathology, and how that feeds into rehabilitation.
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But it's still, I find it's a challenging area.
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So we've come a long way, but I think there's still so much that we need to better manage these injuries.
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I'd love to get a little bit more granular with it.
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Do you have any examples of how your practice has changed?
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Yeah, clinically, the work of Brady and Co.
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informing us around the variances of Sileas versus gastroc return to run in prescriptions.
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I think most practitioners that take an interest in the evolution of our understanding of rehabilitating calf muscle injuries will have heard Brady or one of his colleagues talk about avoiding plotting on return to a Sileas-based run-in program.
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That's a very practical example, Sarah.
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And then profiling, looking at predisposing risk factors.
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We know about the aging athlete, the athlete with a prior history, but also just our ability to objectively measure so much now in clinic, whether that's with four steps, you know, I think that's been a big change.
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And it's nice to engage patients where that's appropriate and where people have the technologies with some of those metrics in terms of helping people buy in and understand their impairments and hopefully reduce risk of recurrences.
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That probably my two off-the-cuff major things I can think of.
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Fantastic.
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And perhaps, Brady, for those of us that haven't heard of avoiding plodding, can you give us a higher level?
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Oh, so one thing I just wanted to add to Brad's good points there is I think what he's describing is really, you know, that intersection between clinical practice and research regarding some of that profiling work and measuring and diagnosing capacities and then doing something about it clinically in order to optimize rehab progression and reduce recurrent susceptibility.
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And why I say that is even if we look at historically what we know in terms of risk factors and some of those historical risk factors that show strong evidence, like having a previous history of a calf strain or like being older, there are certainly modifiable features or factors within a patient that could moderate how strongly those non-modifiable factors impact injury risk.
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And so, what I mean by that as well is an individual's level of strength, their force production, their level of or their proficiency of stretch shortening cycle actions during the stance phase of running, as an example.
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So I think probably where we need to get to with clinical practice and research is recognizing that there are these things that we can act on to impact risk factors.
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And not only can we measure and diagnose and impair our patients with that info, but we can do something about it with our loading prescriptions.
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Far more empowering telling someone to get stronger than get younger, hey.
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Yes.
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Brad, I'm curious, taking that into clinical practice then, what do you think are the top three perhaps mistakes or opportunities that we can correct that you see practitioners making when rehabbing calf muscle strain injuries?
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There's many things I could probably point to here that I've made myself, but I think understanding the mechanism behind the presentation and noting that Silaeus can, from my clinical experience, you can't always pinpoint a mechanism, even that sort of insidious onset, it can sometimes be a bit more elusive.
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So I think just getting clear on the mechanism and the training workloads around that also incorporate in their day-to-day activities, including hobbies, where they're walking around for a long period of time the day before they incurred this soft tissue injury.
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So I think a mistake would be to not gather that information clearly.
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Another mistake, Sarah, would be returning the athlete with progressions for conditioning or progressing the athlete too quickly.
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That's that fine balance of monitoring clinically and trying to at times please your patient with progressions.
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And I think one of the real challenges in private practice is you don't get that day-to-day contact.
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So you're trying to make inferences about a week's time and if you don't see someone for two weeks.
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And I think Brady, having spent time at football clubs, would would appreciate that it's a different environment to private practice.
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And so I think a mistake is too much too soon.
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And then probably the third mistake is not impressing upon the athlete enough the need to continue to pay their taxes with regards to offsetting the risk of what is now something on their scorecard or calf muscle strain injury, particularly the aging athlete, which is all of us.
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So I think that would be the third, Sarah.
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Brady, do you have anything to add on top of that?
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Great points from Brad again.
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And I think ultimately at the start of the podcast, we talked about pathology and anatomical location.
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And from a pathoanatomical perspective, we can have patient A versus patient B who have the same pathology on the scan, but very different underpinning reasons for picking up their calf strain.
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And like Brad's describing, if we don't tease out components of onset and mechanism, their specific impairments, and think about their actual re-exposure and the rate that we're reconditioning them from an isolated strengthening or power or plymetric perspective, as well as from a running perspective, we potentially don't have optimal outcomes in terms of achieving that return to full train or return to play.
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And we also potentially have that ongoing recurrence risk, which we know, unfortunately, for CAF within the literature.
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We have this really protracted period after return to play or return to full training that individuals remain susceptible.
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And that means that we have an ongoing challenge and we have to continue to implement preventative loading and load management potentially for the rest of that season or for the rest of the year or whatever it is.
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I've sort of got two questions that fall out of what each of you have said, but on that idea around the almost protective amount of strength training, what sort of conversation should we be having with patients around what is the protective amount of strength or amount in the reserve that will buffer that risk?
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Right, and I'll let you lead with your any literature insights there.
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Yeah, I think we that's a good point, Brad.
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And we can start off with some data that we'll have out there hopefully really soon, where we actually did some longitudinal monitoring of Silius MVC in Australian football athletes.
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And we demonstrated from repeated measures that individuals actually have the ability to from baseline, so in the preseason to early in the competition season, have an uptick in their MVC in seated position, and then they also have the capacity to maintain that strength over the course of the season, or at least that was the normal trajectory that we found within that data set in those athletes.
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And I think the practical takeaways from that is that in a population where you are doing isolated calf loading to some extent, we should be able to have that incremental rise in strength.
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And then even in and around competitive match play, training demands, and so forth, we should be able to retain that strength, if not improve it.
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And if for whatever reason we're detecting a reduction in strength, if we're having a bit of a drop-off in terms of our preventative loading and we get a decay in strength, the data would suggest that's not a usual pattern and that we should do something about that.
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So I think the devil within the detail around long term, we have evidence that we can improve and then maintain strength.
