What is Gastrocnemius Rupture?
Calf injuries are quite common in sports and can involve different muscles such as the gastrocnemius (the muscle that creates the calf curve), soleus (a flat muscle located under the gastrocnemius), popliteal (located at the back of your knee), and plantaris muscles (a thin muscle in the leg). If the gastrocnemius muscle is injured, it can cause a lot of pain, swelling at the back of the calf, limping, and difficulty in moving around. It’s crucial to correctly identify this injury from other injuries in this part of the lower leg to ensure athletes get the right treatment and recover promptly.
The gastrocnemius is the most prominent and superficial (closer to the skin) muscle at the back of the leg. This muscle starts from the two protruding parts (condyles) of the thigh bone (femur) and few fibers also start from the capsule of the knee joint. The muscle is attached to the heel bone (calcaneus) along with the soleus muscle, by a long and thick tendon known as Achilles tendon. Sometimes, the soleus muscle along with the two heads of the gastrocnemius muscle is considered as one muscle and referred to as triceps surae.
Nourished by the tibial nerve and the posterior tibial artery, this muscle is primarily responsible for pointing our foot downwards (plantar flexion of the ankle). It was previously understood to aid in driving force while walking. However, latest research points out that the triceps surae don’t really propel motion, but only support the body during walking, preventing us from falling. The bigger and stronger part of the gastrocnemius muscle (the medial head) contributes more to the rotational force (torque) of the ankle than the other part in a frontal plane.
What Causes Gastrocnemius Rupture?
The gastrocnemius is the major muscle in the back of your calf. It’s like the powerhouse for actions like running and jumping. This muscle is composed of fast and slow-twitch fibers. Just underneath it, you’ll find the soleus muscle which is mostly made of slow-twitch fibers. The soleus helps you sustain strength and keep going during actions which require pushing down with your foot for longer periods.
There’s also a little muscle called the plantaris, which is nestled between the two parts of your gastrocnemius. While it’s not really important for movement, it may help a bit with bending your foot downward and your knee inward. Another muscle, the popliteus, works to rotate the shin bone inward against your thigh bone and stop it from turning outward.
Movements that involve a sudden stretch on your muscle can result in tearing of the gastrocnemius. This can happen during quick forceful actions like pushing off or jumping, especially when the position of your ankle quickly changes from foot-down to foot-up. This is common in sports like tennis which involve swift changes in direction, such as when hitting a return shot. It can lead to injury in the inner part of the gastrocnemius, often known as ‘tennis leg’.
Risk Factors and Frequency for Gastrocnemius Rupture
Calf muscle injuries are often seen in middle-aged male athletes who are not well-conditioned. These injuries are usually found in sports that involve explosive movements from the lower half of the body, like football, basketball, tennis, and soccer. The likelihood of these injuries increases if the athletes do not warm-up properly or become tired. Most of these injuries are found at the meeting point of the muscle and tendon in the gastrocnemius muscle, that’s the muscle on the inside part of the back of your lower leg. The injury can also occur at a part called the aponeurosis between the medial gastrocnemius and the soleus muscles, that’s the area that connects these two muscles. Only very few injuries happen in the lateral, or the outer part, of the gastrocnemius.
In different sports, certain types of calf injuries can be more common. In Australian rules football, injuries to the soleus muscle (62%) are more common than injuries to the gastrocnemius muscle (24%). But, in US football, gastrocnemius injuries (74%) are more common than soleus injuries (15%).
- Having a previous calf strain, especially near the back.
- Being older in age.
- Having a history of lumbar L5 radiculopathy, a condition that affects the lower back, which can increase the risk of gastrocnemius strain in older soccer players.
Signs and Symptoms of Gastrocnemius Rupture
A gastrocnemius rupture, or a tear in the calf muscle, often occurs following a sudden forceful movement such as sprinting or jumping. Patients usually report a sensation of a tear or a pop in the calf area, along with pain. They can have trouble putting weight on the affected leg, often choosing to walk on their toes to reduce the discomfort. They may also experience calf weakness, increased muscular cramps, and increased pain when flexing the foot downward (active plantarflexion) or upward (passive dorsiflexion).
In a physical examination, medical practitioners might notice swelling, bruising (ecchymosis), and tender spots in the upper region of the calf. There might also be a noticeable gap where the muscle has torn. These patients often have difficulty performing a calf raise, which involves standing on tiptoes while keeping the legs straight. However, the Thompson squeeze test, which is used to check for a rupture in the Achilles tendon, will show normal results with normal downward foot movement (plantar flexion) upon squeezing the calf.
Testing for Gastrocnemius Rupture
While it’s usually not necessary to use imaging to diagnose an injury to the gastrocnemius muscle (the prominent muscle in the calf of the leg), an ultrasound can be quite useful sometimes. This procedure can help doctors figure out how severe the injury is and also track how well you’re recovering. Ultrasound images might show a disruption in the muscle fibers where the muscle and tendon meet, often accompanied by a hematoma or an area of collected fluid.
On the ultrasound image, this fluid collection will appear dark, and it might be found between the soleus (another calf muscle) and the inner part of the gastrocnemius muscle. The size of this fluid collection might increase during the first week after the injury. It could be helpful to perform follow-up ultrasounds after the injury to check how the healing process is going and to make sure the swelling is going down as expected.
MRI (magnetic resonance imaging), which provides a detailed picture of the body’s soft tissues, is considered the best tool for diagnosing soft tissue injuries. However, it’s usually only necessary if there’s any doubt about whether or not the gastrocnemius muscle has been ruptured.
