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BJSM Online First, published on October 26, 2017 as 10.1136/bjsports-2017-098362
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
1
Imaging @ Olympic Park, ABSTRACT tissues, which connect to the tendon. The integrity
Melbourne, Victoria, Australia Objective  The aim of our study was to assess a of the connective tissue scaffold is therefore vital
2
Diagnostic Radiology, Tan
Tock Seng Hospital, Singapore, group of patients with calf muscle tears and evaluate for muscle to function normally. Furthermore,
Singapore the integrity of the connective tissue boundaries and muscle fibres are vulnerable to shear forces at these
3
Department of Medical interfaces. Further, we propose a novel MRI grading muscle fibre-connective tissue interfaces that can
Imaging and Radiation Sciences, system based on integrity of the connective tissue occur during eccentric loading or strain.8
Faculty of Medicine, Nursing Tendon, aponeurosis and epimysium heal slower
and assess any correlation between the grading score
and Health Sciences, Monash
University, Melbourne, Victoria, and time to return to play. We have also reviewed the than muscle. The status of the connective tissue
Australia anatomy of the calf muscles. (epimysium, aponeurosis, intramuscular tendon
4
La Trobe University, Melbourne, Materials and methods  We retrospectively evaluated and free tendon) supporting the muscle fibres may
Victoria, Australia 100 consecutive patients with clinical suspicion and well determine the healing time in muscle injury,
MRI confirmation of calf muscle injury. We evaluated not just in the calf but in other muscles too. We
Correspondence to hypothesise that disruption of the muscle connec-
each calf muscle tear with MRI for the particular muscle
Dr Ashutosh Prakash, Diagnostic
Radiology, Tan Tock Seng injured, location of injury within the muscle and integrity tive tissue is a higher grade injury and will result in
Hospital, Singapore 308433; of the connective tissue structure at the interface. The longer recovery time and time to RTP.
d​ rashutoshprakash@​gmail.c​ om muscle tears were graded 0–3 depending on the degree The objective of this study was to assess the integ-
of muscle and connective tissue injury. The time to return rity of the calf muscle connective tissue in patients
Accepted 4 October 2017
to play for each patient and each injury was found from with acute calf muscle injury. We propose a grading
the injury records and respective sports doctors. system and its correlation with time to RTP.
Results  In 100 patients, 114 injuries were detected.
Connective tissue involvement was observed in 63 out Review of anatomy
of 100 patients and failure (grade 3 injury) in 18. Mean The posterior compartment of the leg is divided by
time to return to play with grade 0 injuries was 8 days, the deep transverse fascia into superficial and deep
grade 1 tears was 17 days, grade 2 tears was 25 days compartments. Collectively the superficial poste-
and grade 3 tears was 48 days (p<0.001). rior compartment muscles of the leg are called the
Conclusion  The integrity of the connective tissue can calf muscle or triceps surae and consist of gastroc-
be used to estimate and guide the time to return to play nemius, soleus and plantaris. The aponeurosis and
in calf muscle tears. 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
Introduction fibres than soleus, reflective of its function in rapid
Calf muscle is one of the four most commonly locomotion, such as jumping and running.10 Its
injured muscles in sportsmen.1 MRI muscle injury two heads arise from two proximal tendon attach-
pattern in hamstring and anterior thigh muscles ments from the femoral condyles and the subjacent
have been researched and used to quantify prog- knee joint capsule. Both these tendons expand and
nosis and predict the time to return to play (RTP).2–6 spread out as thin aponeuroses on the posterior
However, little research has been performed for surface of the respective muscle and give origin
calf injury. to muscle fibres (figure 1A). These muscle fibres
MRI of the calf may not be indicated in all then attach to a broad aponeurosis on the anterior
patients presenting with calf injury, and time to surface of the muscle (figure 1B–D). The anterior
RTP in injured athletes is mostly guided by clinical aponeurosis then gradually condenses as it extends
criteria. However, many elite athletes undergo MRI inferiorly and unites with the posterior aponeu-
in suspected calf tears to confirm the diagnosis, rosis of the soleus to form the Achilles tendon.9 11
access severity and guide rehabilitation. A previous The gastrocnemius aponeurosis is distinctly shorter
MRI study has focused on size and site of tear, medially and longer laterally.11
muscle component affected, intramuscular tendon Soleus is the deeper muscle of the superficial
tear and intermuscular haematoma,7 but did not posterior compartment. It is a broad flat multipen-
focus on the integrity and severity of connective nate muscle, designed for power, with a predomi-
tissue injury. nance of slow twitch fibres and hence contributes
Dense irregular and regular connective tissues to postural control and walking.12 It arises by tendi-
To cite: Prakash A,
form a scaffold to support the muscle fibres. This nous fibres from the posterior fibula head, proximal
Entwisle T, Schneider M, et al.
Br J Sports Med Published connective tissue scaffold is composed of surface one-fourth of the shaft of fibula, middle one-third
Online First: [please include covering (epimysium and aponeuroses) and intra- of the medial border of the tibial shaft and poste-
Day Month Year]. doi:10.1136/ muscular bands (intramuscular tendon and aponeu- rior surface of the tendinous arch between the tibia
bjsports-2017-098362 roses). Muscle fibres attach to these connective and fibula.9 At the origin, there is thickening or