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That backs up the fact that we should be hopefully doing some form of isolated calf loading, whether that's strength-based loads, whether that's different polimetric progressions that we know will build calf capacity as well.
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Great.
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And Brad, your thoughts?
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I was just gonna ask Brady there, Sarah.
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Uh, in that form of isolated calf loading might be just static after a period of time in terms of not progressive across this longitudinal period, Brady, or always progressive or not possible?
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Oh, I think within that, it probably depends on an individual's window for adaptation that they have.
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And sort of coming back to our early points around profiling the individual.
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Say if we have that person that we test them at baseline and they've got an MVC of 1.8 times body weight early in season that jumps up to over double body weight.
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We know, at least in our data sets, that only around 5% or 5 to 15% of the athletes we've tested have above double body weight in an end-of-range dorsiflex position seated.
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So, in that particular person who's well developed in terms of their strength, how much do we gain from still trying to push the envelope and get further rise in that strength across the course of the season?
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That could probably be rightly debated.
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And equally, in that particular person, if they do pick up, say, a low-grade Sileas-based pathology, how much is that related to the stract that the fact that they are weak?
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Well, their data would suggest that they haven't strained their calf because they're weak.
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They've perhaps strained their calf because it could be a stiffness deficiency, an MTU stiffness deficiency, it could be a load management issue with their field-based training or their match-related running workloads.
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And so, in those particular people, if we've identified that, hey, they're going to get the biggest bang from their buck from their stiffness work and their elastics, then that becomes the avenue of prevention for them.
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So I think, yeah, the devil in the detail there, good question, Brad, is probably around profiling that person and where do they sit and what can we expect.
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And the last thing I'll say on that is say if you do have the person, the older athlete or the aging recreational athlete who at baseline they show weakness, or over the course of the season, they show a decay, so their strength is declining.
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That's evidence we need to do something about that.
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And is that go harder on force production?
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Is that there's some issue with load management exposure?
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Are there other impairments that are impacting their calf fatigue ability?
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The point there is that we go to work on identifying what's happening within that individual.
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And Brady, thank you, Sarah.
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I I clinically have this basic drawing that I don't even have printed off, but I draw it each time.
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I don't know how many times I've drawn it, but it's I guess it speaks to that how much what is the preventative amount of strength training for an athlete.
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I'll draw a three-legged stool, and on each leg I'll opt repeated force, so that's how endurance of a calf, peak force, so obviously that speaks for itself, and then uh reactive strength or your plymetric properties.
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And I think it's just knowing your athlete from initial intake in terms of which of those legs might need to be built out, and then I guess my prescription sort of keeps that in mind, which leg has been their more dominant impairment and prescribing with that in mind, Sarah.
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So it's it's gonna vary.
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It comes back to knowing our athletes, and one prescription, I guess, just fundamentally should be different between athlete on athlete A to athlete B.
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So I don't mean to give a political answer there, but that would be my immediate response.
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Yeah, 100%.
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And Brad, you'd see this all the time in the clinic.
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Various athletes, even within that plimetric capability, those athletes who have good, instantaneous, explosive function for several reps, but they lack endurance within their stretch shortening cycle capability, or conversely, those individuals who do have good repeatability within their stiffness work, but they actually lack a bit of that ceiling of output.
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And I think there is scope to even, yeah, refine our run drills, our plyometrics, and our jumps in that regard as well.
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I am looking forward to getting to the return to run stuff shortly as well.
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Brad, that's a great framework, I think.
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And lastly, on this, I just wanted to go back to what you said originally, Brad, around the perhaps errors that practitioners might make.
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Your first point was understanding the mechanism.
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What subjectively, and perhaps objectively, might help you differentiate between, say, a Sileus or a gastroc strain?
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Yeah, I'll keep this simple, Sarah.
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The gastroc may, patient with a gastric strain may have reported its onset around acceleration, deceleration, change of direction, higher velocity running, for example, and as opposed to, in very basic terms, subjective reporting of a Silaeus muscle strain injury, which may be reported as more of a no frank moment in time, a feeling of tightness.
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I'd had about 10 femoral shaft bone stress injuries across my competitive running years, and I used to sort of gloat that I'd never had a calf muscle strain injury, but then I've had two over the 30 plus years of running, and they were classic Sileus mechanism running along, just felt a bit of tightness in my calf, and all of a sudden a few steps later, I'm not running at all.
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That's very basic, Brady.
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You might have anything more to something more to add to that.
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Clinically, when we're triaging, we're thinking about differentiating around those key mechanisms for sure.
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And we also found within the AFL data that injuries that had a gradual, non-specific onset were less likely to have significant connective tissue disruption.
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And that fits with what we see in the clinic.
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So the Sileas saw the gastrocnemius case that limps in and they've had a high energy mechanism, such as an acceleration or high intensity run mechanism.
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And you make the decision to scan it, and surprise, surprise, there's some significant waviness and detensioning and connective tissue disruption versus that more cumulative type presentation and the cumulative failure.
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And we can chat about it a little bit later.
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But I think the architecture within Silias and certain of its structures, such as the lateral aponeurosis, can predispose to a bit of that cumulative stripping and cumulative failure over time.
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And we've evaluated this retrospectively within the straffle data, but also with some stuff coming out hopefully soon where there does still seem to be a prognostic difference around these mechanisms that Brad's describing.
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So a worse prognosis regarding Frank high energy insults versus a more progressive failure.
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And so in the clinic, if we're making decisions around is this a mild versus a moderate versus a long-term type scenario, that's potentially a quick decision-making triage tool as well.
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Yeah, great.
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Anything to add on that one, Brad?
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I keep it pretty basic in terms of framework, looking at how the patient presents, that gate, obviously looking at some of these things before they're even in the room.
