Muscle injuries in the legs are common during sports. Rapid and repetitive movements cause muscle fatigue and can lead to fiber breakage. When this muscle tear (tear or complete) occurs in the inner calf (calf muscle in the lower leg) it is known as “Tennis leg”.
The calf is made up of the gastrocnemius or internal twin muscles, the external gastrocnemius and the soleus. The gastrocnemius is superficial and larger, while the soleus (more centrally positioned) is deeper and smaller. The Achilles tendon connects the gastrocnemius and soleus muscles with the heel bone (calcaneus) (Figure 1).
Figure 1: Anatomical image showing the relationship of the gastrocnemius muscles with the soleus and the Achilles tendon
The medial calf injury known as the tennis leg was first described by Powell in 1883 and occurs during knee extension and forced ankle dorsiflexion. This mechanism can occasionally injure the plantar muscle, although injury to the medial head of the gastrocnemius or injury to the gastrocnemius-soleus aponeurosis is much more common.
This calf injury occurs frequently in athletes between the ages of 30-50 as a result of a sudden contraction of the calf muscles during acceleration, change of direction, or jump. Sometimes the patient can hear the “pop” of the tear, report that he has had a sharp and burning pain in the leg or sometimes even think that a colleague has kicked him or something has hit him from behind the calf (sign of the stone). Generally, the athlete will not be able to continue playing, running or doing sports, but to a large extent that will depend on the severity of the injury.
Figure 2: Image shows the ultrasound where the lesion between the medial gastrocnemius and soleus muscles is clearly observed (marked by arrows)
It is estimated that with a calf injury, 60% will present a partial rupture of the medial head of the gastrocnemius. It should be borne in mind that you can injure the muscle complex without breaking it (20% present edema and fluid between the aponeuroses without fibrillar injury). Another factor that must be taken into account is that 10% of patients with this type of muscle injury may present deep vein thrombosis at the same time.
The diagnosis can be made with high definition ultrasound (Figure 2), but it is recommended to complete the study with an MRI (Figure 3), especially useful for the study of the soleus muscle.
The main goal of treatment is to reduce downtime while reducing the risk of re-breakage. Failure to properly treat a muscle injury carries a high risk of scar formation (fibrosis) that will cause the muscle to break again under intense stimulation. The recurrent rupture of the muscles causes many abandonment of sports practice due to continuous losses.
Figure 3: Magnetic resonance imaging (MRI) that, in addition to showing the muscle injury, serves to rule out associated injuries that are difficult to identify by ultrasound; such as an injury to the soleus muscle or a deep vein thrombosis. This MRI shows an active subacute tennis leg type lesion affecting the right medial twin with focal fibrosis, the tear is located above the most distal UMT of the medial twin
It is important to do ultrasound control to see if there is hematoma or not. In the event that the injury produces a hematoma, it must be drained (always under ultrasound control) by the doctor. Initial physical therapy treatment will focus on reducing pain, edema, improving venous return, and restoring mobility and strength. Ultrasound-guided electrolysis (USGET) helps us treat muscle scars (fibrosis). In the image we can see how electrolysis with the Gymna Acure 8000 device produces a galvanic reaction in the fibrous scar with the aim of undoing it and creating a new labile and linear scar that reduces the risk of re-injury (Figure 4).
Figure 4: Ultrasound-guided electrolysis procedure (Gymna Acure 8000) seen by high definition ultrasound. It is observed how the needle (white line that enters from the left) goes through the medial calf muscle until it penetrates the fibrosis zone between this muscle and the soleus. The gas effect (galvanic current) that takes place at the tip of the needle is observed as a white cloud
Once the biological treatment has been carried out, it is very important to provide mechanical stimulation (exercises) to the muscles involved. Eccentric exercise is widely used in this type of injury because it provides an intense stimulus to the muscles, provides them with strength and allows a speedy recovery and return to sports activity.
Good work in a medical team, physiotherapist, physical trainer … will provide us with security in each of the steps of the treatment. Before returning to competition it is very important that all these phases are meticulously completed and the last phase of return to competition is carried out in a progressive and controlled manner.
Bibliography
Abat F, et al. BMC Sports Sci Med Rehabil. 2015 Apr 17; 7: 7.
Bhatia M, et al. Med J Armed Forces India. 2019 Jul; 75 (3): 344-346.
Powell RW Lawn tennis leg. Lancet. 1883; 122 (3123): 44.
Delgado GJ, et al. Radiology. 2002; 224: 112-119.
About the Author
We talk about Dr. Ferran Abat, sports traumatologist at ReSport Clinic Barcelona
Instagram: @ferranabat
Web: www.resportclinic.com
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