AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

A medial calf injury is a musculotendinous disruption of varying degrees in the medial head of the gastrocnemius muscle that results from an acute, forceful push-off with the foot.^{1, 2, 3, 4, 5, 6} This injury occurs commonly in sports activities (eg, hill running, jumping, tennis), but it can occur in any activity. A medial calf injury is often seen in the intermittently active athlete, often referred to as the "weekend warrior." (See also Characteristics of a "Weekend Warrior": Results from Two National Surveys on Medscape.)

This condition has been termed "tennis leg" because of its prevalence in this particular sport, but medial calf injury can happen in a variety of sports or other activities. One mechanism that occurs is on the back leg during a lunging shot, in which the knee is extended while the foot is dorsiflexed. This action puts maximal tension on the gastrocnemius muscle as the lengthened muscle is contracted at the "push off," resulting in a medial calf injury. (See also the eMedicine article Body Contouring, Calf Augmentation.)

For excellent patient education resources, visit eMedicine's Sports Injury Center and Sprains and Strains Center. Also, see eMedicine's patient education articles Muscle Strain and Sprains and Strains.

Frequency

International

Medial calf injuries occur more commonly in men than in women, and these injuries usually afflict athletes and others in the fourth to sixth decade of life. Medial calf injuries are most commonly seen acutely, but up to 20% of affected patients report a prodrome of calf tightness several days before the injury, thus suggesting a potential chronic predisposition.

Functional Anatomy

The medial head of the gastrocnemius muscle originates from the posterior aspect of the medial femoral condyle, and as it courses distally, the medial head merges with the lateral head of the gastrocnemius. Further distally, the joined heads of the gastrocnemius merge with the soleus muscle-tendon complex to form the Achilles tendon. The main function of the gastrocnemius muscle is to plantar flex the ankle, but it also provides some knee flexion, as well as contributes to the posterior stability of the knee and partially to the motion of the menisci with flexion/extension of the knee. Throughout the belly of the muscle, the medial gastrocnemius has several origins of tendinous formation. Most strains occur at this musculotendinous junction.

Sport-Specific Biomechanics

The medial calf injury usually occurs when an eccentric force is applied to the gastrocnemius muscle, which usually happens when the knee is extended, the ankle is dorsiflexed, and the gastrocnemius attempts to contract in the already lengthened state.^{1, 2, 3, 4, 5, 6} This is the common position of the back leg in a tennis stroke, and it results in the greatest force to the muscle unit; but medial calf injuries can also occur during a typical contraction of ankle plantar flexion, especially if the athlete is pushing or lifting a large weight or force.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• An audible pop when the injury to the medial calf occurred is usually reported, and the patient complains of feeling like a stick struck his/her calf.
• The patient complains of pain in the area of the calf, which also radiates to the knee or the ankle. In addition, the patient complains of pain with range of motion (ROM) of the ankle.
• The patient complains of a swollen leg that extends down to the foot or ankle, as well as the associated color changes of bruising. (See also the eMedicine article Contusions.)

Physical

• Inspection
• • Asymmetric calf swelling and discoloration, potentially spreading to the ankle and foot, is noted on physical examination.
  • If the stage of swelling has resolved, a visible defect in the medial gastrocnemius muscle may be evident.
• Palpation
• • Tenderness is noted upon palpation in the entire medial gastrocnemius muscle, but this tenderness is observed to be exquisitely more painful at the medial musculotendinous junction.
  • Depending on the degree of swelling, a palpable defect may be evident at the medial musculotendinous junction; however, with extreme swelling, this finding may not be appreciable.
  • Palpation of the Achilles tendon should demonstrate an intact tendon.
  • The peripheral pulses should be present and symmetric.
• Provocative maneuvers: Moderate to severe pain is demonstrated with passive ankle dorsiflexion (due to stretching of the torn muscle fibers), as well as with active resistance to ankle plantar flexion (due to the firing of the torn muscle fibers).