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Observation muscle mass, having a good look, their positioning, the differences that may be there side to side.
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And in the kinetic chain as well, just to give it a Craig Purdom's so great at doing this, he'll, you know, I've learned this from Craig over the years, he'll size someone up, so to speak, in terms of their muscle, you know, their muscle distribution.
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And if there's anything that looks a bit different from there, Sarah, I'll sort of go into what in my mind I determine as some little progressive loading tests.
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And I know Brady and team sort of talk about the the look, feel, move over over overlay, and I kind of have that in my head.
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What am I seeing load tests?
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As long as it's stepwise and progressive, I think it's important information.
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I like to get as much objective information as I can in a clinical assessment.
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So even things like RPEs, I think they're often forgotten about, Sarah.
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So look, give me a rating of effort to do that on that side compared to your affected side.
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Just anything that you can get to capture an objective measure point that you may be able to then tie back as you go through rehab to show progression.
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And then, of course, you've got your loading test.
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You know, it'd start with a double leg calf raise, single leg calf raise, I'll progress to higher demands, then might get them to pulse, straight leg, bent legged, always thinking about your differential diagnosis.
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Is this potential bone stress of the lower limb, the tibia?
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Could it be a deep flexor, soft tissue injury, a plantaris injury, calf palpating structure in a systematic way, looking for length of palpable soreness, and then they're probably the big ones.
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You're looking for pain on contraction, pain on stretch, and palpable tenderness.
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Anything you'd add, Brady, just I know they're sort of broad points.
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No, I think that's a really comprehensive, great starting point.
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And then all add to that is as we get going within rehab, we serially assess those same asterisk signs and we can use basic information like that, maximal length of palpation tenderness to tell us about how the person or the athlete is going, and even to identify, not necessarily that they've had an exacerbation, but are they maybe not coping with the loads that they're being exposed to?
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And then within their strength evaluation, too, particularly in the individual who seems to demonstrate good strength, or it could be the problem child that's done six or seven calf strains before, that's where we can think about both ends of the length-tension relationship a little bit more closely.
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And do they actually have residual impairments in their outer range or their inner range strength?
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Because certainly that would be something to make sure we tidy up and clean up with our exercise selection.
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And the quality piece as well, within what Brad's describing.
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So not only can they do certain load-based tests, but what is the quality?
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And a simple example, like with isotonic stress through the calf, is that eccentric phase controlled versus is it a ratchety, shaky contraction and they're telling you that they can do it and that they're pain-free, but you're sort of watching their calf shake and clearly that's visual evidence that maybe they don't have the capacity just there yet within the MTU.
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Quick add on to that too, Brady and Sarah.
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I think there's so much information to capture.
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I remember being at a Sue May's two-day foot and ankle workshop, and Sue would document when and if the the long toe flexes started to claw with one-to-one calf raises.
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And I'm like, all right, I need to incorporate that into clinical practice.
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So I'll keep an eye out for that.
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I'll, like Brady just said, that eccentric phase of the isotonic contraction.
00:23:56.880 --> 00:24:00.160
I'll tend to try and put a numeric around that.
00:24:00.319 --> 00:24:01.920
When do we see that eccentric?
00:24:02.079 --> 00:24:08.880
So, in a basic calf test, you might have reading of perceived effort, left symptomatic versus asymptomatic.
00:24:08.960 --> 00:24:12.079
You might have reps where long toe flexes come on.
00:24:12.240 --> 00:24:16.960
You might have just quality of movement, you might have reps where eccentric control is lost.
00:24:17.119 --> 00:24:18.720
You might have total reps.
00:24:18.799 --> 00:24:20.319
There's so much to be gained.
00:24:20.480 --> 00:24:22.079
I think it's a good reminder.
00:24:22.160 --> 00:24:26.160
And I've been experiencing this through my specialization journey that I'm on at the moment.
00:24:26.400 --> 00:24:28.319
There's so much to be had in an objective exam.
00:24:28.400 --> 00:24:33.839
We've just got to have eyes to see and ears to hear and you know, try and put it together without overcomplicating it.
00:24:34.240 --> 00:24:35.279
It's a fine balance.
00:24:35.359 --> 00:24:39.440
It's often the hardest thing is to make the complex simple, isn't it?
00:24:39.759 --> 00:24:43.200
So I think this is a good time to move into the rehab component.
00:24:43.279 --> 00:24:54.720
And I do have a question about the long toe flexes shortly, but if we move into sort of strength and conditioning, how should clinicians be thinking about developing calf capacity following an injury?
00:24:54.799 --> 00:25:02.799
And I know, Brad, you've already alluded to your three-stool model, but do you mind teasing teasing out your framework and process?
00:25:03.200 --> 00:25:05.039
That's the top of my mind, Sarah.
00:25:05.200 --> 00:25:08.319
The examination items will form the direction.
00:25:08.480 --> 00:25:13.759
Their prior history obviously, you know, it determines what you're going to prescribe.
00:25:13.920 --> 00:25:20.799
But in terms of a framework or how how you just prescribe things, I'm working through those three legs basically.
00:25:20.960 --> 00:25:24.079
And I'll tend to start on repeated force.
00:25:24.160 --> 00:25:28.640
So I just find that's in a simple way, easy for people to be doing things around at home.
00:25:28.880 --> 00:25:38.960
And then at the right time, in terms of clinical markers, tolerance to this, for example, bringing in more formal like gym conditioning, which can exist in concert.
00:25:39.119 --> 00:25:43.200
Other times there might be a delay depending on the severity of symptoms.
00:25:43.440 --> 00:25:54.000
So from home-based repeated force work to gym-based peak force work, somewhere in there, we're going to be throwing in some reactive strength/slash plyometric property training.
