|Position||Average % Difference PPG Change From Pre-Injury Compared to 1st Game After Injury||Average % Difference PPG Change From Pre-Injury Compared to Games 2-3 After Injury||Average % Difference PPG Change From Pre-Injury Compared to Games 4-6 After Injury|
|Position||Average Change in Snap% From Pre-Injury Compared to 1st Game After Injury||Average Change in Snap% From Pre-Injury Compared to Games 2-3 After Injury||Average Change in Snap% From Pre-Injury Compared to Games 4-6 After Injury|
Anatomy of a calf injury
The calf comprises three different muscles that function together to create powerful ankle movements required for high-performing athletes. The three muscles are the medial gastrocnemius, the lateral gastrocnemius, and the soleus. Both gastrocnemius muscles attach from the backside of the femur (thigh) bone, and the soleus muscle attaches from the backside of the shin bones. All three blend through a fascial connection (connective tissue) to form the Achilles tendon, which connects to the calcaneus bone (heel bone).1,2 These three muscles function to help create push-off during running, jumping, and cutting. There is a great deal of elasticity to this muscle group which allows it to function similar to a spring when running and jumping, where the muscles recoil to create energy.1
Any calf muscle can be injured; however, the most common is the medial gastrocnemius.1,2 A phenomenon seen with calf injuries is in addition to the muscle injury, the fascial connection between the three muscles can also be injured, and pockets of swelling can form between the muscles that contribute to pain and impact performance.1,2
Like all muscle injuries, there is a grading scale for severity. Several different scales have been created, and the following is one way to grade calf injuries:3
- Grade I (mild): Minimal or no loss of strength and range of motion, <10% of muscle fibers injured.
- Grade II (moderate): Weakness and loss of range of motion, swelling within the muscles, 10-50% of muscle fibers injured.
- Grade III (severe): Significant weakness and loss of range of motion, 50-100% of muscle fibers injured.
Cause of a calf Injury
Lower body muscle injuries are prevalent in football and can sideline players for several weeks and impact their performance when they return. In the NFL, calf muscle injuries are the fourth most common lower body muscle injury, following injuries to the hamstrings, groin, and quad muscles.4,5 Studies on the NFL show an average of 57 calf injuries occur per season across all position groups, with defensive players accounting for 67%.5 Despite only 33% of calf injuries occurring in offensive players, this is still a very impactful injury for fantasy-relevant players.
The calf is commonly injured when initiating a sprint, jumping, or changing direction. These powerful movements cause the ankle to rapidly change from a plantarflexed position (like pressing the gas pedal) to a dorsiflexed position (the ankle is flexed, so toes go towards the shin) while the knee is fully extended, causing tremendous forces through the calf muscles while they are in a fully stretched position.1-5 This makes sense why these injuries are more common in defensive players, as they are reacting to the offense and changing directions. However, these injuries still frequently occur in fantasy-relevant players.
Factors that may increase the risk of an athlete suffering a calf muscle injury include age, a previous calf injury, or any previous lower-body injury.6,7 Older age reduces the elasticity of muscle tissue, making it less able to withstand significant forces and stretch as much. Previous calf muscle injuries contribute as sometimes players never fully regain the strength they had before the injury. A history of other prior lower body injuries can alter the ankle flexibility or coordination of muscles with an athletic activity that can increase stress on the calf muscles.7
Like all muscle injuries, injury recurrence is a concern. Limited data exists for NFL players and calf injury recurrence rates; however, studies on professional soccer and Australian football show 14-16% injury recurrence.7
Calf injury rehab process
Studies looking at the time it takes to return to playing from a calf injury for NFL players average around 17.4 days, equal to missing two games.5 This is a similar timeline to sports such as soccer and Australian football, which is important to mention because there is much more data on those sports.6,7 Generally, players respond well to conservative care, and surgery is only required in rare circumstances.3,4
Rehab is initially focused on protecting the injured muscle and may briefly consist of immobilizing the ankle in a boot, though this is typically limited to no more than 3-5 days.3,4 During this initial phase, emphasis is on reducing pain, reducing swelling, and preventing loss of range of motion.3,4 This is accomplished through rest, ice, compression, and elevation.3,4 Often, lymphatic massage will also be utilized to help flush out swelling, and electrical stimulation can be used as needed for pain relief.
After the initial few days, as pain and swelling begin to subside, the athlete’s rehab will progress to gentle stretching to regain lost range of motion and gentle isometric muscle contractions where the muscle activates, but the ankle does not move. Isometric exercises help prevent further strength loss.4 During this phase, rehab will address factors that may have contributed to the onset of injury, such as ankle stiffness, imbalances in strength or flexibility of muscles at the hip, and core weakness.4 It is important that the athlete incorporates some form of cardiovascular training. In the case of a lower-body injury, this may be through an arm bike, as this will not stress the injured muscles.