Causes

• Age/activity status: As indicated in the Background section, medial calf injuries occur more commonly in the middle-aged recreational athlete. This population typically continues to be physically active at a moderate to high intensity but not on a regular basis, and these individuals are also likely to have maintained a moderate degree of the muscle mass from their more active days. Yet weekend warriors seem to have started to lose some of the flexibility they had when they were younger, resulting in a relatively large gastrocnemius muscle that is less flexible than it had been, and on occasion, the muscle is challenged with a ballistic or explosive force, leading to a partial or complete rupture.
• Deconditioned/unstretched muscles: The cold and unstretched muscles that recreational athletes often use to compete with are very likely to rupture when challenged compared with conditioned and stretched muscles. However, because medial calf injuries also occur in the physically fit, the role of stretching in prevention is not completely understood. This phenomenon may mean that force versus elasticity is the key formula, and if the force overcomes the elasticity, even in a conditioned athlete, then a rupture or injury can occur.
• Previous injury: The athlete with recurrent calf strains is likely to have healed with fibrotic scar tissue, which absorbs forces differently and is thus more likely to result in rupture when the muscle is challenged.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to Be Considered

Baker cyst rupture
Deep venous thrombosis
Plantaris tendon rupture
Acute compartment syndrome after rupture of the medial head of the gastrocnemius
Chronic exertional compartment syndrome (posterior)
Posterior tibial tendon rupture or tendinitis
Popliteal artery entrapment syndrome
Anomalous gastrocnemius muscle rupture

A Baker cyst is a reactive outpouching of the knee joint capsule. The presence of a Baker cyst implies chronic internal knee pathology, often arthritic in nature, but it may also include traumatic meniscal pathology. The cyst is usually painless but often cosmetically unacceptable to the patient. If the Baker cyst ruptures, the leg swells, and the pain is diffuse. This condition can be confused with a ruptured gastrocnemius muscle.

(See also the eMedicine articles Baker Cyst [in the Radiology section], Knee Injury, Soft Tissue [in the Emergency Medicine section], and Cystic Lesions About the Knee and Limping Child [in the Orthopedic Surgery section].)

A femoral or popliteal deep venous thrombosis (DVT) can cause leg swelling, which can result in leg pain. If this condition occurs in the same time frame as an acute leg injury, the 2 conditions can be confused.

(See also the eMedicine articles Deep Venous Thrombosis and Thrombophlebitis [in the Emergency Medicine section] and Deep Venous Thrombosis, Lower Extremity [in the Radiology section], as well as ASCO Issues Guidelines for Preventing and Treating Venous Thromboembolism in Cancer Patients, VTE Increases Risk of Arterial CV Events, Guidelines Updated for Prevention of DVT and PE Linked With Gynecologic Surgery, and Dual-Contrast MRI Detects and Shows Extent of DVT on Medscape.)

The plantaris tendon originates in the popliteal area, and this tendon is also a plantar flexor of the ankle. If the plantaris tendon ruptures, the leg swells, and the resulting tenderness can be in the same area as where a gastrocnemius strain would occur.

Achilles tendon injury can occur with the identical mechanism of a medial gastrocnemius rupture. Because the ensuing fluid and edema may migrate proximally, the 2 conditions may mimic each other. An Achilles tendon rupture results in an inability to plantar flex the foot, and a more distal defect of the tendon is usually palpable. A Thompson test can be used to differentiate the 2 injuries. The test is performed with the patient prone and the knee held in flexion. Then, the gastrocnemius muscle is squeezed. A negative sign results in normal plantar flexion of the foot and ankle. If the flexion is not appreciated, the test is positive and due to a disrupted Achilles tendon. (See also the eMedicine article Achilles Tendon Rupture.)

Acute compartment syndrome of the lower extremity occurs after trauma, with accumulation of blood or fluid in a closed compartment of the leg. The resultant pressure produces pain and swelling, and if the posterior compartment is affected, this could clinically present similarly to a medial gastrocnemius tear.

(See also the eMedicine articles Compartment Syndrome, Lower Extremity [in the Orthopedic Surgery section], Compartment Syndrome [in the Physical Medicine and Rehabilitation section], and Compartment Syndrome, Extremity [in the Emergency Medicine section].)

