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Medial Gastrocnemius Rupture

Medial gastrocnemius rupture, tennis leg or medial head of the gastrocnemius strain can occur in the same population of patients, it occurs by the same mechanism, eccentric contraction, so the muscle is trying to shorten, while itís actually lengthening because of the external force applied through the joint medial gastrocnemius rupture, tennis leg, gastrocnemius strain, and some musculotendinous disruption, so itís higher up in the leg, itís up in the sort of the meaty part of the calf and itís more subtle, and perhaps even a less severe injury than Achilles tendon rupture. If it occurs in an older patient, you might confuse it with a DVD, you may get a duplex study, you may think itís a palpable cord or a Homans sign, so make sure you see that itís not the medial head of the gastrocnemius strain, and for that reason, there can also be a delay in presentation because the patient is able to walk on this and the pain may be less severe than with a frank Achilles tendon rupture. 

So, they are going to present with a painful, swollen calf, there are times when tests are going to be negative, so when you squeeze their calf, it may hurt, but you are going to watch the ankle plantar flex, because overall, the Achilles tendon is still in continuity, so the ankle is going to plantar flex, and there may be a severe sign and very severe tears, but itís going to be more subtle, so I have to feel through the fleshy portion of the calf, they donít need to be casted, they need to be protected in weight bearing, you put them in a boot to help alleviate the local symptoms and then physical therapy once the acute injury subsides. 

Achilles tendonitis is intrasubstance degeneration of the Achilles tendon and there is a water shed area between 3 and 5 cm or so up from itís attachment onto the calcaneus. Ankle arthritis is probably rarer than knee or hip arthritis, but the patient still is going to be presenting to you with pain, limitation of motion, swelling about the ankle, with or without deformity. X-rays are going to show joint space narrowing with the loss of cartilage, there may be subchondral cyst formation on both the distal tibia and on the talus, and para-articular osteophyte formation. Then your options to treat them are, beginning with activity modification, use of anti-inflammatory medications.

Achilles tendon rupture is sort of the weekend warrior injury, the recreational athlete that perhaps at the start of his or her recreational season, they are out to perform their activities, they havenít sufficiently warmed up and itís been a long winter and they havenít really been doing much activity, they tear their Achilles tendon, and the mechanism here is an eccentric contracture, meaning, as they are trying to contract their Achilles tendon or put the foot into the ankle into plantar flexion, the ankle is actually is actually dorsiflexing from the stress applying to it, so you have that large force to pull the Achilles tendon apart.

Here is how to make the diagnosis, there is pain and swelling over the point of disruption, there is a positive gap sign, meaning you run your finger up here, you feel the muscle belly, you feel the Achilles tendon and then you feel mush. There is a space there, there is an indentation where the tendon is not in continuity. The Thompsonís test can be done here if the patient.

So how to treat this, well, operative versus nonoperative, in a nutshell, the benefits of operative treatment are that there is a lower rate of rerupture associated with Achilles tendons as opposed to nonoperative management, if you are trying to anatomically restore the Achilles tendon to itís length and bring those ends together, so the less scar tissue that intervenes the form between those two torn ends of the Achilles tendon, the likelier it is that itís going to be a stronger repair, so thatís why operative treatment seems to be associated with less of a rerupture rate than nonoperative, but your patient certainly has to accept the associated risks of operative treatment to get the benefits, you have to consider what the patientís expectations are. The young active male or female who has a very active lifestyle and recreation sports are quite important to them, their expectations might lead you to say that operative treatment is the best management versus someone who is older, has other medical problems, perhaps diabetes of peripheral vascular disease or something else that would increase their risk of having surgical treatment, they may need nonoperative management, it may be the best thing for them. Here is a demonstration of an Achilles tendon that basically is looking like spaghetti that needs to be put back together.