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Calf Strain

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Other Names

  • Gastrocnemius Strain
  • Soleus Strain
  • Plantaris Strain
  • GSC Strain
  • Calf muscle strain injuries (CMSI)
  • Tennis Leg
  • Posterior calf injury
  • Calf tear

Background

History

  • First described by Powell in 1883 and termed "tennis leg"[1]

Epidemiology

  • In Soccer players
    • In one study of professional players, 1.32 strains per 1000 exposure hours[2]
    • Among European soccer players with lower extremity injuries, calf strains represented 12% of cases[3]
  • Australian rules football
    • 3 cases per club per season, 16% recurrence rate[4]
    • Second most common muscle injury[5]
  • Tennis
    • Prevalence of 5.2% in collegiate standard players[6]

Pathophysiology

  • General
    • One of the highest soft tissue injuries and recurrences in sports
    • Common when muscles are not warmed up properly or are fatigued significantly
    • 20% of patients report prodromal symptoms[7]
    • Most common in gastric at myotendinous junction of medial head
  • Common in sports involving
    • High speed running
    • High volumes of running load
    • Acceleration and deceleration
    • Fatiguing conditions
  • Mechanism of injury
    • Sudden extension of knee with foot in dorsiflexion, active plantarflexion
    • Examples include sprinting, jumping
  • Strain vs Tear
    • Strain refers to the biomechanical description of the injury
    • Tear describes the structural injury to the muscle fibers

Gastrocnemius strain

  • Most common in medial head, often referred to as 'Tennis Leg'[8]
  • Higher risk because it is crosses two joints (biarthrodial or biarticular), the knee and ankle
  • High density of fast twitch, type 2 muscle fibers
  • More common in middle aged, poorly conditioned, physically active patient
  • Occurs with knee in extension and simultaneous dorsiflexion of the ankle
    • Eccentric load of lengthened gastroc can lead to myotendinous injury

Soleus strain

  • Likely under-reported as often lumped with gastrocnemius or calf strain
  • Lower risk as it only crosses the ankle joint, has slower twitch type 1 fibers
  • Less dramatic injury pattern, more subacute
  • Tend to occur from overuse with the ankle passively dorsiflexed while the knee is flexed

Plantaris strain

  • Considered largely vestigial, rarely involved in calf strains
  • Isolated strains are difficult to distinguish clinically
  • Occur with eccentric load and forceful dorsiflexion

Pathoanatomy

Associated Conditions


Risk Factors

  • Sports
    • Soccer[2]
    • Rugby[9]
    • Australian Rules Football[4]
    • Tennis[6]
    • Pole Vault
    • Professional Dancers
    • Triathletes
  • Occupational
    • Military Training[10]
  • Intrinsic
    • Increasing age
    • Previous calf injury
    • Previous ‘lower leg, knee, thigh, ankle/foot and back’ injury[11]
    • History of a Lumbar Radiculopathy of L5[12]
  • Extrinsic
    • Training volume
    • Overtraining/ fatigue

Differential Diagnosis


Clinical Features

  • History
    • Patients typically report a sudden onset of injury or pain
    • Often describe a "pop" that feels like someone kicked the back of the leg
    • Trouble weight bearing, inability to continue playing sport
    • Gets worse with walking, jogging, running, jumping or any plantarflexion activity
  • Physical Exam: Physical Exam Leg
    • In more severe injuries, swelling and ecchymosis may be present
    • Palpate along the entire muscle including proximal attachments, belly and into the achilles
    • Palpable defects suggest a more severe injury
    • Gastroc tenderness is commonly at medial belly or musculotendinous junction
    • Soleus strains are more commonly tender laterally
    • Knee in flexion: Soleus provides most of plantarflexion (can isolate to this muscle)
    • Knee in extension: Gastroc provides most of plantarflexion (can isolate to this muscle)
    • Inability to do single-leg raise on affected leg
  • Special Tests
    • Thompson Test: squeeze calf to reproduce plantarflexion (exclude achilles tendon injury)

Evaluation

Radiology

Ultrasound

  • General
    • Useful early one when exam is difficult due to pain and swelling
    • Can be performed rapidly after injury to consider broader diagnosis
    • Can trend recovery and stage the healing process
  • Findings
    • Disruption of the normal regular linear echogenic and hypoechogenic appearance of tendon components
    • Hematoma may be present (hypoechoic or anechoic fluid collection)
    • Increased doppler flow suggesting acute inflammation
  • Plantaris tear
    • May show fluid collection or defect in plane between medial head of gastroc and soleus
  • Soleus tear
    • Acute: small focal tear or region of hypoechoic change in area of maximal tenderness
    • Chronic: More generalized hypoechoic changes

MRI

  • General
    • Not typically needed or indicated unless diagnosis is uncertain
  • Findings that predict a delayed RTP[13]
    • Involvement of multiple muscles
    • Deep tissue injury involving the soleus
    • Large fascial defects
    • Tears at a musculotendinous junction

Classification

Classification System for Calf Strains

Grade Symptoms Signs Pathologic Correlation Radiology Correlation
Grade 1: 1st degree mild Sharp pain at time of injury or pain with activity. Usually able to continue activity Mild pain and localized tenderness. Mild spasm and swelling. No or minimal loss of strength and ROM <10% muscle fiber disruption Bright signal on fluid-sensitive sequences. Feathery appearance <5% muscle fiber involvement
Grade 2: 2nd degree moderate Unable to continue activity Clear loss of strength and ROM >10–50% disruption of muscle fibers Change in myotendinous junction. Edema and hemorrhage
Grade 3: 3rd degree severe Immediate severe pain, disability Complete loss of muscle function. Palpable defect or mass. Possible positive Tompson’s test 50–100% disruption of muscle fibers Complete disruption of discontinuity of muscle. Extensive edema and hemorrhage. Wavy tendon morphology and retraction