Chronic compartment syndrome results in affected individuals after a degree of exertion and from vascular compromise with edema in the compartment of the leg. The pain that ensues can mimic that of gastrocnemius muscle strains, but this condition becomes symptom-free after the exertion is completed. (See also the eMedicine article Compartment Syndromes [in the Sports Medicine section].)

The popliteal tendon courses posteriorly on the medial side of the leg. Injuries to this structure can distribute pain in the same regions as a tennis leg injury. (See also the eMedicine articles Pes Planus [in the Orthopedic Surgery section] and Athletic Foot Injuries [in the Sports Medicine section].)

The popliteal artery may be entrapped during its course in the leg. The most common cause is an anomalous gastrocnemius muscle. Typically, popliteal artery entrapment manifests during exertion, and the symptoms of this condition are more consistent with the symptoms of chronic exertional compartment syndrome.

(See also the eMedicine articles Peripheral Arterial Occlusive Disease [in the Vascular Surgery section], Compartment Syndrome, Lower Extremity [in the Orthopedic Surgery section], and Compartment Syndromes [in the Sports Medicine section].)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The ruptured medial gastrocnemius can usually be diagnosed clinically. Although laboratory and imaging studies can also be used to evaluate some of the other diagnostic possibilities (see Differentials and Other Problems to Be Considered), they are not necessary.
• Laboratory studies are usually not necessary in the workup of gastrocnemius strains. They may, however, aid in the evaluation of a potential DVT, if clinical suspicion is present.
• • Complete blood cell (CBC) count: If a DVT is present, the platelet count may be abnormal, but in gastrocnemius strains, the CBC count is normal.
  • Coagulopathy panel: Before initiating treatment for DVT, prothrombin time (PTT), activated partial thromboplastin time (aPTT), protein C, protein S, and D-dimer levels should be measured. Of course, these results all are within the normal reference range in a medial gastrocnemius strain.

Imaging Studies

• Radiographs
• • In the face of a classic history and presentation for a medial gastrocnemius strain, radiographs are usually normal and do not offer additional information for treatment.
• • X-ray films may be ordered to rule out an avulsion fracture, especially when the patient describes an audible pop or any history of impact or trauma to the calf region. (See also the eMedicine article Tibial Tubercle Avulsion.)
• • Plain films of the leg and tibia/fibula are usually normal, except for the finding of soft-tissue swelling.
• Studies have shown that magnetic resonance imaging (MRI) and ultrasound studies can be useful in the diagnosis and/or follow-up of injuries to the lower leg.
• • MRI is the most sensitive and specific imaging method, and this technique is able to show the area of disrupted soft tissue better than other imaging modalities (eg, computed tomography [CT] scanning, ultrasonography).
  • • Koulouris et al retrospectively reviewed 59 MRIs from patients who had sustained calf muscle injuries.⁷ The authors reported that of the 39 isolated strains, gastrocnemius injuries were the most common (48.7%), in which the majority of these (94.7%) involved the medial head, followed by soleus muscle injuries (46.2%), including 2 cases of distal avulsions of the plantaris. In cases in which there were dual injuries, the most common finding (60%) was a combined gastrocnemius and soleus muscle injury. Koulouris et al concluded that dual injuries to the calf region may be more common than has been reported and such injuries may have a prognostic significance. The authors also noted that in the literature, soleus muscle injury is a rarely reported finding with ultrasonography.
  • In areas where ultrasound experience is good, this modality may also demonstrate the medial gastrocnemius injury and usually costs less than MRI. However, limited MRI protocols, in which a few images of the suspected region of pathology are performed, can have competitive pricing and demonstrate superior images than ultrasonography. However, in emergency department settings, rapid diagnostic ultrasonography can be used to evaluate the structure of the medial gastrocnemius and to rule out some of the diagnostic possibilities, such as DVT (see Differentials and Other Problems to Be Considered).⁸
  • • In a Korean study, 22 patients with clinically suspected ruptures of the medial head of the gastrocnemius under went ultrasound examination of both the affected and unaffected limbs.⁹ The authors reported that 7 of the 22 patients were diagnosed with a partial rupture, and the remaining 15 patients were diagnosed with complete ruptures of the head of the gastrocnemius. In addition, the authors noted fluid collection between the head of the gastrocnemius and the soleus muscle in 20 patients, and they reported the thickness of the fluid collection was significantly greater in those patients with complete gastrocnemius medial head ruptures (mean: 9.7 mm) compared with those of the individuals with partial tears (6.8 mm). The authors concluded that ultrasound is a useful imaging modality for the diagnosis and follow-up of patients with ruptures of the medial head of the gastrocnemius.

