Return to Play in Gastrocnemius and Soleus Injuries. From Scientific to Practical Experience

1. 5th MuscleTechNetwork
From Scientific Evidence to Clinical Practice. 14-15 Oct. 2013
Return to Play in Gastrocnemius and Soleus Injuries.
From Scientific to Practical Experience
Dr. Miguel Angel Khoury
Buenos Aires - Argentina

2. Return to play :
gastrocnemius and soleus injuries
From scientific to practical experience
At present: What do we know?
Optimal decision-making
When and why they go wrong?

3. “How Doctors Think”

4. How Doctors think?
1.
Experts Studying misguided care have
concluded that the majority of errors are due
to flaws in physician thinking, not technical
mistakes.
2.
The quality of our practice is highly
influenced by the way we think.

5. How Doctors Think
DECISIONS ARE MADE ON THE BASIS OF:
-INTUITION: System I (Unconscious process of making decisions on
the basis of experience and accumulated judgment)Automatic,
fast, emotional. Limbic, Heuristics
-RATIONALITY: System II (Problem is clear, alternatives are known,
evidence based practice )slow, logic progressive and mainly
conscious process, cortical

6. Cognitive Traps: Heuristics
ü Availability
ü Anchoring
ü Attribution
ü Satisfaction Search
ü Confirmation Bias
ü Commission Bias
ü Affective error

7. Epidemiology of Muscle Injuries in Professional
Football (Soccer)
ü 31% of all injuries
ü 27%of total injury absence
ü Hamstring 37%
ü Adductor 23%
ü Quadriceps 19%
ü Calf Muscles 13%
AJSM 2011 Jan Ekstrand, MD, PhD*† Martin Hägglund, PT, PhD†
arkus Waldén, MD, PhD†

8. Gastrocnemius vs. soleus strain injury
MTJ grastrocnemius

9. SIMULTANEOUS GASTROC-SOLEUS
TEARS
•
Koulouris G. et.al. similar
incidence in gastrocnemius
and medial soleus injuries.
Skeletal Radiol.2007
•
Balius R. et.al. reported six
cases of dual lesions. Skeletal
Radiol.2012
•
Most likely dual lesions are
under-reported

10. US longitudinal view
Normal Gastroc-Soleus muscle unit
GASTROCNEMIUS
APONEUROSIS SOLEUSGASTROC.
SOLEUS
PROXIMAL
They Look Like Twins!!
DISTAL

11. The Gastrocnemius-Soleus Unit
(Non-Identical Twins)
Gastrocnemius Muscle
Soleus Muscle
Type II Fibers
Predominant Type I
fibers
Tow Joints Muscle
One Joint muscle
Anaerobic
Aerobic
Fatigue
Resistant

12. Different personality
(Non-Identical Twins)

13. The Gastrocnemius-Soleus Unit
• The Soleus muscle accounts for 70% of the total area of the triceps
surae (Fukunaga T. et al, JOR, 1992)

14. The soleus muscle: MRI, anatomic and
histologic findings in cadavers with clinical
correlation of strain injury distribution
ü Myotendon-junction:Proximal medial strains:
25.5%, Proximal Lateral strains 12.7% and
central tendon strains 12.7%
ü Myofascial sites: anterior 21.8%, posterior
21.8%
Balius R., Alomar X, Rodas G. et. al. Skeletal Radiol. 2012,

15. Soleus muscle contraction
ü Primary plantar
flexor of the foot
ü Invertor of the foot
ü Acts as an agonist
for the ACL (Elias J.J.,
AJSM, 2003)

16. Gastrocnemius - Soleus Unit
ü With knees flexed 90 degrees the gastrocnemius are
virtually inactive.
ü The load is borne almost entirely by the soleus.

17. The Gastrocnemius-Soleus Muscle Unit
Dorsiflexion of the foot during take off phase or jumping
• Silverskiöld test: pain with dorsiflexion of the foot with knee flexion

18. Effect of Increased Excursion of the Ankle on the
Severity of Acute Eccentric ContractionInduced Strain Injury in the Gastrocnemius
An In Vivo Rat Study
Hongsun
Song,
MS
Koichi
Nakazato,
PhD*,
and
Hiroyuki
Nakajima,
MD
AJSM,
2007.

