Gastrocnemius Strain

Etiology

Gastrocnemius strain usually develops with knee posture. This occurs during maximal knee extension with the ankle in full dorsiflexion, which maximally stretches the gastrocnemius muscle. The posture increases the tension in the muscle's elastic elements, allowing them to approach the threshold for muscle tear, especially during eccentric muscle contraction.

Epidemiology

Gastrocnemius strain occurs most commonly in middle-aged or older patients. Gastrocnemius strain may also occur in younger athletes and is sometimes referred to as tennis leg.[5] The term is derived from the posture to serve tennis, which involves maximal knee extension and ankle dorsiflexion. The medial head of the gastrocnemius muscle is injured more commonly than the lateral head, as results from some studies have shown the medial head to be more active than the lateral head.[6]

Gastrocnemius injury is common among young athletes engaged in activities such as racquet sports, running, basketball, football, and skiing. Findings from one report stated that this injury occurred after praying namaz.[3] The activity mentioned above requires the participant to kneel with the head touching the ground. The calf muscle is eccentrically stretched when the participant attempts to stand up.

Pathophysiology

Muscle fatigue and impaired coordination are common factors contributing to gastrocnemius muscle strain. Some research has revealed that impaired vascular supply to the gastrocnemius muscle might result in weakness of the musculotendinous unit. Failure of muscle relaxation also contributes to muscle strain. Due to the inability to fully relax, muscle fibers are more vulnerable to stretching injury.[5] The associated symptoms include muscle stiffness, indicating a decline in muscular elasticity. A common prodrome before the injury event comprises a dull muscle ache.[5]

History and Physical

Often, patients report feeling as if something struck their calf. Accompanying this feeling is an audible snap or pop, sounding like breaking a twig. At the moment of injury, there may be no pain. After the patient takes a few steps, the pain develops on the posteromedial part of the calf. Intense pain may limit their ability to ambulate.[5] Prodromal symptoms play an interesting role in gastrocnemius muscle injury. Patients may recall similar prodromic discomfort. There might be a dull pain initially noted in the affected calf. Findings from one report state that 20% of patients experience prodromic symptoms.[7]

The physical examination will frequently demonstrate edema, ecchymosis, and tenderness over the muscle tear site and possibly extending to the knee and ankle. Clinicians should palpate the calf along the full length of the muscles. Gastrocnemius strains usually present with pain on palpation of the medial belly or the musculotendinous junction. In soleus strains, the tenderness is frequently more lateral.[1] A subcutaneous gap may be palpated if there is a frank retraction across the injury site. The Achilles tendon should be palpated to determine if it is intact. If the clinician is unable to ascertain this from palpation, the Thompson test can be done.[1] The peripheral pulses should also be assessed. Provocative muscle testing should be done. The patient may have severe pain during passive ankle dorsiflexion or resistive plantarflexion, which may indicate a more severe injury.[3] A neurological examination should include both motor and sensory testing. Some patients with a complete tear may develop a large hematoma. The hematoma may compress the sural nerve, causing loss of sensation in the lateral calf and ankle.

Evaluation

Although the diagnosis of a gastrocnemius strain is primarily clinical, imaging studies can help differentiate partial from complete ruptures. The utility of plain films and CT scans in soft tissue injury is limited. Ultrasound offers the advantage of nonionizing radiation and is relatively inexpensive. The examiner should be aware of sonographic findings such as the disruption of the normal fiber arrangement at the myotendinous junction, hematoma, and fluid collection between the gastrocnemius and soleus muscles. Ultrasonography can also differentiate partial from complete muscle tears and determine the size of the hematoma. A bigger hematoma usually indicates a complete gastrocnemius muscle tear rather than a partial tear. Ultrasonography can also determine the extent of a complete rupture and help guide percutaneous aspiration of the hematoma. Deep vein thrombosis (DVT) can also be evaluated with ultrasound, which is sometimes concomitant with gastrocnemius strain.[3][8] Findings from a study of 141 patients with clinically diagnosed tennis leg showed that 67% had a partial tear of the medial gastrocnemius, 1.4% had an associated plantaris tendon rupture, and 21% had an intermuscular fluid collection without a medial gastrocnemius muscle tear. Ten percent had deep vein thrombosis without visible gastrocnemius pathology.[9]

