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BJSM Online First, published on October 26, 2017 as 10.1136/bjsports-2017-098362
1
Imaging @ Olympic Park,
Melbourne, Victoria, Australia
2
Diagnostic Radiology, Tan
Tock Seng Hospital, Singapore,
Singapore
3
Department of Medical
Imaging and Radiation Sciences,
Faculty of Medicine, Nursing
and Health Sciences, Monash
University, Melbourne, Victoria,
Australia
4
La Trobe University, Melbourne,
Victoria, Australia
Correspondence to
Dr Ashutosh Prakash, Diagnostic
Radiology, Tan Tock Seng
Hospital, Singapore 308433;
d​ rashutoshprakash@​gmail.c​ om
Accepted 4 October 2017
To cite: Prakash A,
Entwisle T, Schneider M, et al.
Br J Sports Med Published
Online First: [please include
Day Month Year]. doi:10.1136/
bjsports-2017-098362
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.
Original article
Connective tissue injury in calf muscle tears and
return to play: MRI correlation
Ashutosh Prakash,1,2 Tom Entwisle,1 Michal Schneider,3 Peter Brukner,4 David Connell1
ABSTRACT
Objective  The aim of our study was to assess a
group of patients with calf muscle tears and evaluate
the integrity of the connective tissue boundaries and
interfaces. Further, we propose a novel MRI grading
system based on integrity of the connective tissue
and assess any correlation between the grading score
and time to return to play. We have also reviewed the
anatomy of the calf muscles.
Materials and methods  We retrospectively evaluated
100 consecutive patients with clinical suspicion and
MRI confirmation of calf muscle injury. We evaluated
each calf muscle tear with MRI for the particular muscle
injured, location of injury within the muscle and integrity
of the connective tissue structure at the interface. The
muscle tears were graded 0–3 depending on the degree
of muscle and connective tissue injury. The time to return
to play for each patient and each injury was found from
the injury records and respective sports doctors.
Results  In 100 patients, 114 injuries were detected.
Connective tissue involvement was observed in 63 out
of 100 patients and failure (grade 3 injury) in 18. Mean
time to return to play with grade 0 injuries was 8 days,
grade 1 tears was 17 days, grade 2 tears was 25 days
and grade 3 tears was 48 days (p<0.001).
Conclusion  The integrity of the connective tissue can
be used to estimate and guide the time to return to play
in calf muscle tears.
Introduction
Calf muscle is one of the four most commonly
injured muscles in sportsmen.1 MRI muscle injury
pattern in hamstring and anterior thigh muscles
have been researched and used to quantify prog-
nosis and predict the time to return to play (RTP).2–6
However, little research has been performed for
calf injury.
MRI of the calf may not be indicated in all
patients presenting with calf injury, and time to
RTP in injured athletes is mostly guided by clinical
criteria. However, many elite athletes undergo MRI
in suspected calf tears to confirm the diagnosis,
access severity and guide rehabilitation. A previous
MRI study has focused on size and site of tear,
muscle component affected, intramuscular tendon
tear and intermuscular haematoma,7 but did not
focus on the integrity and severity of connective
tissue injury.
Dense irregular and regular connective tissues
form a scaffold to support the muscle fibres. This
connective tissue scaffold is composed of surface
covering (epimysium and aponeuroses) and intra-
muscular bands (intramuscular tendon and aponeu-
roses). Muscle fibres attach to these connective
Prakash A, et al. Br J Sports Med 2017;0:1–6. doi:10.1136/bjsports-2017-098362
tissues, which connect to the tendon. The integrity
of the connective tissue scaffold is therefore vital
for muscle to function normally. Furthermore,
muscle fibres are vulnerable to shear forces at these
muscle fibre-connective tissue interfaces that can
occur during eccentric loading or strain.8
Tendon, aponeurosis and epimysium heal slower
than muscle. The status of the connective tissue
(epimysium, aponeurosis, intramuscular tendon
and free tendon) supporting the muscle fibres may
well determine the healing time in muscle injury,
not just in the calf but in other muscles too. We
hypothesise that disruption of the muscle connec-
tive tissue is a higher grade injury and will result in
longer recovery time and time to RTP.
The objective of this study was to assess the integ-
rity of the calf muscle connective tissue in patients
with acute calf muscle injury. We propose a grading
system and its correlation with time to RTP.
Review of anatomy
The posterior compartment of the leg is divided by
the deep transverse fascia into superficial and deep
compartments. Collectively the superficial poste-
rior compartment muscles of the leg are called the
calf muscle or triceps surae and consist of gastroc-
nemius, soleus and plantaris. The aponeurosis and
tendons of these muscles unite to form the Achilles
tendon.9
Gastrocnemius is the most superficial muscle. It