Management

Prognosis

  • Timeline
    • Healing typically takes 3-6 weeks[14]
  • Medial head of gastroc
    • Healing is slow, taking 3-16 weeks[15]
  • Recurrence
    • High mean time in return to sport
    • more likely to occur during critical competitive periods, such as the end of the competition season in football[16]
  • MRI Findings that predict a delayed RTP[17]
    • Involvement of multiple muscles
    • Deep tissue injury involving the soleus
    • Large fascial defects
    • Tears at a musculotendinous junction
  • Prakesh et al found MRI findings correlated closely with time to RTP[18]
    • Grade 0: 8 days
    • Grade 1: 17 days
    • Grade 2: 25 days
    • Grade 3: 48 days

Nonoperative

  • Indications
    • Vast majority of calf strains

Acute management (3-7 days)

Subacute management

Operative

  • Indications
    • Consider in grade III strains
    • Prolonged symptoms refractory to conservative management with evidence of contracture
    • Large intramuscular Hematoma
  • Technique

Rehab and Return to Play

Rehabilitation

  • Weeks 1-2
    • Passive stretching, range of motion
    • Non-weight bearing if possible
  • Weeks 2-6+
    • Ween off crutches, out of cast sleeve
    • Progress from isometric and isoteonic to dynamic training exercises

Return to Play/ Work

  • There is no clear consensus on RTP guidelines following calf injuries[20]
  • Complete recovery of strength and flexibility should be achieved prior to return to pre-injury activity
    • Premature return may result in a prolonged recovery or incomplete return to pre-injury baseline
    • This typically takes 4-12 weeks

Complications


See Also


References

  1. Hawkins, Clement. "LAWN TENNIS LEG." The Lancet 124.3194 (1884): 890.
  2. 2.0 2.1 Carling C, Le Gall F, Orhant E. A four-season prospective study of muscle strain reoccurrences in a professional football club. Res Sports Med 2011;19:92–102.
  3. Armfield, Derek R., et al. "Sports-related muscle injury in the lower extremity." Clinics in sports medicine 25.4 (2006): 803-842.
  4. 4.0 4.1 Orchard J, Seward H, Orchard J. AFL injury report. Australian Football League (AFL) 2014;2014:1–20.
  5. Waterworth G, Wein S, Gorelik A, Rotstein AH. MRI assessment of calf injuries in Australian Football League players: findings that influence return to play. Skeletal Radiol. 2017 Mar;46(3):343-350.
  6. 6.0 6.1 Colberg RE, Aune KT, Choi AJ, et al. Incidence and prevalence of musculoskeletal conditions in collegiate tennis athletes. JMST 2015;20:137–44.
  7. Campbell JT. Posterior calf injury. Foot Ankle Clin. 2009 Dec;14(4):761-71.
  8. Brukner P, Khan K. Clinical sports medicine. Revised 2nd ed. Australia: McGraw-Hill; 2002.
  9. Brooks JH, Kemp SP. Injury-prevention priorities according to playing position in professional rugby union players. Br J Sports Med 2011;45:765–75.
  10. Schwartz O, Malka I, Olsen CH, Dudkiewicz I, Bader T. Overuse Injuries Among Female Combat Warriors in the Israeli Defense Forces: A Cross-sectional Study. Mil Med. 2018 Nov 1;183(11-12):e610-e616.
  11. Nilstad A, Andersen TE, Bahr R, et al. Risk factors for lower extremity injuries in elite female soccer players. Am J Sports Med 2014;42:940–8.
  12. Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection? Br J Sports Med. 2004 Aug;38(4):502-4; discussion 502-4.
  13. Waterworth G, Wein S, Gorelik A, Rotstein AH. MRI assessment of calf injuries in Australian Football League players: findings that influence return to play. Skeletal Radiol. 2017 Mar;46(3):343-350.
  14. Delgado GJ, et al. Tennis Leg: Clinical US study of 71 patients and anatomic investigation of four cadavers with MR Imaging and US. Radiology. 2002;224:112–9
  15. Kwak, Hyo-Sung, Kwang-Bok Lee, and Young-Min Han. "Ruptures of the medial head of the gastrocnemius (“tennis leg”): clinical outcome and compression effect." Clinical imaging 30.1 (2006): 48-53.
  16. Mallo J, Dellal A. Injury risk in professional football players with special reference to the playing position and training periodization. J Sports Med Phys Fitness 2012;52:631–8.
  17. Waterworth G, Wein S, Gorelik A, Rotstein AH. MRI assessment of calf injuries in Australian Football League players: findings that influence return to play. Skeletal Radiol. 2017 Mar;46(3):343-350.
  18. Prakash A, Entwisle T, Schneider M, Brukner P, Connell D. Connective tissue injury in calf muscle tears and return to play: MRI correlation. Br J Sports Med. 2018 Jul;52(14):929-933.
  19. Dixon J. Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries. Curr Rev Musculoskelet Med. 2009;2:74–77.
  20. Orchard J, et al. Return to play following muscle strains. Clinical J Sport Medicine. 2005;15:436–441.
Created by:
John Kiel on 7 July 2019 07:20:20
Authors:
Last edited:
25 April 2021 14:48:34
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