It's so easy to be wise after the event but we should really have seen this one coming. Of all the injuries in football, and in particular this season at Real Madrid, it's the soleus muscle injuries that appear to be the most problematic. After Gareth Bale's troubles with his soleus this season, Raphaël Varane's absence from the Clásico on Saturday was attributed to a similar injury.
Reading the background to this and noting that he didn't train on Friday with the squad, the injury history tells a familiar story. Raphaël felt the injury in France's first game last weekend against the Netherlands. It was then reported that following a thorough examination by the French medical people, no exact injury was identified and he played in the next game against Russia as a result. His symptoms were reported to have worsened on returning to Madrid and he took part in a recovery / cool down session but felt the discomfort even then. Not surprisingly Raphaël was withdrawn from all training and Real issued a medical report on Friday before the Barça game to say that tests had revealed "a muscular injury to the outside of his left calf. His recovery will continue to be assessed."
We can only hope that the lessons learned from Gareth Bale's injury will be allowed for in Raphaël's recovery. The whole world had it's say on how Gareth Bale's soleus problems were managed and it's to be hoped that the investigations carried out on Varane's calf will allow for the variation in symptoms that the research shows accompanies soleus muscle injuries. Specifically, returning to play after a soleus injury needs to be managed correctly (Pedret et al, 2015); since previous experiences have shown that players simply reporting that they are "feeling right" isn't an accurate objective marker when it comes down to post- injury recovery.
The characteristics of a soleus muscle injury are illustrated by a gradual feeling of an underlying niggle that develops over time; and like most injuries to the deeper-lying muscles can easily be mistaken for muscular tightness or cramp (Armfield et al, 2006). This is exactly how the scenario surrounding Gareth Bale's troubles initially began to unfold; with Gareth coming off with what was perceived at the time to be cramp. As we now know, this turned out to be a soleus strain; and research into these injuries indicated that soleus strains are frequently reported to mimic the symptoms of muscular cramp, only for these symptoms to worsen via gradual development until a clear muscular tear can be seen when the area is investigated by MRI scanning.
The reason for using MRI as opposed to ultrasound scanning - which is actually the preferred method of investigating muscular injuries - lies in the depth of the soleus muscle within the calf group and the difficulty in visualising this using ultrasound due to the obstructed view caused by the more superficial structures in the calf (Balius et al, 2014). Ultrasound scanning is ideal for detecting tears in the thigh or hamstring muscles but you need a clear view of the injured area in order to do this. With the soleus muscle located deep in the calf and with certain views obstructed, it's easy to see why the French medical team were unable to identify a clear injury upon initial examination at the time of the first presentation after the Holland game. Zinedine Zidane referred to this when commenting on the injury and mentioned the fact that Madrid had initially performed an ultrasound scan on Raphaël but would be following up with an MRI "to see what it really is that he has."
Symptoms of soleus strain, as we have learned from the Gareth Bale experience are low level initially, progressive, difficult to isolate and often show no actual definitive site of injury in the early stages (Dixon, 2009). As we said at the start, we should have seen this one coming. Let's trust that the lessons learned from Gareth Bale will translate into the management of Raphaël Varane's injury; and that he will be spared the soul-destroying cycle of returning to play only for symptoms to return on increased activity leading to repeated and recurrent injury.
Armfield DR, Kim DH, Towers JD, Bradley JP, Robertson DD (2006). Sports-related muscle injury in the lower extremity. Clinics in Sports Medicine. Vol. 25; 803 - 842.
Balius R, Rodas G, Pedret C, Capdevila L, Alomar X, Bong DA (2014). Soleus muscle injury: sensitivity of ultrasound patterns. Skeletal Radiology. Vol. 43; 805 - 812.
Dixon JB (2009). Gastrocnemius v Soleus strain: how to differentiate and deal with calf muscle injuries. Current Reviews in Musculoskeletal Medicine. Vol. 2 (2): 74 - 77.
Pedret C, Rodas G, Balius R, Capdevila L, Bossy M, Vernooij WM, Alomar X (2015). Return to play after soleus muscle injuries. Orthopaedic Journal of Sports Medicine. Vol. 3 (7). Published online 2015 Jul 22; doi: 10.1177/2325967115595802