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

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Original article
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-
Figure 1  Anatomy of gastrocnemius aponeuroses: (A) PD and (B)
ness or muscle overload MRI pattern, Achilles tendon tear,
PD fat saturated images showing proximal posterior (arrowhead) and
muscle contusion MRI pattern or history, bone stress reaction,
distal anterior aponeurosis (thin arrow) of the gastrocnemius. (C,D)
pre-existing non-healed muscle tear in either leg and follow-up
PD fat saturated images of an athlete with grade 2 posterior soleus
studies were excluded. Patients were also excluded if they were
aponeurosis tear and sliver of fluid between gastrocnemius and
out of play for any other reason and if we could not obtain the
soleus muscles; the intermuscular fluid clearly demarcates the anterior
RTP details.
aponeurosis (thin arrow) of the gastrocnemius muscle.

Return to play
localised aponeuroses on the anterior and posterior aspects of RTP was defined as time from the date of injury to return to full
the muscle (figure 2A). Distal to the origin, there are proximal competition.
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 MRI technique
inferiorly. Proximal muscle fibres arise from these aponeuroses. The MRI imaging technique included placing an external marker
Distally the muscle fibres insert into a long central intramuscular (vitamin E capsule) over the area of maximum symptom, as indi-
tendon (figure 2B,C), which arises from the anterior aponeu- cated by the patient. All scans were carried out using 3T MRI
rosis of the soleus, and also to the posterior aponeurosis of the scanners. A dedicated surface coil was used to obtain high-reso-
soleus (figure 2C). The central intramuscular tendon and poste- lution image with 2.5 mm axial proton density (PD) and PD fat
rior aponeurosis merge to form the soleal contribution to the saturated axial images, as well as 2 mm sagittal and coronal PD
Achilles tendon.13 In our experience, the soleus intramuscular fat saturated images.

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

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

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

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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. Cross et al16 found the rectus femoris central tendon injury iden-
In patients with more than one injury, they were graded as tified on MRI was associated with a significantly longer rehabil-
per their highest injury. Eight patients had grade 0, 29 grade 1, itation time.
45 grade 2 and 18 had a grade 3 injury. Time to RTP according Similarly, we felt that the integrity of the connective tissue
to the grade of injury is shown in table 2 for all calf muscles, in supporting the calf muscles could be linked to the recovery time.
table 3 for the soleus and table 4 for only the gastrocnemius. However, rather than a simple intramuscular tendon, the calf
There was a statistically significant difference between the injury muscles have a complex scaffold of epimysial boundaries and
grade and time to RTP (p<0.001). Figure 8 shows the grade of flat aponeuroses which support muscle fibres. We therefore
injury against days to RTP in a scatter plot. 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
Discussion
connective tissue are associated with longer time to RTP.
Our study has demonstrated, for the first time, the importance
We believe that measuring the extent of muscle oedema or
of connective tissue integrity in calf muscle tears and its correla-
bleeding for grading a muscle tear is inaccurate. Blood fluid
tion with time to RTP. Our proposed MRI grading system shows
products travel well beyond the margins of the actual myofi-
correlation between higher grade of calf muscle injury and
bril tear and the margin is usually ill-defined. An analogy can be
longer time to RTP.
drawn with muscle contusions, in which the size of an intramus-
Other authors have highlighted the importance of integrity
cular haematoma does not always correlate with loss of muscle
of the connective tissue and time to RTP. Comin et al15 focused
function and the usual MRI grading systems used for indirect
on the integrity of the biceps femoris intramuscular connective
muscle injury cannot be applied to direct injuries.17 Likewise,
tissue and showed significant longer recovery time in biceps
measurements in the craniocaudal or transverse plane do not
femoris tears when the intramuscular tendon was disrupted.
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.

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Original article

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

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Original article
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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

Updated information and services can be found at:

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