Medial Gastrocnemius Strain Treatment & Management
- Author: Anthony J Saglimbeni, MD; Chief Editor: Sherwin SW Ho, MD more...
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.
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.
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.
As with any large muscle strain, hematoma formation can be complicated by heterotopic ossification resulting in myositis ossificans. Studies do support the use of nonsteroidal anti-inflammatory medication, which may help prevent this.
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.
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.
A 2014 randomized trial reported that the use of shock-absorbing insoles during 3 weeks of training on artificial turf resulted in a significant increase in the pain threshold for the medial head of the gastrocnemius muscle.
Brown DE. Ankle and leg injuries. Walsh W, Shelton GL, eds. The Team Physician's Handbook. Philadelphia, Pa: Hanley & Belfus; 1990. Vol 1: 448-9.
Canale T, ed. Campbell's Operative Orthopaedics. 8th ed. St. Louis, Mo: Mosby; 1998. 1413-25.
Glazer JL, Hosey RG. Soft-tissue injuries of the lower extremity. Prim Care. 2004 Dec. 31(4):1005-24. [Medline].
Johnson MD. Physiology of musculoskeletal growth. Sallis RE, Massimino R, eds. ACSM's Essentials of Sports Medicine. St. Louis, Mo: Mosby; 1997. Vol 1: 534-8.
Pedowitz R, Saglimbeni A. The leg. Safran MR, McKeag DB, Van Camp SP, eds. Manual of Sports Medicine. Philadelphia, Pa: Lippincott-Raven; 1998. Vol 1: 460-6.
Taunton J, Smith C, Magee DJ. Leg, foot and ankle injuries. Athletic Injuries and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996. Vol 1: 730-6.
Yilmaz C, Orgenc Y, Ergenc R, Erkan N. Rupture of the medial gastrocnemius muscle during namaz praying: an unusual cause of tennis leg. Comput Med Imaging Graph. 2008 Dec. 32(8):728-31. [Medline].
Tao L, Jun H, Muliang D, Deye S, Jiangdong N. Acute Compartment Syndrome after Gastrocnemius Rupture (Tennis Leg) in a Nonathlete without Trauma. J Foot Ankle Surg. 2014 Nov 27. [Medline].
Darby J, Hodson-Tole EF, Costen N, Loram ID. Automated Regional Analysis of B-Mode Ultrasound Images of Skeletal Muscle Movement. J Appl Physiol. 2011 Oct 27. [Medline].
Lindberg F, Öhberg F, Granåsen G, Brodin LÅ, Grönlund C. Pennation angle dependency in skeletal muscle tissue doppler strain in dynamic contractions. Ultrasound Med Biol. 2011 Jul. 37(7):1151-60. [Medline].
Koulouris G, Ting AY, Jhamb A, Connell D, Kavanagh EC. Magnetic resonance imaging findings of injuries to the calf muscle complex. Skeletal Radiol. 2007 Oct. 36(10):921-7. [Medline].
Legome E, Pancu D. Future applications for emergency ultrasound. Emerg Med Clin North Am. 2004 Aug. 22(3):817-27. [Medline].
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. 2006 Jul-Sep. 7(3):193-8. [Medline]. [Full Text].
Madeleine P, Hoej BP, Fernández-de-Las-Peñas C, Rathleff MS, Kaalund S. Pressure pain sensitivity changes after use of shock-absorbing insoles among young soccer players training on artificial turf: a randomized controlled trial. J Orthop Sports Phys Ther. 2014 Aug. 44(8):587-94. [Medline].
Abellaneda S, Guissard N, Duchateau J. The relative lengthening of the myotendinous structures in the medial gastrocnemius during passive stretching differs among individuals. J Appl Physiol. 2009 Jan. 106(1):169-77. [Medline].
Shin DD, Hodgson JA, Edgerton VR, Sinha S. In vivo intramuscular fascicle-aponeuroses dynamics of the human medial gastrocnemius during plantarflexion and dorsiflextion of the foot. J Appl Physiol. 2009 Jul 16. epub ahead of print. [Medline]. [Full Text].