possesses a higher proportion of type II fast twitch
fibres than soleus, reflective of its function in rapid
locomotion, such as jumping and running.10 Its
two heads arise from two proximal tendon attach-
ments from the femoral condyles and the subjacent
knee joint capsule. Both these tendons expand and
spread out as thin aponeuroses on the posterior
surface of the respective muscle and give origin
to muscle fibres (figure 1A). These muscle fibres
then attach to a broad aponeurosis on the anterior
surface of the muscle (figure 1B–D). The anterior
aponeurosis then gradually condenses as it extends
inferiorly and unites with the posterior aponeu-
rosis of the soleus to form the Achilles tendon.9 11
The gastrocnemius aponeurosis is distinctly shorter
medially and longer laterally.11
Soleus is the deeper muscle of the superficial
posterior compartment. It is a broad flat multipen-
nate muscle, designed for power, with a predomi-
nance of slow twitch fibres and hence contributes
to postural control and walking.12 It arises by tendi-
nous fibres from the posterior fibula head, proximal
one-fourth of the shaft of fibula, middle one-third
of the medial border of the tibial shaft and poste-
rior surface of the tendinous arch between the tibia
and fibula.9 At the origin, there is thickening or
   1
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Original article
Figure 1  Anatomy of gastrocnemius aponeuroses: (A) PD and (B)
PD fat saturated images showing proximal posterior (arrowhead) and
distal anterior aponeurosis (thin arrow) of the gastrocnemius. (C,D)
PD fat saturated images of an athlete with grade 2 posterior soleus
aponeurosis tear and sliver of fluid between gastrocnemius and
soleus muscles; the intermuscular fluid clearly demarcates the anterior
aponeurosis (thin arrow) of the gastrocnemius muscle.
localised aponeuroses on the anterior and posterior aspects of
the muscle (figure 2A). Distal to the origin, there are proximal
intramuscular medial and lateral aponeuroses (figure 2B). These
medial and lateral intramuscular aponeuroses run inferiorly, are
directed towards the midline of the muscle belly and fade out
inferiorly. Proximal muscle fibres arise from these aponeuroses.
Distally the muscle fibres insert into a long central intramuscular
tendon (figure 2B,C), which arises from the anterior aponeu-
rosis of the soleus, and also to the posterior aponeurosis of the
soleus (figure 2C). The central intramuscular tendon and poste-
rior aponeurosis merge to form the soleal contribution to the
Achilles tendon.13 In our experience, the soleus intramuscular
Figure 2  PD fat saturated images obtained through normal (A), proximal (B), mid and (C) distal leg showing anterior (thin white arrow in A and
B), posterior (curved white arrow in A, B and C), medial and lateral intramuscular (block arrows in B) aponeuroses and central intramuscular tendon
(arrowhead in B and C). Plantaris tendon is shown by the thin black arrow in A and B.
2 Prakash A, et al. Br J Sports Med 2017;0:1–6. doi:10.1136/bjsports-2017-098362
aponeuroses and tendon are subject to considerable variation in
terms of number, position and dominance.
The plantaris arises from the lateral supracondylar line of the
distal femur and from the oblique popliteal ligament. The small
muscle belly lies deep to the lateral head of the gastrocnemius
muscle, but the long thin plantaris tendon courses obliquely and
medially, lying between the soleus and the medial head of the
gastrocnemius muscles (figure 2A,B). Distally, the tendon inserts
on the calcaneus just anteromedial to the Achilles tendon.14
Materials and methods
We retrospectively searched our database backwards from March
2017 to September 2015 for patients who were referred for MRI
of the leg to our clinic.
Inclusion criteria
Consecutive patients in the age between 20 and 50 years,
were referred for MRI of the leg with the clinical suspicion and
MRI confirmation of acute calf muscle tear, and with injury
occurring within the previous 2 weeks were included in the study.
Exclusion criteria
MRI-negative studies, patients with delayed onset muscle sore-
ness or muscle overload MRI pattern, Achilles tendon tear,
muscle contusion MRI pattern or history, bone stress reaction,
pre-existing non-healed muscle tear in either leg and follow-up
studies were excluded. Patients were also excluded if they were
out of play for any other reason and if we could not obtain the
RTP details.
Return to play
RTP was defined as time from the date of injury to return to full
competition.
MRI technique
The MRI imaging technique included placing an external marker
(vitamin E capsule) over the area of maximum symptom, as indi-
cated by the patient. All scans were carried out using 3T MRI
scanners. A dedicated surface coil was used to obtain high-reso-
lution image with 2.5 mm axial proton density (PD) and PD fat
saturated axial images, as well as 2 mm sagittal and coronal PD
fat saturated images.
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Original article