When the range of motion is normal, there is no pain with isometrics or gentle stretching, and they can stand on the injured leg without pain, athletes can progress to the next phase of rehab. Balance exercises can be initiated, stretching can be advanced as tolerated, and if pain-free, they can begin progressing calf strengthening to concentric motions (muscle contracts and joint moves). However, this progression should be against very light resistance at first.3,4 Cardiovascular exercise can be progressed to a bike, elliptical, and treadmill (anti-gravity ideally), though they may or may not be ready to start running.
The last rehab phase begins when there is no pain with standing, walking, or concentric calf strengthening with fairly heavy resistance.4 At this point, athletes, begin eccentric calf strengthening (muscle contracts forcefully as it is stretching), initiate and progress running (initially with an anti-gravity treadmill), progress to full weight lifting, and eventually progress to plyometrics, sprinting, cutting, and sport-specific movements.4
|Rehab Phases4||Treatments4||Criteria to Enter Phase4|
|Early Phase||Rest, ice, compression, elevation.|
Brief immobilization in boot and crutches (3-5 days).
Lymphatic massage for swelling.
Glute and core strength.
Calf isometrics if tolerable.
Cardiovascular training (arm bike)
|N/A first phase|
|Intermediate Phase||Gentle stretching.|
Gentle calf concentrics.
Soft tissue work, dry needling.
Glute and core strength.
Cardiovascular training (bike>elliptical>anti-gravity treadmill>treadmill)
|Full range of motion.|
No pain with early phase exercises.
|Sports Specific||Calf eccentrics.|
Full weight lifting.
Running (anti-gravity treadmill initially, progress to treadmill or land).
Agility, plyometrics, jumping, position-specific drills
|No pain with standing, or walking. |
No pain with any intermediate phase exercises.
Players who have had a calf injury
|Quarterbacks||Games Missed||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Joe Burrow (2023 preseason)||0||19.5||3.2 (-16.3)|
|Dak Prescott (2021 week 6)||1||22.3||19.9 (-2.4)||15.5 (-6.8)||16.5 (-5.8)|
|Jimmy Garoppolo (2021 week 4)||1||14||7.2 (-6.8)||23.8 (+9.8)||14.4 (+0.4)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||0/3 (0%)||1/2 (50%)||1/2 (50%)|
|Running Backs||Games Missed||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|James Conner (2023 week 1)||0||17.2||16.6 (-0.6)|
|Brandon Bolden (2022 week 12)||1||1||0 (-1)||0 (-1)||1 (0)|
|Josh Jacobs (2022 week 11)||0||20.4||50.3 (+29.9)||20.2 (-0.2)|
|Antonio Gibson (2021 week 6)||0||13.1||6.6 (-6.5)||13.9 (+0.8)||15.7 (+2.6)|
|Kareem Hunt (2021 week 6)||5||14.9||2 (-12.9)||2.8 (-12.1)*||N/A|
|Nick Chubb (2021 week 5)||2||16.2||7.4 (-8.8)||25.4 (+9.2)||9.6 (-6.6)|
|Rashaad Penny (2021 week 1)||5||1.1||0.9 (-0.2)||0.8 (-0.3)||12.8 (+11.7)|
|Ezekiel Elliot (2020 week 14)||1||8.9||18.4 (+9.5)||7 (-1.9)||12.1 (+3.2)|
|Aaron Jones (2020 week 6)||2||22.8||10.4 (-12.4)||13.6 (-9.2)||13.4 (-9.4)|
|Jeff Wilson Jr. (2020 week 5)||1||4||31 (+27)||4.5 (+0.5)||15.9 (+11.9)|
|Mark Ingram (2019 week 16)||1||15.9||3.4 (-12.5)ρ||N/A||N/A|
|Blial Powell (2017 week 5)||1||12.3||9.3 (-3)||9.4 (-2.9)||6.4 (-5.9)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||3/12 (25%)||5/10 (50%)||7/9 (78%)|