19. Soleus strain injury
Clinical Manifestation

20. Soleus Muscle Strain Injuries: Clinical and
Magnetic Resonance Imaging Study
1. Early vs. Delayed diagnosis
2. Myofascial vs. MTJ injuries
3. Acute vs. Chronic injuries
M. Khoury, E. Santa Coloma, A. Rolon From Cleveland Sports Medicine,
Buenos Aires, Argentina
10.1177/0363546511415619 Am J Sports Med August 2011 vol. 39 no. 8
1800-1802

21. Soleus Anatomy Mio-tendon junctions
MRI
T1
STIR

22. Acute soleus muscle strain injuries
Soccer Player
Degree II
Perifascial fluid
aedema
strain

23. Soleus muscle strain injury
Post gadolinium

24. Chronic soleus muscle strain injury
37 years old – tennis player - Rerupture
fibrosis

25. Chronic soleus muscle strain injury
28 years old – Tennis player
calcification
Ca++

26. Chronic exertional compartmental syndrome
Post-exercise
Soleus
muscl
e
Soleus
muscl
e

27. Return to Competitive Play After Hamstring Injuries
Involving Disruption of the Central Tendon
ü Longer rehabilitation when the central
tendon was disrupted, enclosed within the
muscle belly
ü Lower time in: only muscle fiber, epimisial or
muscle tendon junction strains
ü 21 vs. 72 days (p<0.001)
Jules
Comin,
MBBS*,†,
Peter
Malliaras,
PhD†,
Peter
Baquie,
MBBS‡,
Tim
Barbour,
MBBS‡
and
David
Connell,
MBBS†§
AJSM
2013

28. Acute soleus muscle strain injuries
L
Central Tendon
R
L
R

29. Soleus Muscle Injuries: Special
Considerations
ü Untrained or returning to play injury
ü Delayed diagnosis and reruptures are
common
ü Increased rehabilitation time
ü Chronic injuries: should be
considered in evaluating leg pain

30. Muscle-tendon junction
Medial Gastrocnemius

31. Relationship between sports trauma and muscular injury
Medial Gastrocnemius

32. Grade II – Medial Gastrocnemius

33. Dynamic US

34. Gastrocnemius strain injury

35. Chronic Tear
Organized Haematoma

36. Haematoma Aspiration

37. PRP Aplication

38. PRP after injection

39. Medicine: Imperfect Science

40. Are you Ready to Play?
Stop and Think Again!

41. HEALING RESPONSE EVALUATION
Healing response

42. COMPARATIVE VIEW REINJURY
NORMAL
GASTROCNEMIUS
GASTROCNEMIUS
INJURY

43. The Balance: Intuition vs. Rationality

44. The Grastrocnemius – Soleus Unit

45. When and why they go wrong?
Gastrocnemius muscle
Soleus muscle
Bleeding or fluid
Underdiagnosis or
collecction
Underestimation
Delayed cicatrization
Rerupture
Rerupture, chronic
pain

46. How to Get Better
¤ Multiple Inteligences. The theory in
practice: Howard Gardner. Seven
types of inteligence
¤ “Improve our medical
Inteligence”
¤ Thinking better: What make us
powerfull is the way we think!

47. Thank You!!!!
drmiguelkhoury@gmail.com

48. Comparative View Acute Tear
NORMAL
GASTROCNEMIUS
GASTROCNEMIUS
TEAR

49. Gastrocnemius special concerns
ü Fluid colection or organized
haemathoma
ü Moist heat and massage should be
avoided the first week
ü Compression

50. Soleus Anatomy
Axial View
Lateral View
Coronal View

51. Soleus Anatomy
Mio-tendon
junctions

55. Acute soleus muscle strain injuries
30 years old – Tennis Player
Medial Tendon
Fat Sat
T1 W

56. Acute soleus muscle strain injuries
28 yearlL old – Runner
Lateral Tendon

57. Flexor hallucis longus strain injury
HL
GL
TP
FHL
Soleus
GL
Soleu
s

58. Longitudinal View
GASTROCNEMIUS
FLUID COLECTION

59. PRP Treatment

62. Grade II – Medial Gastrocnemius

63. Summary
ü Non-Identical Twins
ü Soleus Muscle Strains: Early diagnosis,
Tendon rupture
ü Gastrocnemius Muscle Strains:
Haematoma, Fluid Colection
ü Aspiration and PRP Treatment

64. Judgment
Rationality: Is rarely a calculating weighing
of all options, but rather a form of pattern
recognition

65. Objective:
¤ How to improve our thinking
about gastrocnemius and
soleus strains

66. We all develop
conclusions from a very
incomplete body of
information