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Overview A medial calf injury is a musculotendinous disrup/on of varying degrees in the medial head of the gastrocnemius muscle that results from an acute, forceful push‐oﬀ with the foot Commonly occurs in sports (hill running, jumping, tennis), but it can occur in any acEvity Common injury in the intermiFently acEve athlete
Overview One mechanism that occurs is on the back leg during a lunging shot (tennis), in which the knee is in extension and the foot in dorsiﬂexion. This movement puts maximal tension on the gastrocnemius muscle as the lengthened muscle is contracted at the “push oﬀ”, resulEng in a medial calf injury
Epidmiology More commonly in men than in women Usually occurs in athletes aged 40‐60 Medial calf injuries are most commonly acute injuries, but up to 20% of aﬀected paEents report a syndrome of calf Eghtness several days before the injury
FuncEonal Anatomy The medial head of the gastrocnemius (a) muscle originates from the posterior aspect of the medial femoral condyle The medial head merges with the lateral head of the gastrocnemius Further distally, the merged heads of the gastrocnemius merge with the soleus (b) muscle‐tendon complex to form the Achilles tendon (a) (b)
FuncEonal Anatomy The main funcEon of the gastrocnemius muscle is plantar ﬂexion of the ankle, but it also helps bends the knee The gastrocnemius contributes to the posterior stability of the knee and parEally to the movement of the menisci during ﬂexion and extension of the knee Most strains occur at this musculotendinous juncEon
Sport‐speciﬁc biomechanics This injury usually occurs when an eccentric force is applied to the gastrocnemius muscle, which usually happens when the knee is extended, the ankle dorsiﬂexed, and the gastrocnemius aFempts to contract in a lengthened state This is the common posiEon of the back leg in a tennis stroke Calf injuries can also occur during a typical contracEon of ankle plantar ﬂexion, especially of the person is pushing or liWing a heavy weight or force
History An audible pop when the injury occurs is usually reported The person complains of feeling like something struck his/her calf Pain the area of the calf, which also can radiate to the knee or the ankle The person complains of pain with movement of the ankle SomeEmes we can observe a swollen leg that goes down to the foot or ankle (associated color changes of bruising)
Physical evaluaEon (inspecEon) Asymmetric calf swelling and discoloraEo, potenEally spreading to the ankle and foot AWer the stage of swelling, a visible defect in the medial gastrocnemius may be observed
Physical evaluaEon (palpaEon) Tenderness is noted upon palpaEon in the enEre medial gastrocnemius muscle, but this tenderness is observed to be much more painful at the medial musculotendinous juncEon Depending on the degree of swelling, a palpable defect may be evident at the medial musculotendinous juncEon The Achilles tendon should normally be intact The peripheral pulses should be present and symmetric
Physical evaluaEon (provocaEve maneuvers) Moderate to severe pain with passive ankle dorsiﬂexion Moderate to severe pain during acEve resistance to ankle plantar ﬂexion
Age/acEvity status Occur more commonly in the middle‐aged recrea/onal athlete. These athletes typically conEnue to be physically acEve at a moderate to high intensity but not on a regular basis, and these people are also likely to have maintained a moderate degree of the muscle mass from their more acEve days. Yet these athletes started losing the ﬂexibility they had when they were younger, resulEng in a relaEvely large gastrocnemius muscle that is less ﬂexible than it had been, and on occasion, the muscle is challenged with a ballisEc or explosive force, leading to a parEal or complete rupture.
DecondiEoned‐unstretched muscles The cold and unstretched muscles that recreaEonal athletes oWen use to compete with are very likely to rupture when challenged compared with condiEoned and stretched muscles Medial calf injuries also occur in the physically ﬁt, the role of stretching in prevenEon is not completely understood. This phenomenon may mean that force versus elas/city is the key formula, and if the force overcomes the elasEcity, even in a condiEoned athlete, then a rupture or injury can occur
Previous injury The athlete with recurrent calf strains is likely to have healed with ﬁbro/c scar /ssue FibroEc scar Essue absorbs forces diﬀerently and is thus more likely to result in rupture when the muscle is challenged
Laboratory studies The ruptured medial gastrocnemius can usually be diagnosed clinically. Laboratory and imaging studies can be used to evaluate some of the other diagnosEc possibiliEes, but normally they are not necessary. Laboratory studies may aid in the evaluaEon of a potenEal DVT, if clinical suspicion is present.