Treatment Options for Gastrocnemius Rupture
If you’ve been injured and are having trouble walking, the first step to treatment is to rest until you can walk without limping. If the pain is quite severe, you may need to use a special walking boot to be mobile. Sometimes, using heel lifts that help reduce stretching might be suggested. To keep swelling down, you should apply ice to the hurt area for 20 minutes four times a day, and pain relievers may be recommended.
If your injury is rather serious, preventing you from walking, you might require a specially designed physical therapy regimen. During your first follow-up visit (after about a week) the doctor will check for swelling using an ultrasound. If there’s swelling present, you’ll need to continue applying ice and use what’s called a compression sleeve. Once you no longer need crutches, you’ll be encouraged to spend more time on your feet and start doing exercises to strengthen your calf muscles. You’ll continue to use the compression sleeve, the heel lifts, and ice until the swelling is completely gone.
The Alfredson protocol is a rehabilitation program used for injuries of the heel and has been documented to help with calf muscle injuries that involve the Achilles tendon. It’s a step-by-step program that works on improving your ability to support weight on the affected limb.
As your calf muscle strengthens and the pain reduces, you can start light running. If you can do 15 calf raises on the injured leg without much pain and walk normally, light running may be recommended. This can build up over time, but it should be a gradual process, increasing only slightly week by week.
Each person’s healing journey is different, so there’s no specific point at which you’ll be fully recovered. Generally, if you can perform specific exercises without feeling pain and run for a half-hour without problems, you might be able to resume full activity. Patience is key, as full recovery may take up to 3 to 4 months. You’ll need to continue wearing compression sleeves and using heel lifts even after you return to activities, but at some point, you get to decide when to stop using them.
What else can Gastrocnemius Rupture be?
When a person experiences a rupture in their gastrocnemius muscle, which is in the calf, there could be many different potential causes, both urgent and non-urgent. Some other injuries related to the calf muscles could include strains or damage to the soleus muscle, the plantaris muscle, or the popliteal tendon. These all present with varying degrees of pain and specific symptoms. For instance, a plantaris strain could feel less severe and be located around the mid-Achilles region. An exam could reveal a full or near-full range of motion without much pain and only mild functional complications. Diagnoses can be supported through the use of ultrasound and MRI.
A soleus strain usually comes about from overuse, often from long-distance running. It manifests as generalized deep calf pain that gets worse with knee bending or ankle flexion, such as running uphill.
Popliteal tendinopathy usually appears in sprint runners and presents as pain on the side of the knee or top-side of the calf. Running downhill could make symptoms worse, and an exam might reveal tenderness at the origin of the popliteal tendon on the side of the knee.
Popliteal artery entrapment is characterized by symptoms similar to intermittent claudication, which worsen with repetitive plantar and dorsiflexion but get better with rest. Symptoms could include a tingling sensation in the feet or cold feet, and a physical exam might note decreased pulses in the foot when doing certain movements.
In differentiating a gastrocnemius injury from Achilles tendinopathy or tear, one must consider the type of pain, its location, and associated factors. Tendinopathy usually manifests gradually along the tendon and is linked to overuse or a sudden increase in activity. If the tendon ruptures, it is typically accompanied by a “pop” sound or feeling and a detectable gap in the tissue. People with complete tears often cannot fully flex their foot down but may manage to partially do so using other muscles. A positive Thompson squeeze test (loss of foot flexion when squeezing the calf) helps in diagnosing a complete tear; ultrasound and MRI can further aid diagnosis.
The gastrocnemius, plantaris, and soleus are the muscles at the back of your leg, and it’s crucial to exclude acute compartment syndrome (ACS), which is typically linked to trauma and can cause rapidly worsening leg pain. Any suspicion of ACS warrants urgent medical attention.
The doctor might also need to rule out other musculoskeletal issues like chronic exertional compartment syndrome, exercise-related muscle cramps, medial tibial stress syndrome, and osteomyelitis. Furthermore, conditions not related to the musculoskeletal system such as claudication, deep vein thrombosis (DVT), and peripheral nerve entrapment should also be considered. For example, DVT usually causes worsening pain and swelling in the calf without any injury history; however, in some cases, it has been linked to calf injuries.
What to expect with Gastrocnemius Rupture
Generally, most injuries to the gastrocnemius (a large muscle in the calf) heal without any problems. The average recovery time usually spans from several weeks to 3 to 4 months. If the muscle is completely torn or there is a large blood clot (hematoma), it may take a longer time to heal. The good news is that most people can return to their normal activities, provided they adhere to the physical therapy routines that their doctors prescribe.
Possible Complications When Diagnosed with Gastrocnemius Rupture
Immediate, but uncommon, complications can involve acute compartment syndrome, which is a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues, or Deep Vein Thrombosis (DVT), which is a blood clot in a deep vein, mainly in your legs.
Non-emergency complications, though rare, can sometimes involve myositis ossificans, a condition where bone tissue forms within a muscle, calf muscle wasting, and more commonly, mild strength loss in the calf muscle. Some patients have reported chronic tightness in the calf muscle and sharp pains during exercise, even after recovery.
Common Complications:
- Acute compartment syndrome
- Deep Vein Thrombosis (DVT)
- Myositis ossificans
- Calf muscle wasting
- Mild strength loss in the calf
- Chronic tightness in the calf muscle
- Sharp pains during exercise
Preventing Gastrocnemius Rupture
Teaching patients during their recovery stage is critical for their healing process. Each person’s physical therapy plan should be tailored to their individual needs, which can change depending on their age, their ability levels after being injured, and how well they can recover.
The medical professional should pay close attention to the patient’s walking pattern, the amount of work they do, and their rest times during therapy. This is to ensure that the person recovering from injury doesn’t push themselves too hard beyond what is recommended. This can prevent their recovery from being slowed down, stop their healing from getting delayed, or avert getting hurt again.