Table 1  Grading system for evaluation of calf muscle tear on MRI

Oedema or Connective tissue Connective
fluid adjacent increased signal, tissue
to connective Myofibril delamination or retraction or
tissue detachment defect failure
Grade 0 Yes No No No
Grade 1 Yes Yes No No
Grade 2 Yes Yes Yes No
Grade 3 Yes Yes Yes Yes

MRI evaluation and grading

Three experienced musculoskeletal radiologists evaluated the
MRI of 100 patients meeting the criteria by consensus. They
were blinded to the clinical history, sporting background and
outcome. Each muscle tear was evaluated for muscle involved,
location within the muscle, myofibril disruption and integrity
of the connective tissue. The soleus muscle tear was designated
as proximal or distal, the distal end of the lateral gastrocnemius
muscle belly being the landmark. In addition, each calf muscle
tear was graded 0–3 (table 1). Grade 0 injury was defined as
oedema or fluid adjacent to an intact tendon/aponeurosis/epimy-
sium without myofibril detachment (figure 3). Grade 1 injury
was defined as myofibril detachment without tendon/aponeu-
rosis/epimysium change (figure 4). Grade 2 injury was defined as
myofibril detachment with adjacent tendon/aponeurosis/epimy-
sium increased signal, delamination or defect but no retraction
(figure 5). Grade 3 injury was defined as myofibril detachment
with adjacent tendon/aponeurosis/epimysium retraction indi-
cating failure (figures 6 and 7).
Statistical analysis
The data were analysed using SPSS V.23. Frequency analyses were
carried out to identify the number of injury locations according
to injury grades. Analysis of variance was used to compare the
mean RTP duration periods according to injury grades. A p value
<0.05 was used to afford significance.
Results
Out of 260 studies during the time period, 100 patients met
the criteria. Of the 100 patients, 89 were men and 11 women.
The ages ranged between 20 and 49 years, with a mean age of
Figure 4  (A) Axial PD fat saturated and (B) coronal PD fat saturated
images of a 23-year-old male athlete showing grade 1 muscle injury
of the soleus. There is myofibril detachment without any change to the
central intramuscular tendon. His time to return to play was 14 days.
30.5 years. Injuries were related to various sports and included
Australian Football League (AFL), soccer, rugby, hockey and
running. The majority of the patients were professional or semi-
professional footballers, or elite athletes. Right calf muscle was
injured in 55 and left in 45 of the patients. A total of 114 muscle
tears were detected in 100 patients. Of the 114 muscle tears, 79
(69.3%) were located in the soleus, 31 (27.2%) in the medial
gastrocnemius and 4 (3.5%) in the lateral gastrocnemius. Ninety
patients had a single injury, eight had two injuries and two had
four muscle injuries in a single event.
Of the 79 soleus tears (in 71 patients), 43 (54.4%) involved
the proximal soleus muscle and 36 (45.6%) involved the distal
soleus muscle. Twenty (25.3%) involved the anterior epimysium/
aponeurosis, 16 (20.25%) the posterior epimysium/aponeurosis,
15 (19%) the medial intramuscular aponeurosis, 16 (20.25 %)
the lateral intramuscular aponeurosis and 12 (15.2%) the central
intramuscular tendon of the soleus.
Of the 35 gastrocnemius tears (in 34 patients), 1 (2.85%)
involved the proximal myotendinous junction, 5 (14.3%) the
posterior aponeurosis/epimysium, 15 (42.85%) the anterior
aponeurosis/epimysium and 14 (40%) the distal myotendinous
junction.
There were 66 patients who had injury to only soleus, 29 had
injury to only gastrocnemius and 5 had injury to both soleus and

Figure 3  (A) Axial PD fat saturated and (B) sagittal PD fat saturated
images of a 30-year-old athlete showing grade 0 muscle injury of
the soleus (arrow). There is oedema adjacent to a normal posterior
aponeurosis of the soleus without myofibril detachment. He had no time
out of play.
Figure 5  (A) Axial PD fat saturated and (B) coronal PD fat saturated
images of a 24-year-old professional player showing grade 2 muscle
injury of soleus. There is myofibril detachment. The lateral intramuscular
aponeurosis shows increased intermediate signal intensity consistent
with delamination (arrow in B), but no aponeurosis retraction. His time
to return to play was 30 days.

