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Medial Gastrocnemius Strain Workup

  • Author: Anthony J Saglimbeni, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Oct 27, 2015
 

Laboratory Studies

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  • 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.
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Imaging Studies

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  • 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 Medscape Reference 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).[9, 10]
      • Koulouris et al retrospectively reviewed 59 MRIs from patients who had sustained calf muscle injuries.[11] 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).[12]
      • 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.[13] 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.
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Other Tests

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  • 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.
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Contributor Information and Disclosures
Author

Anthony J Saglimbeni, MD President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

References
  1. 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.

  2. Canale T, ed. Campbell's Operative Orthopaedics. 8th ed. St. Louis, Mo: Mosby; 1998. 1413-25.

  3. Glazer JL, Hosey RG. Soft-tissue injuries of the lower extremity. Prim Care. 2004 Dec. 31(4):1005-24. [Medline].

  4. 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.

  5. 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.

  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.

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. Legome E, Pancu D. Future applications for emergency ultrasound. Emerg Med Clin North Am. 2004 Aug. 22(3):817-27. [Medline].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

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