|Wide Receivers||Games Missed||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Jerry Jeudy (2022 week 10)||2||9.8||8.5 (-1.3)||13.1 (+3.3)|
|Byron Pringle (2022 week 3)||6||6.7||1.7 (-5)||4.4 (-2.3)||5.1 (-1.6)|
|Scotty Miller (2022 week 2)||0||3.7||0.9 (-2.8)||2.8 (-0.9)||4.9 (+1.2)|
|Mike Evans (2022 week 1)||0||14.3||7.6 (-6.7)||18.5 (+4.2)||10.1 (-4.2)|
|AJ Brown (2021 week 16)||0||15.4||5.1 (-10.3)||18.8 (+3.4)ρ||N/A|
|Jameson Crowder (2021 week 15)||2||4.1||1.6 (-2.5)||N/A||N/A|
|Deebo Samual (2021 week 8)||0||17.5||8.8 (-8.7)||21.9 (+4.4)||16.5 (-1)|
|Michael Gallop (2021 week 1)||7||12.1||5.7 (-6.4)||10 (-2.1)||8.4 (-3.7)|
|Sammy Watkins (2020 week 16)||3||6.5||1.8 (-4.7)ρ||N/A||N/A|
|Jameson Crowder (2020 week 13)||0||10||1.7 (-8.3)||17.7 (+7.7)||5.1 (-4.9)*|
|Michael Pittman Jr. (2020 week 3)||3||3.9||2.8 (-1.1)||11.7 (+7.8)||8.3 (+4.4)|
|John Brown (2020 week 2)||0||11||0 (-11)||3.1 (-7.9)||5.5 (-5.5)|
|Robby Anderson (2019 week 16)||0||9.5||5.5 (-4)||N/A||N/A|
|TY Hilton (2019 week 13)μ||2||13.7||4.5 (-9.2)||6.4 (-7.3)||N/A|
|TY Hilton (2019 week 9)||3||13.7||3.3 (-10.4)μ||N/A||N/A|
|Alshon Jeffery (2019 week 2)||1||13.7||11.3 (-2.4)||13.4 (-0.3)||6.3 (-7.4)|
|Deandre Hopkins (2017 week 16)||1||17.4||N/A||N/A||N/A|
|Antonio Brown (2017 week 15)||2||22.7||28.7 (+6)ρ||N/A||N/A|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||1/17 (6%)||6/12 (50%)||5/9 (56%)|
|Tight Ends||Games Missed||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Juwan Johnson (2023 week 1)||0||11.4||2.3 (-9.1)|
|Logan Thomas (2023 preseason)||0||5.4||6.3 (+0.9)|
|Hayden Hurst (2022 week 13)||3||5.9||3.4 (-2.5)||3.5 (-2.4)||N/A|
|Logan Thomas (2022 week 5)||3||6.7||0 (-6.7)||1.1 (-5.7)||4.6 (-2.2)|
|Zach Ertz (2022 preseason)||0||7.9||10.4 (+2.5)||9.5 (+1.6)||10.6 (+2.7)|
|George Kittle (2021 week 4)μ||3||8||17.1 (+9.1)||12.5 (+4.5)||21.5 (+13.5)|
|George Kittle (2021 week 3)||0||8||6 (-2)||N/Aρ||N/Aρ|
|Evan Engram (2021 preseason)||2||7||1.1 (-5.9)||6.2 (-0.8)||6.8 (-0.2)|
|Dallas Goedert (2020 week 16)||1||10||N/A||N/A||N/A|
|Trey Burton (2020 preseason)||3||1.7||2.6 (+0.9)||12.9 (+11.2)||4.5 (+2.8)|
|Dallas Goedert (2019 week 2)||1||4.4||0 (-4.4)||5.1 (+0.7)||10 (+5.6)|
|Trey Burton (2019 week 10)||7||1.7||N/A||N/A||N/A|
|Mo Alie-Cox (2018 week 11)||3||4.4||0 (-4.4)||1.3 (-3.1)||0 (-4.4)ρ|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||4/11 (37%)||4/8 (50%)||4/7 (57%)|
Tom Christ, PT, DPT, OCS
- Bright J, Fields K, Draper R. Ultrasound Diagnosis of Calf Inuuries. SPH. 2017;9(4):352-355.
- Harwin J, Richardson M. “Tennis Leg”: gastrocnemius injury is far more common cause than plantaris rupture. Radiol. Case Rep. 2017;12:120-123.
- Hsu D, Chang K. Gastrocnemius Strain. StatPearls. 2021. Treasure Island (FL): StatPearls Publishing: 2022.
- Palermi S, Massa B, Vecchiato M, et al. Indirect Structural Muscle Injuries of Lower Limb: Rehabilitation and Therapeutic Exercise. J. Funct. Morphol. Kinesiol. 2021;6(75).
- Werner B, Blkin N, Kennelly S, et al. Acute Gastrocnemius-Soleus Complex Injuries in National Football League Athletes. Orthop. J. Sports. Med. 2017;5(1).
- Green B, Pizzari T. Calf muscle strain injuries in sport: a systematic review of risk factors for injury. Br. J. Sports. Med. 2017;51:1189-1194.
- Green B, Lin M, McClelland J, et al. Return to Play and Recurrence After Calf Muscle Strain Injuries in Elite Australian Football Players. Am. J. Sports. Med. 2020;48(13):3306-3315.