00:25:54.160 --> 00:26:05.440
I like to use pulsing in in home programs quite early as a way of exposing that calf muscle tendon unit to a bit more work than just slow isotonic contractions.
00:26:05.759 --> 00:26:10.079
And that's a very simple framework, but it's a big question.
00:26:10.559 --> 00:26:11.039
It is.
00:26:11.200 --> 00:26:11.599
It is.
00:26:11.759 --> 00:26:17.200
And what might some examples of repeated force work at home look like?
00:26:17.599 --> 00:26:23.599
Yeah, I that can be standing single-leg calf raises, calf risers, Sarah.
00:26:23.759 --> 00:26:31.200
That could be time spent doing some stair walk-in, aka suma's stair walk-in for duration.
00:26:31.519 --> 00:26:33.279
They're probably the two big obvious ones.
00:26:33.359 --> 00:26:36.960
It could even be like a wall sit up into a planar flex position.
00:26:37.039 --> 00:26:40.640
There's many ways that you could bring that in at home.
00:26:41.200 --> 00:26:41.920
Absolutely.
00:26:42.079 --> 00:26:49.440
And I'm curious, in terms of your positioning, I know Andrew Wallace was someone that got me thinking about this as well.
00:26:49.680 --> 00:26:54.400
What do you cue for body positioning for things like calf raises?
00:26:54.960 --> 00:27:06.319
Because I know Andrew's spoken a lot about being in a more, if it's a runner, being in that more forward position rather than straight vertical, just to replicate the demands of running.
00:27:06.640 --> 00:27:10.640
Well, very quickly, and then obviously Brady will have a whole lot to offer here and add here.
00:27:10.799 --> 00:27:19.440
But I heard a colleague through this training program I'm on just use a great queue one day for the vertical, and it was right an elevator, just straight up and down.
00:27:19.519 --> 00:27:22.079
So I've started to incorporate that straight up, straight down.
00:27:22.160 --> 00:27:23.599
Obviously, that's the vertical component.
00:27:23.680 --> 00:27:31.039
I think Andre's point obviously to have full context is fair about some forward lean horizontal component, which we know is important.
00:27:31.599 --> 00:27:34.400
I do like to, I'm a bit of a stickler for a metronome.
00:27:34.640 --> 00:27:39.519
I do think that may confer better thought and awareness of what people are doing.
00:27:39.599 --> 00:27:42.960
So, you know, one to one, one up, one down.
00:27:43.039 --> 00:27:50.400
Obviously, the line of force, that first or second toe, just watching for ciclin, falling out over the second or fifth with fatigue.
00:27:50.559 --> 00:27:56.640
And just little tricks, just teaching people about watch when your hips start to get involved and many cues that we can use.
00:27:57.119 --> 00:28:00.799
I'm sure Brady, you've got a you've got probably an hour on this.
00:28:01.359 --> 00:28:02.640
Your thoughts, Brady.
00:28:03.039 --> 00:28:06.160
Nah, again, I think Brad's done a really comprehensive job.
00:28:06.400 --> 00:28:20.000
Yeah, and I guess summarising, like if we strip it back and simplify, ultimately it's that question around what is the property that we're reconditioning, what is the stimulus that we're trying to apply.
00:28:20.240 --> 00:28:33.759
And like Brad mentioned, if we're keeping it simple and this strength endurance work is about vertical propulsion and the vertical component, then it makes sense to be queuing and positioning the body in order to do that.
00:28:33.920 --> 00:28:51.039
And I think early post-injury and while we're redeveloping strength, it's less likely if we have the metronome out, if it's more vertical, if it's queued really well, if it's just that rate of one second to one second, it's less likely that we're going to exacerbate or flare anything up.
00:28:51.200 --> 00:29:07.200
And then after we've had a good level of strength demonstrated, we can bring within the mix, and this is probably where Andrew Wallace is coming from, the horizontal component and coordinating ankle with knee and hip for horizontal force production.
00:29:07.440 --> 00:29:15.839
And I think you can do some really nice drills involving steps and boxes in front of the body, sort of within that intermediate phase.
00:29:15.920 --> 00:29:28.880
I think there's value for a lot of people in pushing the sled or pushing the prowler in various different positions because that's a nice way to start to incorporate, yeah, again, that horizontal force production.
00:29:29.200 --> 00:29:38.720
So summarizing, I think it's really about based on onset, based on patient impairments, based on what you're trying to redevelop.
00:29:39.039 --> 00:29:41.440
What do I need to get from this exercise?
00:29:41.599 --> 00:29:44.400
And then therefore we're doing it in these ways.
00:29:44.799 --> 00:29:46.640
Fantastic framework, as you say.
00:29:46.720 --> 00:29:48.160
It's so individualized.
00:29:48.240 --> 00:29:54.319
So you've both done very well to summarize what is going to be very different for everyone.
00:29:54.559 --> 00:29:59.920
Speaking of another difficult question for you, ready to run and return to run programs.
00:30:00.160 --> 00:30:07.599
I know one of the difficult decisions is perhaps knowing when somebody is actually ready to start running and how they progress through.
00:30:07.839 --> 00:30:11.599
What are both of your return to run criteria, Brad?
00:30:11.680 --> 00:30:13.119
I might throw to you first.
00:30:13.599 --> 00:30:15.039
Yeah, these are you thanks, Sarah.
00:30:15.119 --> 00:30:17.119
These are obviously broad questions.
00:30:17.200 --> 00:30:19.039
That's the nature of physio disgust.
00:30:19.279 --> 00:30:21.279
Obviously, we're not talking about case studies.
00:30:21.519 --> 00:30:24.240
I'm just going to borrow straight from Brady and colleagues on this.
00:30:24.319 --> 00:30:29.680
And they and they talk, um, Sarah, about clinical resolution of symptoms and performance readiness.
