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What is the diagnosis?

Medial Head Gastrocnemius Tear

What is the mechanism of injury?

Most commonly caused by activities involving an extended knee and dorsiflexed ankle [1]. 

• Pearl: The medial gastrocnemius head is injured far more commonly than the lateral head due to a pattern of greater muscle activation in the medial head with muscle contraction [2].

What physical exam findings are expected?

On examination, patients will often have tenderness at the medial gastrocnemius muscle belly or myotendinous junction.  A palpable defect may be appreciated, indicating more severe injury. Patients will also likely have pain with passive dorsiflexion and resisted plantar flexion of the ankle.

• Pearl: The gastrocnemius originates above the knee while the soleus arises from below the knee. When the knee is in maximal flexion the soleus acts as the primary force in plantar flexion, however when the knee is in full extension the gastrocnemius provides a greater contribution. Testing plantar flexion with the knee in full extension allows you to isolate the gastrocnemius and better identify the location of injury [1].  

Which imaging modalities can be used?

While MRI can be used to evaluate more severe injuries, ultrasound is an effective method to both identify and characterize the severity of a medial gastrocnemius injury [3].

• Pearl: Evaluate the achilles with ultrasound in addition to the gastrocnemius as an achilles rupture has a similar presentation of difficulty with ambulation and plantarflexion.

What is the management in the ED?

Rest, ice, and compression with ACE bandage may be sufficient to treat symptoms. For more severe pain patients may be placed in a cam walking boot with a heel lift. NSAIDs should be avoided for the first 48 hours to avoid risk of bleeding. 

When do you consult Orthopedics?

Orthopedics should be consulted if there is concern for developing compartment syndrome secondary to compressive hematoma. In rare cases, patients may need to consider outpatient surgical referral for failure to regain adequate strength after injury. 

• Pearl: Other possible complications include DVT, myositis ossificans, calf atrophy, mild calf weakness, calf tightness with pain during exercise [4].