Other Tests

• Other tests are not necessary for the diagnosis of an uncomplicated medial gastrocnemius strain. If the suspicion of DVT persists, then further evaluation with Doppler ultrasonography is indicated.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Initial treatment of a medial calf injury includes relative rest, ice, compression, elevation (RICE), and early weight bearing, as tolerated. The initial treatment should continue for 24-72 hours. Ice therapy is best instituted over a damp elastic wrap, which also provides compression. Preventing the limb from hanging dependently prevents further swelling. The use of crutches with a feathering gait and bilateral heel lifts is indicated if normal gait is compromised. Active foot and ankle ROM can be carried out if there is pain-free ROM.

Medical Issues/Complications

Pain management should include analgesics as indicated. Caution should be used with nonsteroidal anti-inflammatory drugs (NSAIDs) during the acute injury phase, as these agents can predispose the patient to increased bleeding and hematoma formation in the initial days after an injury. Theoretically, cyclooxygenase-2 (COX-2) inhibitors may provide pain control without the risk of bleeding in acute injuries, which is a concern with traditional NSAIDs.

Other Treatment

Ankle/foot bracing should be used to keep the ankle in a position of maximal tolerable dorsiflexion. Studies have shown an increased rate of healing with this intervention.

Recovery Phase

Rehabilitation Program

Physical Therapy

Ice therapy and active resistance dorsiflexion exercises can be undertaken until the athlete is pain free. Then, light plantar flexion exercises against resistance are initiated. Progression of therapy includes reduction in heel-lift height and gradual introduction of stationary cycling, leg presses, and heel raises. At this stage, ultrasonography, used with or without phonophoresis, and muscle stimulation are also applicable. Massage techniques can help with the removal of interstitial fluid. Apply compression dressing from the metatarsal heads to the gastrocnemius for the first 2 weeks. Partial weight-bearing ambulation should begin as soon as tolerable to maximize the contact of the sole of the foot to the ground, then progress to increased cyclic loading, advanced proprioception and balance training, and eventual full weight-bearing ambulation, with dynamic change of speed and direction as tolerable.

Maintenance Phase

Rehabilitation Program

Physical Therapy

Once the athlete is pain free with full and symmetric ROM and full strength is regained, sports-specific activities can be resumed. Strengthening and stretching of the injured area should continue for several months to overcome the increased risk for reinjury due to the deposition of scar tissue that is involved in the healing process.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medications are directed at maintaining patient comfort in what can be a very painful injury of the medial head of the gastrocnemius. Clinicians must carefully consider pain therapy in the first 48 hours, as decreased platelet activity may result in increased bleeding and larger hematoma formation—with resultant effects on healing.

The simplest, yet least powerful of the recommended analgesics is acetaminophen. Typical doses of 1000-1300 mg, 3-4 times daily can be used as needed. This agent does not affect platelet function but may not greatly control pain.

To gain better pain control, more potent analgesics can be used, such as NSAIDs or an acetaminophen/narcotic combination. As referred to above (see Medical Issues/Complications in the Treatment, Acute Phase section), NSAIDs may enhance bleeding shortly after the injury has occurred. These agents are also likely to cause symptoms of gastrointestinal (GI) discomfort, and they can result in mucosal injury and even bleeding ulcers. On the other hand, opioid analgesic agents may cause GI side effects but not result in bleeding issues; these medications are generally better at pain control, but opioid analgesics have the possible complication of addiction or abuse.

