Calf Muscle Tear (Gastrocnemius Tear)

Summary

Calf (Gastrocnemius) muscle tears commonly occur in middle-aged recreational athletes while performing actions that require sudden changes in direction (ex: basketball, hill running, tennis, etc.). This puts maximal tension on the gastrocnemius muscle. Calf muscle tears have similar symptoms and occur by a similar mechanism to Achilles tendon ruptures. The difference is the location of the injury, as the Achilles tendon runs below the calf muscle connecting it to the heel of the foot (Figure 1). Achilles tendon rupture presents with pain at the back of the heel, rather than the lower calf region. Because of the similarities between the injuries, an Achilles tendon rupture must be ruled out in the diagnosis. Calf tears occur where the muscle attaches to the fascia (musculotendinous junctions) leading to the Achilles tendon, most commonly on the inside (medial) portion of the calf because this region is under the greatest amount of tension. Treatment is non-surgical. In most instances treatment includes limiting muscle-loading activities, wearing a boot (Cam Walker), and using crutches in the short term, before progressing to physical therapy exercises aiming to regain full range of motion and muscular strength. Significant improvement can be expected within the first two weeks, but full recovery can take up to 6-8 weeks. It may take many more months to regain muscle mass in the calf that had been lack of use.

Figure 1: Typical Location of Calf Tear vs Achilles Tendon rupture

Calf Muscle Tear

Clinical Presentation

Calf (Gastrocnemius) muscle tears typically occur in moderately active individuals in their 30s, 40s, and 50s while performing actions that put maximal tension on the gastrocnemius muscle. “Weekend warriors”, who have often lost flexibility in their muscles are at greater risk for partial or complete muscle rupture. However, if the muscular force is greater than the muscle elasticity even the well-conditioned athlete may suffer a calf tear. The mechanism of injury is very similar to that of an Achilles tendon rupture, which must be ruled out in the diagnosis. Calf tears occur where the muscle attaches to the fascia (musculotendinous junctions) leading to the Achilles tendon. Patients with Gastrocnemius muscle tears usually describe a sudden, sharp pain in the lower calf region. Symptoms are usually precipitated by a sudden changes in direction as typically occurs in some sporting activities (ex: basketball, hill running, tennis, etc.). Immediately after suffering a calf tear patients will walk with a painful limp. Bruising in the calf area will often develop over the next 24-36 hours. It is common for the tearing to occur on the inside (medial) portion of the calf as this region is under the most tension.

Physical Examination

Clinical examination of a calf (Gastrocnemius) muscle tear will find acute tenderness upon palpation in the entire inside aspect of the calf muscle (medial gastrocnemius muscle). This tenderness will be significantly more painful at the lower aspect of the calf. Depending on the degree of swelling, a palpable defect may be evident. The Thompson Squeeze Test is negative for an Achilles tendon rupture, as the squeezing of the calf will be painful but still produce a foot-jerk [plantar flexion] indicating that the Achilles tendon is intact. Passive movement of the ankle in an upward direction (dorsiflexion) will produce moderate-severe pain (due to stretching of the torn muscle fibers). Similar pain will be noted with active resistance to downward ankle motion (ankle plantar flexion) due to the contraction of the torn muscle fibers. Patients will have pain and difficulty performing a calf raise (due to both stretching and contracture of the torn muscle fibers). They will also tend to walk with a limp during the initial phase of the injury.

Imaging Studies

Plain x-rays will be negative as this injury does not effect the bones. If there is a question as to whether the Achilles tendon is involved, an MRI may be indicated. MRI will be able to accurately assess the soft tissue and differentiate between an injury to the Achilles tendon and the calf muscle tear.

Treatment

Treatment of Gastrocnemius muscle tears is usually non-surgical, and dependent upon the individual’s symptoms. Limiting activities or using crutches in the short term (1-2 weeks following injury) will often be necessary. It is likely to be helpful to protect the area with a boot (Cam Walker). Significant improvement can be expected within the first two weeks, but near full recovery can take up to 6-8 weeks – and it may take many more months to regain muscle mass in the calf that had been lost by staying off of it. Occasionally, excessive scarring will form in the location of the tear. This can cause chronic pain in the area or render it more likely for future tearing as the fibrotic scar tissue absorbs forces differently than regular healthy muscle tissue.

Initial (Acute Phase) Treatment

Immediately after the injury (first 24-72 hours) treatment should include:

  • Relative rest. Limit the use of the injured calf, by limiting standing and walking and possibly using crutches if needed.
  • Ice applied to the injured area (w10 minutes on, 10 minutes off and then repeat)
  • Compression. Light compression with a wrap may be helpful
  • Elevation. Elevate the leg at or slightly above the level of the heart. For example by lying on a bed with the foot propped up by a couple pillows.
  • Early weight bearing only as tolerate. Patients initially may feel more comfortable walking with crutches.
  • Immobilize the foot and lower leg to improve comfort. This can be done in a CAM walker or equivalent.
  • Active foot and ankle range of motion (ROM) exercises can be carried out if there is pain-free ROM.
  • Splint with the ankle in a neutral position. Studies have shown an increased rate of healing with the ankle braced in a position of maximal tolerable dorsiflexion (ex. foot at a right angle to the lower leg).

Recovery Phase

Once pain free, the patient should progress from plantar flexion exercises against resistance to gradual introduction of stationary cycling, leg presses, and heel raises. Massage techniques can help with the removal of interstitial fluid and breaking up of scar tissue.

Maintenance Phase

Once pain free full range of motion and near normal strength has been regained, sports-specific activities can be resumed. Calf strengthening and calf stretching should continue for several months. The goal of rehabilitation is to overcome the increased risk for re-injury due to the deposition of scar tissue (part of the healing process) and loss of muscle mass from relative inactivity.

Edited September 6th, 2009