1. Medial Gastrocnemius Strain
Sport Injuries by Haroun Cherif

2. Overview
Medial Gastrocnemius Strain

3. 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

4. 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

5. 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

6. FuncEonal anatomy
Medial Gastrocnemius Strain

7. 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)

8. 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

9. FuncEonal Anatomy

10. 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

11. Injury EvaluaEon
Medial Gastrocnemius Strain

12. 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)

13. 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

14. 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

15. Physical evaluaEon (provocaEve maneuvers)
 Moderate to severe pain with passive ankle dorsiflexion
 Moderate to severe pain during acEve resistance to ankle plantar flexion

16. Causes
Medial Gastrocnemius Strain

17. 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.

18. 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

19. 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

20. 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.

21. 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

22. 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

23. RehabilitaEon Program
Medial Gastrocnemius Strain

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.

30. 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)

31. 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

32. 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

33. 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 one's chances of
sustaining this type of injury.

34. Prognosis
If the above treatments are followed, the prognosis for
recovery and return to sports aWer a medial calf injury is
excellent.

35. EducaEon
InstrucEons for appropriate stretching and warm‐up
techniques should be provided to the paEent for the
implementaEon of maximal prevenEon of reinjury.