00:30:29.839 --> 00:30:35.759
So I think it comes back to understanding the demands of the athlete that you're returning to sport.
00:30:36.000 --> 00:30:38.240
Are they a trail long-distance runner?
00:30:38.319 --> 00:30:39.599
Are they a middle distance runner?
00:30:39.759 --> 00:30:44.559
Are they a on-field athlete, AFL, football, whatever?
00:30:44.880 --> 00:30:51.519
And reverse engineering the demands of that game, of course, to the athlete and how they first presented.
00:30:51.839 --> 00:30:53.119
And then the clinical resolution.
00:30:53.440 --> 00:31:05.920
So we obviously, I shouldn't say obviously, but we do not want feelings of pain, feelings of fatigue, which we know can be associated with a calf that may be at heightened risk of a restrain.
00:31:06.240 --> 00:31:09.839
Feelings of tightness, that will grab my attention.
00:31:09.920 --> 00:31:24.799
And I think if we've done a good process through the rehabilitation as therapists, we've given the athlete these tools to self-monitor and become aware of how to adapt their training around those signs, those clinical signs.
00:31:25.039 --> 00:31:34.240
And return to running from an early stage rehab point of view, I will I just like to see them be able to produce some repeated force.
00:31:34.400 --> 00:31:38.079
And that might be slow calf raises, 20 plus.
00:31:38.400 --> 00:31:41.119
Depends on what who you're looking at, their background, etc.
00:31:41.359 --> 00:31:47.039
You might change that number clinically to more at times if they've had a big history.
00:31:47.279 --> 00:31:51.039
Some degree of stretch-shortened cycle, reactive strength loading.
00:31:51.119 --> 00:31:59.279
So I'd borrowed this from Brady from five years ago, our first online podcast, and that was 20 to 30 single-legg pogo hops as a marker.
00:31:59.359 --> 00:32:04.799
And the quality of those, does it look like they're unaffected leg now, or is there still a quality difference?
00:32:05.279 --> 00:32:09.599
Sarah, and the resolution and symptoms, and I'll start them running from there.
00:32:09.759 --> 00:32:14.079
And depending on whether it's a gastroc or soleus strain, my programming will vary.
00:32:14.400 --> 00:32:15.200
Fantastic.
00:32:15.440 --> 00:32:17.440
Brady, do you have any thoughts on that one?
00:32:17.759 --> 00:32:23.680
Yeah, look, I think all I'll add is calf rehabs and mitigating recurrence risk.
00:32:23.920 --> 00:32:40.720
You're not necessarily going to lose out if you hold your nerve for a few days or several sessions where, as Brad's describing, the patient or the athlete has the ability to do things well versus being just at the level.
00:32:40.960 --> 00:32:45.599
Because we all know those situations where it's like, oh, I think they'll be okay.
00:32:45.680 --> 00:32:47.039
They're probably just at the level.
00:32:47.119 --> 00:32:50.079
Let's do our first run and they get through it.
00:32:50.319 --> 00:32:53.920
But then there are those ones where unfortunately that's not the case.
00:32:54.079 --> 00:33:00.400
And they get 500 meters or a K in, and then they get that progressive tightness and those symptoms.
00:33:00.559 --> 00:33:08.240
And in those situations, it's yeah, a reminder that perhaps we could have been a little bit more rigorous and perhaps we could have seen more.
00:33:08.400 --> 00:33:21.200
But as mentioned, I don't think once we get to the tail end or the back end of rehab, you really lose out with eventual time frames if you just add a bit of rigor and a bit of quality control within this process.
00:33:21.359 --> 00:33:25.839
And as Brad mentioned as well, it can be a bit of a different landscape.
00:33:26.000 --> 00:33:40.079
And if we consider on opposite ends of the spectrum, athlete A, who is young, it's an index or a first-time injury, there's no connective tissue involvement or maybe some subtle delamination.
00:33:40.240 --> 00:33:47.200
They've never strained their calf before and they have no soft tissue injury history, and they've got an entire pre-season behind them.
00:33:47.680 --> 00:33:53.119
Athlete A versus the 30-year-old who strained their calf four or five times.
00:33:53.279 --> 00:34:02.079
They've got more significant pathology, they've got a chondral knee or a chondral ankle, whatever it is, and significant impairments throughout that limb.
00:34:02.319 --> 00:34:07.279
Clearly, your return to run process for athlete B is going to be more involved.
00:34:07.359 --> 00:34:16.639
And with athlete B, that's where I'd throw things in the miss the mix, like the horizontal component regarding strength and also plyos.
00:34:16.960 --> 00:34:29.679
And of course, where you can, we haven't teased this out too much, but getting the force plates out and getting some numbers and having some data behind you to tell you that, hey, RSI is actually looking okay.
00:34:29.920 --> 00:34:36.800
Hey, these various qualities within our metrics actually do look reasonable and stack up left versus right.
00:34:37.199 --> 00:34:39.119
So just on that, that's a great point.
00:34:39.280 --> 00:34:49.199
Let's say we have we're working in a space with access to force plates and testing equipment without overtesting and knowing we've already done our objectives.
00:34:49.360 --> 00:35:00.559
What sort of metrics would you typically list and probably reassess as their on this journey of return to run, return to play, or whatever it is they're getting back to?
00:35:27.889 --> 00:35:43.089
Yeah, so I think um first just a quick shout shout out to Greg Mullings and Chris Hutcho Hutchinson at the clinic, who you know they look after us and make sure that we've got kid available to do these sorts of testing protocols.
00:35:43.569 --> 00:36:07.650
But, you know, if we talk for a moment about that MVC pathway, we can be using testing of our MVC initially submaximally, so lower relative percentages and getting feedback from our patients about simple isometric contraction and isometric force control, which ultimately is a form of training as it is a form of testing.
