What are common symptoms of a Gastrocnemius Strain (a.k.a. “Tennis Leg”)?

Common Symptoms:

• Sudden sharp pain or “popping” sensation
• Swelling and bruising
• Difficulty weight-bearing
• Tenderness over the medial calf

When bleeding occurs within the muscle belly, it can lead to a gastrocnemius hematoma—a localized collection of blood that can prolong recovery and increase discomfort.

What is the Role for Diagnostic Ultrasound in Calf Strains?

Most calf strains can be diagnosed through clinical history and exam. However, ultrasound or MRI may be used to:

• Confirm the location and grade of the tear
• Identify hematomas or fluid collections
• Rule out other injuries (e.g., deep vein thrombosis—an important differential diagnosis!)

Ultrasound is a valuable tool for diagnosing gastrocnemius strain due to its non-invasive nature, cost-effectiveness, and ability to provide real-time imaging. Several studies have demonstrated its efficacy in identifying and classifying muscle injuries, including those of the gastrocnemius.

Ultrasound Classification of Gastrocnemius Injuries

High-resolution ultrasound can detect both partial and complete tears of the gastrocnemius muscle, as well as associated hematomas and fluid collections[Yoon et al, 2021].

For instance, Pedret et al. proposed a classification system for medial gastrocnemius injuries based on sonographic findings, which correlated significantly with return-to-play and return-to-work times [Pedret et al, 2020].

This classification includes various types of injuries, such as
myoaponeurotic injuries and injuries involving the gastrocnemius aponeurosis.

What the Evidence Says About Calf Strain Management

Conservative Treatment

• Most Grade I and II calf strains respond well to nonoperative treatment:
  
  • RICE protocol in the acute phase
    
  • Progressive rehabilitation including stretching, eccentric strengthening, and mobility work
    
  • Compression therapy may help resolve hematoma faster
    
  • Crutches or heel lifts may be needed initially for pain relief
    
• Evidence shows that early, structured rehab can accelerate return to play and minimize the risk of re-injury [Bayer et al, 2018].

Imaging-Guided Aspiration

• In cases with significant hematoma, ultrasound-guided aspiration of musculoskeletal hematomas has been shown to be safe and effective, providing symptomatic relief without significant complications [Yoon et al, 2021; Szopinski & Smigielski, 2012].
• Ultrasound-guided aspiration can help:
  
  • Decompress the muscle
    
  • Reduce pain and pressure
    
  • Improve mobility and speed up healing
    
  • While not routine, aspiration is supported by small studies and case reports showing earlier functional recovery and reduced fibrosis risk.
• The literature indicates that early intervention, ideally within 3-5 days of hematoma formation, may improve outcomes and prevent complications such as compartment syndrome [De la Corte-Rodriguez, 2014; Mithöfer et al, 2002].

It is important to note that while aspiration can provide symptomatic relief, it may not always be successful, and there is a risk of hematoma recurrence [Szopinski & Smigielski, 2012].

(781) 591-7855

info@BSBortho.com

20 Walnut St

Suite 14

Wellesley MA 02481

References:

1. Bayer ML, Hoegberget-Kalisz M, Jensen MH, Olesen JL, Svensson RB, Couppé C, Boesen M, Nybing JD, Kurt EY, Magnusson SP, Kjaer M. Role of tissue perfusion, muscle strength recovery, and pain in rehabilitation after acute muscle strain injury: Arandomized controlled trial comparing early and delayed rehabilitation. Scand J Med Sci Sports. 2018 Dec;28(12):2579-2591.
   
2. Cicvarić T, Sustić A, Miletić D, Veselko M, Mozetic V, Spanjol J. Endoscopic evacuation of a hematoma resulting from strain injury of the medial head of the gastrocnemius muscle. Arthroscopy. 2006 Aug;22(8):912.e1-3.
3. De la Corte-Rodriguez H, Rodriguez-Merchan EC. Treatment of muscle haematomas in haemophiliacs with special emphasis on percutaneous drainage. Blood Coagul Fibrinolysis. 2014 Dec;25(8):787-94.
4. Mithöfer K, Lhowe DW, Altman GT. Delayed presentation of acute compartment syndrome after contusion of the thigh. J Orthop Trauma. 2002 Jul;16(6):436-8.
5. Pedret C, Balius R, Blasi M, Dávila F, Aramendi JF, Masci L, de la Fuente J. Ultrasound classification of medial gastrocnemious injuries. Scand J Med Sci Sports. 2020 Dec;30(12):2456-2465.
   
6. Szopinski KT, Smigielski R. Safety of sonographically guided aspiration of intramuscular, bursal, articular and subcutaneous hematomas. Eur J Radiol. 2012 Jul;81(7):1581-3.
7. Yoon ES, Lin B, Miller TT. Ultrasound of Musculoskeletal Hematomas: Relationship of Sonographic Appearance to Age and Ease of Aspiration. AJR Am J Roentgenol. 2021 Jan;216(1):125-130.