Prakash A, et al. Br J Sports Med 2017;0:1–6. doi:10.1136/bjsports-2017-098362 3

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Original article

Table 2  Time to return to play (RTP) in patients after calf muscle tear

(n=100)
Range of number of Mean days to
Injury grade Patients (n) days to RTP RTP±SD
0 8 0–20 8.1±7.45
1 29 0–49 17.17±8.84
2 45 0–42 24.69±9.71
3 18 12–70 48±15.95

Table 3  Time to return to play (RTP) in patients after only soleus

muscle tear (n=66)
Range of number of
Figure 6  (A) Axial PD fat saturated and (B) sagittal PD fat saturated Injury grade Patients (n) days to RTP Mean days to RTP
images of a 29-year-old professional player showing grade 3 muscle
0 6 0–20 9±7.58
injury of the soleus. There is myofibril detachment. There is lateral
1 24 0–28 16±6.61
intramuscular aponeurosis defect with retraction (arrow in B). His time
2 29 0–40 23.2±10.66
to return to play was 70 days.
3 7 28–70 52±15.19

gastrocnemius muscles. One patient had injury to both medial

and lateral gastrocnemius muscles.
In patients with more than one injury, they were graded as
per their highest injury. Eight patients had grade 0, 29 grade 1,
45 grade 2 and 18 had a grade 3 injury. Time to RTP according
to the grade of injury is shown in table 2 for all calf muscles, in
table 3 for the soleus and table 4 for only the gastrocnemius.
There was a statistically significant difference between the injury
grade and time to RTP (p<0.001). Figure 8 shows the grade of
injury against days to RTP in a scatter plot.
Discussion
Our study has demonstrated, for the first time, the importance
of connective tissue integrity in calf muscle tears and its correla-
tion with time to RTP. Our proposed MRI grading system shows
correlation between higher grade of calf muscle injury and
longer time to RTP.
Other authors have highlighted the importance of integrity
of the connective tissue and time to RTP. Comin et al15 focused
on the integrity of the biceps femoris intramuscular connective
tissue and showed significant longer recovery time in biceps
femoris tears when the intramuscular tendon was disrupted.
Cross et al16 found the rectus femoris central tendon injury iden-
tified on MRI was associated with a significantly longer rehabil-
itation time.
Similarly, we felt that the integrity of the connective tissue
supporting the calf muscles could be linked to the recovery time.
However, rather than a simple intramuscular tendon, the calf
muscles have a complex scaffold of epimysial boundaries and
flat aponeuroses which support muscle fibres. We therefore
proposed a grading system for calf muscle tears concentrating
on the integrity of the connective tissue as well as the myofibrils.
Our study has shown that involvement and failure of calf muscle
connective tissue are associated with longer time to RTP.
We believe that measuring the extent of muscle oedema or
bleeding for grading a muscle tear is inaccurate. Blood fluid
products travel well beyond the margins of the actual myofi-
bril tear and the margin is usually ill-defined. An analogy can be
drawn with muscle contusions, in which the size of an intramus-
cular haematoma does not always correlate with loss of muscle
function and the usual MRI grading systems used for indirect
muscle injury cannot be applied to direct injuries.17 Likewise,
measurements in the craniocaudal or transverse plane do not
necessary reflect the true extent of muscle injury.
In our study, the soleus muscle was much more commonly
injured than the gastrocnemius. This is in contrast to previous
reports that have reported a higher incidence in medial gastroc-
nemius injury.10 12 18–20 Our study cohort of patients came from
a variety of sports and therefore this outcome is unlikely to be
related to a particular sport or activity. It is probably related
to the increased use of MRI and detection of otherwise occult
soleus tears. A higher incidence of soleus tears was also noted
in studies by Koulouris et al12 and Waterworth et al.7 However,

Table 4  Time to return to play (RTP) in patients after only

gastrocnemius muscle tear (n=29)
Range of number of
Injury grade Patients (n) days to RTP Mean days to RTP
0 2 0–14 7±9.89
Figure 7  (A) Axial PD fat saturated and (B) sagittal PD fat saturated
1 1 20 20±0
images of a 25-year-old professional footballer showing grade 3 injury
2 15 14–42 27.9±7.24
of the medial gastrocnemius. There is rupture and retraction of the distal
3 11 12–70 46±16.69
aponeurosis (arrow). His time to return to play was 56 days.