Ultrasonography is useful for following the healing course. Signs of recovery on sonography include progressive decrease in hematoma size, reparative tissue, signified by a peripheral hypoechoic area that extends toward the center, and rearrangement of muscle fibers.[10] Magnetic resonance imaging (MRI) is indispensable in certain conditions because it offers outstanding soft-tissue imaging. Findings include rupture or discontinuity of muscle fibers and retraction of the torn muscle fibers. MRI also allows differentiation between gastrocnemius and Achilles tendon injury, which can help to improve direct treatment. MRI can also assess surrounding connective tissues in some muscle injury cases. Three MRI studies reported that connective tissue injury plays an important role in evaluating the return to sports after muscle injury.[11][12][13]

Treatment / Management

Early and accurate diagnosis and treatment can have a major impact on patient outcomes. Early treatment emphasizes symptomatic relief. Limiting further bleeding, decreasing pain, and preventing joint contracture are the main goals of early management of the gastrocnemius strain. Rest, ice packing, compressive wrapping, and elevation are common measures to minimize swelling and pain of injured muscle. The application of moist heat and massage is considered contraindicated early in treatment as they are thought to increase the risk of further hemorrhage.[1] 

Medications may be necessary to reduce pain and muscle spasms. Early mobilization is also paramount for preventing contracture. Nonsteroidal anti-inflammatory drugs are not recommended within the first 24 to 72 hours of injury due to an increased risk of bleeding from their antiplatelet effects. Celecoxib and possibly other cyclooxygenase-2 inhibitors are options during this period because of their weaker antiplatelet effects. Acetaminophen or narcotic pain medication can also be used.[1] If a patient is not improving despite these measures, reexamination and imaging studies should be considered to look for complications or possible surgical indications.[1]

Once the acute phase of treatment has been successful, that patient should be started on the rehabilitative phase of treatment. Physical therapy should be prescribed to promote functional recovery. Initially, gentle stretching can help lengthen the intramuscular scar of the injured muscle. Later, strengthening, heel raises, and proprioceptive exercises should be added, along with core muscle strengthening and general reconditioning. The patient is allowed to ambulate as tolerated and gradually increase activity level after the pain subsides. In patients with severe injury, weight-bearing on the affected lower extremity should be limited, and a cast or orthosis may be needed for ambulation. Weight-bearing exercise or dorsiflexion stretching should be delayed until the pain subsides. 

Most patients recover well under nonoperative treatment. Surgical repair of the muscle tear may be needed in certain cases. However, the procedure is technically challenging due to the difficulty of performing a suture through muscle tissue. Fibrosis and contracture at the incision site appear to be another concern. The absolute surgical indication is still unclear.[1][14]

Differential Diagnosis

The differential diagnosis includes:

• Achilles tendon pathology
• Soleus muscle injury
• Plantaris muscle injury
• Deep vein thrombosis
• Compartment syndrome 

Among calf muscle injuries, injury of the medial head of the gastrocnemius muscle remains the most frequent. Plantaris strain is relatively rare. The soleus muscle has a lower risk of injury in contrast to the gastrocnemius muscle. The soleus muscle mainly consists of type 1 slow-twitch muscle fibers and crosses only the ankle joint. Soleus strain tends to be less severe than gastrocnemius strain.[1]

Staging

Grade 1 Injury (Mild)

Patients may feel a sharp pain at the time of injury or with activity. They are usually able to continue the activity. Loss of strength and range of motion are minimal. An MRI study shows bright signals on fluid-sensitive sequences with less than 5% feathery appearance of muscle fiber involved. Pathologically, grade 1 injury indicates less than 10% of muscle fibers disrupted.

Grade 2 Injury (Moderate)

The patient cannot walk at the moment of injury. The patient may report weakness during ankle dorsiflexion and plantar flexion. One MRI study describes changes at the myotendinous junction as edema or hemorrhage. Grade 2 injury implies 10% to 50% disruption of muscle fibers. 

Grade 3 Injury (Severe)

A palpable defect may be present on the affected calf. The MRI findings include complete disruption of the continuity of muscle, wavy tendon morphology and retraction, and extensive hemorrhage or edema. Dixon et al suggested that grade 3 injury indicates 50% to 100% disruption of muscle fibers.[1][10]

Prognosis

Most studies indicate that gastrocnemius strains have a good prognosis. Most patients can have a marked decrease in pain and return to exercise after adequate management.

Complications

Complications include:

• Scar tissue formation
• Chronic pain or dysfunction
• Reinjury
• DVT formation
• Compartment syndrome