Gastrocnemius Muscle Tear (Calf Tear)

The patient was a 46 year old man, referred from his neighborhood GP.

The story was that he was helping a friend push a stalled car. While doing so, he heard a "snapping" sound from the back of his right leg. This was accompanied by pain; however he still managed to limp back. Back home, he applied some ice onto the leg (good for him), the swelling and bruising didn't appear until the next morning.

He related the story to me on the initial visit, nine days after the injury. Why nine days? Well apparently I was the fourth medical professional he has sought, the 3rd one being the GP who finally referred him here.

Listening to his story carefully, my initial suspicion was that he may have torn his achilles tendon. However a complete tear would render him almost incapable to walk; he was limping to my clinic, sure, but not to the extent that he had to be wheeled into the room.

Examination of his leg showed some swelling of his lower leg, with bruising around the ankle and foot. Tenderness could be felt around the calf muscles. There was no palpable defect on his achilles tendon indicating a torn tendon nor was Simmons test positive for achilles cut.

So that rules out an achilles tendon injury.

Hmmm...

Bruising lower leg

with swelling of the lower leg

An ultrasound or MRI scan would help in this matter. I promptly sent him across the hallway to see the radiologist requesting for an ultrasound of his calf muscle, failing which we may proceed on to do a MRI scan.

The ultrasound report noted fluid/blood collection within the medial gastrocnemius (calf) muscle, which in the light of the patients history, confirmed the patient's diagnosis:

Gastrocnemius muscle tear (calf tear)

A tear of the gastrocnemius muscle  most commonly occurs in the middle-aged, male athlete (the "weekend warrior") when the muscle actively contracts against a foot which is dorsiflexed with an extended knee, as may occur in tennis or jogging; in this particular case, the patient was loading the calf muscles while pushing the car.

As in this patient, the diagnosis can be confused with an achilles tendon rupture. However as explained above, palpation of the achilles tendon should demonstrate an intact tendon. In any case, imaging studies such as ultrasound and magnetic resonance imaging (MRI) can be useful to ascertain the diagnosis.

Only conservative management is required to treat ruptures of the gastrocnemius muscle. 

RICE (Rest, Ice, Compression , Elevation) therapy together with adequate analgesics are the mainstay of treatment for the first 24-72 hours after injury . Ambulation with crutches is advised with gradual weight bearing in the following weeks. A walker-type brace can be used. Physiotherapy is initiated as soon as the patient feels comfortable out of the walker.

A walker type brace - patient would need a longer version

Swelling and bruising should gradually decrease over the next couple of weeks. Recovery may take up to 6 weeks or more depending on the severity of the injury. Patients can expect a full recovery provided that the rehabilitation protocol is followed.

- the BomohTulang -

ESWT for Plantar Fasciitis - the video

Let me share with you a bit more on the extra-corporeal shock wave treatment (ESWT).

ESWT works by bombarding the tissue with high-pressure sound waves and is thought to stimulate blood flow for a beneficial immune response; it also causes microtrauma to the tissue to stimulate healing.

Typically each session lasts about 15-20 minutes; the patients do not experience any pain, with most reporting a tingling feeling. The heel is iced after the session to prevent soreness.

So okay, ready for the video? Just hit the "play button"..

 

- the BomohTulang -

PLANTAR FASCIITIS - heel pain

Patients often come to me complaining of heel pain,  the usual story being that they have pain in the heel right after getting out of bed or after taking the first few steps in the morning. The pain will ease somewhat, but tend to be progressively worse throughout the day when they are constantly on their feet.

Now there are many causes of heel pain but PLANTAR FASCIITIS ( interpreted as inflammation of the PLANTAR FASCIA - this is a misnomer, as I would explain later) remains the most common cause of heel pain.

The PLANTAR FASCIA is a thickened fibrous band of tissue that stretches from the heel (calcaneum bone) to the head of the metatarsals of the foot. Likened to a bowstring, it acts to maintain the arch of the foot and also helps in shock absorption when the foot strikes the ground.

The Plantar Fascia

It was thought that inflammatory changes was the cause of this pain; however we now know it is mainly due to degenerative changes in the fascia, especially at the interface where the fascia attaches to the bone, hence the misnomer in the "fasciitis" as I informed earlier.

Causes

Tight heel cord ie the gastrocnemeus, soleus and the Achilles tendon, high arch feet, flat feet are some of the incriminating causes of plantar fasciitis, as is obesity, occupations requiring prolonged standing and weight-bearing, and heel spurs. Talking about heel spurs, one does not necessarily have plantar fasciitis if the heel spurs are present on x rays.

Seeking relief from the pain

There are a variety of measures that one can do to alleviate this problem:

Stretching your plantar fascia

• usage of a well fitting shoe, with adequate arch support and well cushioned heel
• adding insole into the shoe - the soft silicone ones applied to the heel area are the best 
• stretching exercises - this can be done first thing in the morning or anytime before starting any prolonged activity
• ice helps to soothe the pain after a painful episode

Seeing the doctor

This condition is typically self-limiting with the majority of patients having resolution of symptoms with simple measures described above.
If the problems still persist, your friendly orthopedic surgeon can rule out other causes of heel pain and maybe order some imaging studies to help in making a diagnosis.
Along with the measures above, the good doctor could try any of these modalities to help you along:

• Anti-inflammatory medications (NSAIDS)
• Splints and orthoses - typically to be used at night
• Physiotherapy
• Steroid /  platelet rich plasma (PRP) injection
• Extra-corporeal shock wave therapy (ESWT)
• Radiofrequency (RF) microdebridement (TOPAZ)- a relatively new technique in which a wand like instrument is inserted percutaneously under the heel and a bipolar radiofrequency pulse applied to the plantar fascia

Whew. Now that's a lot of choice innit? Do contact your orthopedic surgeon if you have any more questions or need to know more about this or any foot-related problems.

You know how to contact me:

Dr Saiful Akhtar Shamsuddin

Columbia Asia Hospital - Bukit Rimau

No3, Persiaran Anggerik Eria, Bukit Rimau, Seksyen 32

40460 Shah Alam, Selangor Darul Ehsan

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Tel: 603-51259999  Fax: 603-51259998


 - the Bomoh Tulang -