00:36:07.889 --> 00:36:26.449
One good thing about doing some submax ISO testing exposure is that it also gives you an understanding around how they're going on the pathway to do a max test, because you don't want to be in a situation where it's like, oh, I think they'll go okay with the max test without exacerbating their calf, but I can't be fully sure.
00:36:26.610 --> 00:36:36.529
So if you have a bit of that leading with some submax testing, and one thing that you can have on the pathway too is that progression of ankle position.
00:36:36.929 --> 00:36:45.889
So clearly we're gonna be safer and happier in a more neutral ankle position and then some slight dorsiflexion.
00:36:46.130 --> 00:37:02.849
But as things progress, you'd be hoping to see some confidence to push and produce force in a dorsiflex position, which from some of Seth O'Neill and Mike Lancaster's work, you can have the spirit level out and lining up the knee with the spirit level.
00:37:03.009 --> 00:37:06.130
So like a knees for wall of zero centimeters type position.
00:37:06.449 --> 00:37:22.210
And not prior to the first run, but certainly within a rehab process, you'd want to get symmetry within your strength and strength at a decent level in end-of-range dorsiflexion to normalize that outer range type strength as we talked about.
00:37:22.369 --> 00:37:33.569
I could talk about this for the whole podcast, but then from MVC, when you're in the advanced phase, you can adopt the same position, but change the constraint to rate of force development.
00:37:33.730 --> 00:37:34.049
Yep.
00:37:34.130 --> 00:37:55.650
And that's obviously not something that you do prior to strength resolution, a demonstration of strength, but particularly for more protracted rehabs or big aponeurotic insults, you would want to see that that RFD and that intent is there prior to exposure to your fastest run velocities and your hardest accelerations.
00:37:55.809 --> 00:38:01.650
So a little bit there, but hopefully just a bit of a pathway along that strength evaluation.
00:38:01.809 --> 00:38:05.409
And I've missed a bunch of things, including the plimometric component, Brad.
00:38:05.489 --> 00:38:06.769
So feel free to jump in.
00:38:07.089 --> 00:38:27.409
I just think about a couple of numbers, and obviously there's timing considerations that you make with your athlete, like Brady just alluded to, Sarah, but you know, your peak, peak MVC output isometrically, affected versus unaffected limb, is a number I think we need to have in terms of the three-leg stool model reactive strength index is an important one.
00:38:27.650 --> 00:38:32.769
And I've even at times used the force plate for like pulsing to time to fatigue.
00:38:32.929 --> 00:38:40.929
So I might put the athlete on standing straight, the extended or knee bent, and have them fingertips sort of sternum height on a wall.
00:38:41.250 --> 00:38:47.009
Force plates there, and then have a look at their trace, their force plate trace with an audible cue for metronome.
00:38:47.250 --> 00:38:48.929
And I find it's a nice visual cue.
00:38:49.009 --> 00:38:54.130
You can actually look at the quality of the output until fatigue, and you can compare that left to right.
00:38:54.210 --> 00:38:56.369
And I don't know if there's any science around that.
00:38:56.529 --> 00:39:06.049
I haven't pulled that out every day of the week with runners with calf muscle strain injuries, but there's times for I guess the problem calf patient where I've done that, and I think it's quite a nice visual.
00:39:06.130 --> 00:39:11.489
And I just take a photo of that screen grab, put it on their file, have a look at it down the track.
00:39:11.650 --> 00:39:14.610
That's probably the only other immediate thought there, Sarah.
00:39:14.929 --> 00:39:19.569
I think you've discovered your PhD topic once you've done your specialization, maybe, Brad.
00:39:19.889 --> 00:39:21.650
No, I'll be I'll be done at that.
00:39:22.289 --> 00:39:23.809
That's what Brady's for.
00:39:24.130 --> 00:39:26.210
Oh, well, that's a great summary.
00:39:26.369 --> 00:39:29.329
I'm keen to move on to footwear.
00:39:29.489 --> 00:39:31.969
And I know, Brad, you've got some thoughts on this.
00:39:32.289 --> 00:39:38.130
How much attention should clinicians really be paying to footwear during calf rehab and return to running?
00:39:38.529 --> 00:39:43.170
I'll keep it really simple, just because it could be a big topic, but I've got two views on this.
00:39:43.329 --> 00:39:45.250
We need to know and then we don't need to know.
00:39:45.329 --> 00:39:51.329
And by don't need to know, this is a very noisy world when it comes to footwear now and running.
00:39:51.489 --> 00:39:53.170
It hasn't always been like that.
00:39:53.250 --> 00:39:59.250
It would probably be a reflection of mine from being a junior triathlete at 10 years of age back in the 90s.
00:39:59.489 --> 00:40:10.690
And I think in many ways, and it might be critiqued for being overly simplistic, but I'd like to think that any patient that walks into a consult room or an encounter with a sports-based physiotherapist or physio.
00:40:11.089 --> 00:40:15.569
Could and should be able to get back to the sport they want to do, irrespective of the footwear that they use.
00:40:15.730 --> 00:40:18.130
So I sort of see footwear as a tool.
00:40:18.289 --> 00:40:23.009
If you're taking someone through rehabilitation, you want to have an understanding of what they have been wearing.
00:40:23.170 --> 00:40:26.289
Has that been a moderating factor, a risk factor that may have contributed?
00:40:26.369 --> 00:40:28.289
And we've got the drop considerations.
00:40:28.449 --> 00:40:34.769
Obviously, lower drop confers more work demands on the planar flexors, higher drop takes work away in very simple terms.
