Calf pain

injuries to the calf and ankle region in athletes

1. CALF AND ANKLE PAIN -Dr. Krupal Modi (MPT) 19/9/2018

2. 1) Gastrocnemius muscle strains Acute strain occurs typically when the athlete attempts to accelerate from a stationary position with the ankle in dorsiflexion , or when lunging forward, such as while playing tennis or squash. Sudden eccentric overstretch , such as when an athlete runs onto a kerb and the ankle drops suddenly into dorsiflexion , is another common mechanism.

3. The patient complains of an acute, stabbing or tearing sensation usually either in the medial belly of the gastrocnemius or at the musculotendinous junction. Examination reveals tenderness at the site of muscle strain. Stretching the gastrocnemius reproduces pain, as does resisted plantarflexion with the knee extended.

4. In grade III muscle tears, there may be a palpable defect. Assess functional competence of the injured muscle by asking the patient to perform a bilateral heel raise . If necessary, a unilateral heel raise, a heel drop or hop may be used to reproduce the pain. This places the muscle under progressively greater load concentrically and eccentrically.

5. Calf muscle strain can be graded as shown in Table.

6. Chronic strain Chronic gastrocnemius muscle strain may occur as an overuse injury or following inadequate rehabilitation of an acute injury. Inadequate rehabilitation results in disorganized, weak scar tissue that is susceptible to further injury .

7. 2) Soleus muscle strains Strains of the soleus muscle are a relatively common sports injury. sudden onset pain, history of increasing calf tightness over a period of days or weeks. Examination reveals tenderness deep to the gastrocnemius, usually in the lateral aspect of the soleus muscle. Both the soleus stretch and resisted soleus contraction provoke pain. This can be differentiated from the stretch and contraction that provoke pain in gastrocnemius strains.

8. 3) Achilles tendon rupture (complete) Complete rupture of the Achilles tendon classically occurs in athletes in their 30s or 40s. male:female ratio is 10:1. The patient describes feeling ‘as if I was hit or kicked in the back of the leg’; pain is not always the strongest sensation. This is immediately followed by grossly diminished function. A snap or tear may be audible.

9. The patient will usually have an obvious limp but may have surprisingly good function through the use of compensatory muscles. That is, the patient may be able to walk, but not on the toes with any strength .

10. Four clinical tests can greatly simplify examination of complete Achilles tendon rupture : 1. On careful inspection with the patient prone and both ankles fully relaxed, the foot on the side with the ruptured tendon hangs straight down (because of the absence of tendon tone); the foot on the non-ruptured side maintains a little plantarflexion . 2 . Acutely, there may be a palpable gap in the tendon, approximately 3–6 cm proximal to the insertion into the calcaneus. 3 . The strength of plantarflexion is markedly reduced.

11. 4. Simmond’s (also known as Thomson’s) calf squeeze test is positive.

12. Surgical management Open surgical treatment of Achilles tendon rupture is associated with a 27% lower risk of re-rupture compared with non-surgical treatment . Complications including infection, adhesions and disturbed skin sensitivity. Another approach to reduce these complications is to perform surgery ‘ percutaneously ’. Early post-operative mobilization with a functional brace reduced the complication rate compared with in those who had been managed with post-operative cast immobilization for eight weeks.

13. A protocol consisting of open surgical end-to-end repair, a brief period of post-operative cast immobilization (one to two weeks), followed by controlled range of motion training until the eighth post-operative week provided excellent outcomes

14. Non-surgical management It involves cast immobilization , initially in a position of maximal plantarflexion to protect the tendon for four weeks, then after four weeks gradually reducing the amount of plantarflexion . The total immobilization time is eight weeks .

15. 4) Sever’s lesion Sever’s lesion or calcaneal apophysitis is a common insertional enthesopathy among adolescents It can be considered the Achilles tendon equivalent of Osgood- Schlatter lesion at the patellar tendon insertion.

16. Lateral ligament injuries occur in activities requiring rapid changes in direction, especially if these take place on uneven surfaces (e.g. grass fields ). They are also seen when a player, having jumped, lands on another competitor’s feet.

17. The usual mechanism of lateral ligament injury is inversion and plantarflexion , and this injury usually damages the ATFL before the CFL. This occurs because the ATFL is taut in plantarflexion and the CFL is relatively loose . Also, the ATFL can only tolerate half the strain of the CFL before tearing.

18. Complete tear of the ATFL, CFL and PTFL results in a dislocation of the ankle joint and is frequently associated with a fracture. Swelling usually appears rapidly, although occasionally it may be delayed some hours . Ankle sprain may be accompanied by an audible snap, crack or tear.

19. Medial (deltoid) ligament injuries Because the deltoid ligament is stronger than the lateral ligament, and probably because eversion is a less common mechanism of ankle sprain , medial ankle ligament injuries are less common than lateral ligament injuries. Occasionally , medial and lateral ligament injuries occur in the same ankle sprain.

20. Medial ligament injuries may occur together with fractures (e.g. medial malleolus, talar dome, articular surfaces). Medial ligament sprains should be treated in the same manner as lateral ligament sprains, although return to activity takes about twice as long (or more) as would be predicted were the injury on the lateral side.