4 Prakash A, et al. Br J Sports Med 2017;0:1–6. doi:10.1136/bjsports-2017-098362

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Figure 8  Scatter plot of the study with grade of injury in x-axis and time to return to play (RTP) in y-axis.
our study did not show a significant difference in time to RTP
between soleus and gastrocnemius injuries.
The findings in our study did not show any particular soleus
aponeurosis or epimysium being significantly more commonly
injured than others. However, in gastrocnemius, most tears
were located in the anterior aponeurosis and distal myotendi-
nous junction. There were no isolated lateral gastrocnemius tears
in our cohort. In addition, there were no plantaris tears in our
cohort; in our experience this is an uncommon injury. While the
soleus was the more commonly injured muscle, the incidence
of grade 3 injury was higher in the gastrocnemius, particularly
failure of the distal aponeurosis.
Our results show that the time to RTP is significantly longer in
patients with higher grades of connective tissue injury. An earlier
study among AFL players with calf injuries identified an asso-
ciation between missing at least one game and injury involving
multiple muscles, musculotendinous junction strains, deep strain
location and intramuscular tendon tears.7 Balius et al21 studied
55 cases of soleus injury by MRI and ultrasound (US), and
concluded that US is not a sensitive technique for detecting and
assessing soleus traumatic tears compared with MRI.
Pedret et al22 evaluated the association of different typical
locations of the soleus muscle tears and their recovery times,
which showed wide variation. However, soleus central intramus-
cular tendon injuries had a significantly longer recovery time.
They did not grade the injuries in their study. We think severity
of connective tissue injury is more important than just the loca-
tion of the injury. It is a topic for future research to correlate
What are the findings?
MRI-detected connective tissue injury in calf muscle tears is
associated with longer time to return to play.
How might it impact on clinical practice in the future?
The proposed MRI grading system for calf muscle tears can be
used to guide the time to return to play in athletes.
Prakash A, et al. Br J Sports Med 2017;0:1–6. doi:10.1136/bjsports-2017-098362
Original article
between similar grades of calf injury at different locations with
time to RTP.
Our study has a number of limitations. Majority of our
patients were professional and elite athletes; therefore our
findings may not be representative of the general population.
The number of higher grade injuries in this study group may
be over-represented due to bias in the patient population
recruited, as clinically higher grade injuries were more likely
to be referred for MRI. MRI evaluation was done by consensus
between three radiologists; the intraobserver and interobserver
reliability is therefore not known. The doctors deciding the
time to RTP were not blinded to the MRI findings. We did not
correlate between MRI and clinical findings; we therefore do
not know if the MRI clinical findings add to clinical evalua-
tion. We recognise that time to RTP in players may slightly vary
during preseason, season and postseason. Time to RTP may
also be influenced by players’ motivation to RTP and pressure
to play exerted by the clubs. We did not follow up patients in
this study for reinjury.
Conclusion
Calf muscle injuries involve muscle fibre disruption at the inter-
face with the connective tissue structures, such as epimysium,
aponeurosis and intramuscular tendon. These connective tissue
structures are likely to fail with higher grade muscle injuries.
Attention should be directed to the connective tissue integrity
rather than focused solely on the characteristics of the injured
muscle fibre component. We propose a MRI grading system that
can be used to assess the extent of injury and integrity of the
connective tissue structures involved. As demonstrated in this
study, higher grades of connective tissue injury have a longer
time to RTP and are important in determining the duration of
rehabilitation among athletes.
Competing interests  None declared.
Ethics approval  Monash University Human Research Ethics Committee, Victoria,
Australia.
Provenance and peer review  Not commissioned; externally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
5
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Original article
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 Downloaded from http://bjsm.bmj.com/ on October 27, 2017 - Published by group.bmj.com

Connective tissue injury in calf muscle tears

and return to play: MRI correlation
Ashutosh Prakash, Tom Entwisle, Michal Schneider, Peter Brukner and
David Connell

Br J Sports Med published online October 26, 2017

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