00:40:34.929 --> 00:40:43.329
You've got factors like stiffness of the shoe, which can take work away, rocker bottoms, which can shorten the lever arm and reduce work at the calf.
00:40:43.409 --> 00:40:47.170
And then we've got these stack heights, which my gosh, I remember.
00:40:47.409 --> 00:41:01.889
I remember the minimalist movement and uh as a life lifelong sufferer of patellophemoral pain, the joy that I had from minimalist shoes in terms of my knee pain, and then the stacks started to get bigger and bigger over, you know, from about 2010 onwards.
00:41:02.130 --> 00:41:08.690
And I'm not exactly sure as a clinician at times what that does in terms of specifically the calf muscle.
00:41:08.929 --> 00:41:10.529
Brady, you might have some insight.
00:41:10.610 --> 00:41:13.969
So I think we don't need to overcomplicate it, but we do need to be aware.
00:41:14.210 --> 00:41:15.569
It's a perfect summary.
00:41:15.889 --> 00:41:17.250
Brady, your thoughts?
00:41:17.569 --> 00:41:19.250
Yeah, don't overcomplicate it.
00:41:19.329 --> 00:41:20.690
We do need to be aware.
00:41:20.849 --> 00:41:27.250
And I'm always mindful of sudden changes in terms of what people are wearing on their feet.
00:41:27.489 --> 00:41:45.250
I'm also mindful of talking about team sport athletes and field sport athletes, those transitions from a runner to a boot, the actual transition of different run activities within the boot as well, in terms of high-end acceleration, deceleration, and change of direction units.
00:41:45.489 --> 00:41:47.009
I think simple is good.
00:41:47.089 --> 00:42:03.329
And also at times I think the chat around footwear is part of the general chat around foot and ankle health and identifying any impairments in terms of control, stability, the strength component, whatever it is.
00:42:03.489 --> 00:42:19.569
And you do see, particularly in individuals within team sports who do have some significant laxity within their ankle, or they could have an old turf toe or an old syntosmosis injury, and their foot and ankle mechanics aren't actually perfect.
00:42:19.889 --> 00:42:35.969
And yeah, they're picking up recurrent calf strains, or they've had a high grade strain, and that's evidence for you to diagnose impairments locally around the calf that could impact the types of works and load exposures that the calf is facing.
00:42:36.210 --> 00:42:44.529
So I think simple is good on one level, and then also a bit of a pathway to the chat around foot and ankle health more broadly.
00:42:44.849 --> 00:42:49.329
Fantastic summary with a high level of don't overcomplicate it, but be aware.
00:42:49.489 --> 00:42:55.889
And I like what you said, Brad, as well, around the barrier to return to sport or return to run shouldn't be the shoe.
00:42:56.130 --> 00:43:00.289
So you've both done well to answer, as you say, a very noisy question.
00:43:00.610 --> 00:43:12.210
Yep, the patients that bring all of their six pairs of runners into the clinic at times, it's great to see the level of enthusiasm, but it's it can be overly complicated sometimes.
00:43:12.610 --> 00:43:13.489
Agreed.
00:43:13.809 --> 00:43:16.210
So let's move on to imaging.
00:43:16.690 --> 00:43:21.009
Imaging of muscle injuries has obviously advanced and changed considerably.
00:43:21.250 --> 00:43:26.369
What can it tell us now about a calf injury that genuinely changes our clinical management?
00:43:26.610 --> 00:43:28.690
Brady, I might throw to you first.
00:43:29.089 --> 00:43:38.529
Yeah, look, I think the weight of evidence seems to suggest that more significant connective tissue disruption or involvement does matter.
00:43:38.690 --> 00:43:45.170
And there's been a number of studies from different sports and research groups that seems to seem to substantiate that.
00:43:45.329 --> 00:43:55.889
And that makes sense based on the role of different connective tissue structures within the CARF MTU, what their job or what their role is in function, rates of healing, and so forth.
00:43:56.049 --> 00:44:04.289
Probably where it gets a little bit tricky is at times the nuance between grades or pathologies that are side by side.
00:44:04.610 --> 00:44:13.730
And the strength of the evidence also suggests that the largest difference is between our more mild presentations versus our more significant presentations.
00:44:13.969 --> 00:44:25.489
And so the biggest bang for our bark or the largest contrast is in the comparison between those two polar opposite groups, and clinicians can find it challenging in the middle ground.
00:44:25.730 --> 00:44:26.610
I'm going to use the word.
00:44:27.089 --> 00:44:51.170
Grade two, although there's issues within that terminology, but we'll use grade two in that the grade twos are often the hardest because the grade ones turn around really quickly, mild, no connective tissue involvement, and so forth, versus the grade threes are so self-limiting that you can't push them along, even if you tried or if you're being not sensible and things.
00:44:51.329 --> 00:45:01.730
But there are lots of those middle ground, moderate type presentations that some you can turn around really quickly, and some unfortunately take longer than you expect.
00:45:01.969 --> 00:45:05.650
So, you know, probably that's a bit of a summary around the literature.
00:45:05.889 --> 00:45:09.969
Probably my decision-making framework is a top-down approach.
00:45:10.210 --> 00:45:17.489
So, firstly, is an index or a recurrent presentation because that impacts prognosis regardless of pathology.
00:45:17.730 --> 00:45:20.449
Secondly, what is the mechanism of onset?
00:45:20.690 --> 00:45:27.009
Frank high energy insult versus nil specific onset because that impacts prognosis as well.
00:45:27.250 --> 00:45:37.409
Thirdly, is this a Silius or gastrocnemius-based presentation, even though our average return to play time frames are similar on average between these two groups?
00:45:37.569 --> 00:45:43.009
As Brad mentioned, we should have different processes for Silius versus gastrocnemius-based pathology.