Opioid medications come in various forms and various dosages. An alternative to the above medications is to use a newer NSAID from the COX-2 inhibitor class. The new COX-2 inhibitor drugs affect inflammation in a more specific manner by not affecting the prostaglandins that can cause the above side effects; these agents have also been shown to provide equianalgesia to the traditional NSAIDs.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet (ie, decrease pulmonary secretions, open the airways), and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Drug Category: Cyclooxygenase-2 (COX-2) inhibitors

COX-2 inhibitors promote control of moderate pain and anti-inflammatory effects, especially in patients who have sensitivity to the traditional NSAIDs. Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeding is clearly less with COX-2 inhibitors than with the traditional NSAIDs. Ongoing analysis of the cost avoidance of GI bleeding will further define the populations that will benefit from the use of COX-2 inhibitors.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Return to Play

When an athlete will be able to return to play is predicated on the patient being pain free and recovering full ROM. This period can last 1-12 weeks, depending on the degree of tissue damage that was sustained. Strength testing should reveal that more than 90% of the uninjured side accounts for the patient's dominance preference.

Complications

The most common complication of a medial calf injury is scar-tissue formation, which results in chronic pain or dysfunction that is caused by a functional shortening of the muscle-tendon unit. This scar tissue can then predispose to frequent reinjury. Another complication is the formation of a DVT as a result of patient inactivity and trauma.

Prevention

A medial calf injury may not be preventable, but regular physical activity with maintenance of flexibility in the gastrocnemius muscle may help to reduce one's chances of sustaining such an injury.

Prognosis

If the above treatments are followed (see Treatment, Acute Phase, Recovery Phase, and Maintenance Phase), the prognosis for recovery and return to sports after a medial calf injury is excellent.

Education

Instructions for appropriate stretching and warm-up techniques should be provided to the patient for the implementation of maximal prevention of reinjury.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The most common legal pitfall is failure to consider DVT in the differential diagnosis, especially in a patient with other risk factors (eg, deconditioning, oral contraceptives, previous DVT, prolonged inactivity). (See Differentials and Other Problems to Be Considered).
• Another pitfall is failure to thoroughly evaluate the distal posterior leg to rule out the possibility of an Achilles tendon rupture, which may require surgery for healing.
• Finally, when a medial gastrocnemius injury manifests, great leg swelling is likely, and, therefore, vascular injury and compartment syndrome should also be considered in the differential diagnosis.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Brown DE. Ankle and leg injuries. In: Walsh W, Shelton GL, eds. The Team Physician's Handbook. Vol 1. Philadelphia, Pa: Hanley & Belfus; 1990:448-9.
2. Canale T, ed. Campbell's Operative Orthopaedics. 8^th ed. St. Louis, Mo: Mosby; 1998:1413-25.
3. Glazer JL, Hosey RG. Soft-tissue injuries of the lower extremity. Prim Care. Dec 2004;31(4):1005-24. [Medline].
4. Johnson MD. Physiology of musculoskeletal growth. In: Sallis RE, Massimino R, eds. ACSM's Essentials of Sports Medicine. Vol 1. St. Louis, Mo: Mosby; 1997:534-8.
5. Pedowitz R, Saglimbeni A. The leg. In: Safran MR, McKeag DB, Van Camp SP, eds. Manual of Sports Medicine. Vol 1. Philadelphia, Pa: Lippincott-Raven; 1998:460-6.
6. Taunton J, Smith C, Magee DJ. Leg, foot and ankle injuries. Athletic Injuries and Rehabilitation. Vol 1. Philadelphia, Pa: WB Saunders Co; 1996:730-6.
7. Koulouris G, Ting AY, Jhamb A, Connell D, Kavanagh EC. Magnetic resonance imaging findings of injuries to the calf muscle complex. Skeletal Radiol. Oct 2007;36(10):921-7. [Medline].
8. Legome E, Pancu D. Future applications for emergency ultrasound. Emerg Med Clin North Am. Aug 2004;22(3):817-27. [Medline].
9. Kwak HS, Han YM, Lee SY, Kim KN, Chung GH. Diagnosis and follow-up US evaluation of ruptures of the medial head of the gastrocnemius ("tennis leg"). Korean J Radiol. Jul-Sep 2006;7(3):193-8. [Medline]. [Full Text].

Article Last Updated: Nov 27, 2007