Imaging studies X‐rays are usually normal and do no oﬀer addiEonal informaEon for treatment X‐ray may be ordered to rule out an avulsion fracture MRI and ultrasound images can be usefeul in the diagnosis and/or follow‐up of injuries to the lower leg
Other tests Other tests are not necessary for the diagnosis of a simple medial gastrocnemius strain If the suspicion of DVT persists, then further evaluaEon with Doppler ultrasonography is indicated
RehabilitaEon Program Medial Gastrocnemius Strain
Physical Therapy IniEal treatment of this injury includes relaEve rest, ice, compression, elevaEon (RICE principles), and early weight bearing, as tolerated The iniEal treatment should conEnue for 24‐72 hours The use of crutches is indicated if normal gait is compromised AcEve foot and ankle ROM can be carried out if there is pain‐free ROM
Medical Issues/complicaEons Pain management should include analgesics Be careful with NSAIDs during the acute injury phase, as these agents can predispose the paEent to increased bleeding and hematoma formaEon in the iniEal days aWer the injury
Other treatment Ankle/foot bracing should be used to keep the ankle in a posiEon of maximal tolerable dorsiﬂexion Studies have indicated an increased rate of healing with this intervenEon
Physical Therapy Ice therapy and acEve resistance dorsiﬂexion exercises can be undertaken unEl the person is pain free Then, light plantar ﬂexion exercises against resistance are started Progression includes reducEon in heel‐liW height and gradual introducEon of staEonary cycling, leg presses, and heel raises At this stage utrasonography and electric muscle sEmulaEon are very useful Massage therapy can help remove the intersEEal ﬂuid
Physical therapy Apply compression dressing from the metatarsal heads to the gastrocnemius for the ﬁrst 2 weeks ParEal weight‐bearing ambulaEon should begin as soon as tolerable to maximize the contact of the sole of the foot to the ground, then you can progress to increased cyclic loading, advanced propriocepEon and balance training In the end we will do full weight‐bearing trainging, with dynamic change of speed and direcEon as tolerable
Physical therapy Once the athlete is pain free with full and symmetric ROM and full strength is regained, sports‐speciﬁc acEviEes can be resumed. Strengthening and stretching of the injured area should conEnue for several months to overcome the increased risk for reinjury due to the deposiEon of scar Essue that is involved in the healing process.
MedicaEon Directed at maintaining paEent comfort Clinicians must carefully consider pain therapy in the ﬁrst 48 hours, as decreased platelet acEvity may result in increased bleeding and larger hematoma formaEon (this can aﬀect the healing negaEvely)
Return to play When an athlete is pain free and has a full recovered ROM (1‐12 weeks, depending on the degree of Essue damage) Strength tesEng should reveal that more than 90% of the uninjured side accounts for the paEent’s dominance perference
ComplicaEons Scar Essue formaEon: can result in chronic pain or dysfuncEon that is caused by a funcEonal shortening of the muscle‐tendon unit This scar Essue can then predispose to frequent reinjury FormaEon of a DVT as a result of paEent inacEvity and trauma
PrevenEon A medial calf injury may not be preventable, but regular physical acEvity with maintenance of ﬂexibility in the gastrocnemius muscle may help to reduce ones chances of sustaining this type of injury.
Prognosis If the above treatments are followed, the prognosis for recovery and return to sports aWer a medial calf injury is excellent.
EducaEon InstrucEons for appropriate stretching and warm‐up techniques should be provided to the paEent for the implementaEon of maximal prevenEon of reinjury.