00:45:43.250 --> 00:45:50.049
Then within Silius, do we have connective tissue involvement of one of our key aponeuroses?
00:45:50.369 --> 00:45:53.809
And if so, what is the extent of that disruption?
00:45:53.969 --> 00:46:10.769
And within gastrocnemias, probably something I'll say within that is more distal injuries involving that GA, so the deep gastrocnemia saponeurosis that also extend down to involve the FGA, the free gastrocnemia saponeurosis.
00:46:10.929 --> 00:46:23.489
There's certainly emerging evidence that those sorts of injuries, so your type three and type four type presentations according to the Pedrac grading, do take longer to return to play.
00:46:23.569 --> 00:46:28.769
And we'll have some new data hopefully out soon in that regard from the AFL.
00:46:29.089 --> 00:46:33.809
But summarizing, I think there's strong variation in the literature.
00:46:33.969 --> 00:46:46.049
And secondly, I think we can use a top-down approach to reconciling is this mild versus moderate versus severe based on those, you know, five or six steps within the framework.
00:46:46.369 --> 00:46:47.170
Great summary.
00:46:47.409 --> 00:46:49.009
Brad, anything to add there?
00:46:49.409 --> 00:46:54.449
My quick comment would be: I think the clinical front line, use your discretion around imaging.
00:46:54.610 --> 00:47:13.170
We know that we're going to progress rehabilitation based off clinical signs, the end with the end in mind of where we're trying to get the athlete and that higher energy mechanism, greater demands the athlete's returning to some timeline around an event that you're trying to make considerations around.
00:47:13.250 --> 00:47:16.690
I think they're my clinical triggers for when I would use imaging.
00:47:16.849 --> 00:47:25.889
And I think Brady's just done a, as we'd expect, a brilliant job in briefly touching on some of the advances there and current understanding of the imaging side.
00:47:26.210 --> 00:47:27.170
Absolutely.
00:47:27.489 --> 00:47:28.610
It's super tricky.
00:47:28.769 --> 00:47:47.329
Like even if we look at individual data points within in quotation marks, those grade threes that I described, there are data points where there's a return to play in less than two weeks for those types of presentations, which again, if we're entirely patho-anatomical, that's difficult to reconcile.
00:47:47.489 --> 00:48:05.809
But as Brad's describing, if we're rigorous with our clinical process, profiling our patient, working out exactly where they're at right now relative to where they need to be for return to full train or return to sport, then these sorts of turnarounds are more realistic.
00:48:06.130 --> 00:48:21.569
So my final question for the physio listening who sees, or the clinician listening who sees a calf strain tomorrow morning, what's one thing that each of you would like them to do perhaps differently after listening to this conversation?
00:48:21.969 --> 00:48:24.769
I'm happy to lead first there, Sarah, because I've got this highlighted.
00:48:24.849 --> 00:48:26.849
Whenever Brady talks, I'm taking notes.
00:48:27.089 --> 00:48:29.170
So I've got two pages filled up there.
00:48:29.250 --> 00:48:34.369
And what jumped out to me was do things well, not just at the level.
00:48:34.610 --> 00:48:36.449
Like that's clinical brilliance.
00:48:36.610 --> 00:48:39.170
Do things well, not just at the level.
00:48:39.409 --> 00:48:41.489
That's what I'm applying tomorrow, Sarah.
00:48:41.650 --> 00:48:42.610
Thanks, Brady.
00:48:44.289 --> 00:48:45.089
I love that.
00:48:45.329 --> 00:48:46.369
Oh, thanks, Brad.
00:48:46.529 --> 00:48:47.650
Appreciate that, mate.
00:48:47.809 --> 00:48:51.650
Yeah, sort of from my end, a few really quick things.
00:48:51.809 --> 00:48:59.969
I think there are the non-negotiables, the big rocks, like Brad was mentioning, those three points of the stool with that analogy.
00:49:00.369 --> 00:49:04.849
And so people need to be demonstrating those after a calf strain.
00:49:05.089 --> 00:49:15.409
While we're working on the big rocks, the three points of the stool, also just teasing out etiology and teasing out patient A versus patient B.
00:49:15.489 --> 00:49:18.049
Why has this person actually strained their calf?
00:49:18.210 --> 00:49:20.529
And Craig Purdom talks about this as well.
00:49:20.690 --> 00:49:22.929
The calf isn't always the culprit.
00:49:23.170 --> 00:49:30.049
There are people who are overloading calf and they have kinetic chain impairments and load management issues.
00:49:30.210 --> 00:49:33.409
And yes, they're straining calf, but it's not the main thing.
00:49:33.650 --> 00:49:44.529
So I just wanted to make that quick little point around profiling that specific etiology because I think that gives us our biggest bang for our buck in mitigating the risk of recurrence.
00:49:44.849 --> 00:49:47.009
Once again, a fantastic summary.
00:49:47.170 --> 00:49:49.969
Well, Brad and Brady, thank you both.
00:49:50.289 --> 00:49:58.210
I think you've both done a fantastic job of sharing such a practical intersection of the emerging evidence and the clinical experience.
00:49:58.369 --> 00:50:04.769
So we've learned do things well and not just at the level and don't overcomplicate it, but be aware of it.
00:50:05.009 --> 00:50:08.529
So we've got many excellent takeaways from today.
00:50:08.610 --> 00:50:09.489
So thank you both.
00:50:09.730 --> 00:50:11.089
Well, thank you very much for having me.
00:50:11.329 --> 00:50:12.610
Awesome to join you, Brad.
00:50:12.690 --> 00:50:15.569
Yep, likewise, Brady and Sarah, keep up the great work.
00:50:15.809 --> 00:50:16.289
Thank you.
00:50:16.529 --> 00:50:17.569
Appreciate it.