Honestly, I was not doing anything crazy. I was running an incline on my treadmill; but good grief it was only a 5% grade. I suddenly felt a sharp pain. I turned around, expecting to see someone standing there with a sling shot pointed at my calf, but no one was behind me. It felt like someone shot me with a BB gun!I lowered the incline and walked slowly to cool down, but the pain intensified. I hobbled downstairs to assess the damage. I had a huge purple bruise behind my left knee. My left calf was warm to the touch and beginning to swell. It was almost impossible to take a step. I could move my ankle so I knew I had not torn my Achilles tendon. As a Physical Therapist, I hoped it was only a plantaris tendon rupture. Surely, I did not tear one of the more important muscles in my calf. It just wasn’t a good time to be injured. I had concert tickets for the upcoming weekend and I fully intended on wearing some very cute shoes.
The plantaris muscle is a small, unimportant muscle in the back of the leg. Running along with the gastrocnemius and soleus, injury to the plantaris muscle can mimic some of the symptoms of an Achilles tendon tear. The plantaris muscle-tendon complex is one of evolution’s leftovers; 3% of the population does not have a plantaris muscle. As we get older, the plantaris muscle gradually grows more and more brittle until one day your run comes to a sudden halt; and the tendon ruptures. Fun fact, plantaris tendon rupture is virtually unheard of in people under forty. The diseases of the aging athlete are not fun. The good news is, recovery from a plantaris tendon rupture only takes about two weeks. I just might get to wear those cute shoes after all.
The gastrocnemius is the largest and most superficial of the calf muscles. This muscle is the main propellant in walking and running. A medial calf injury results from an acute, forceful push-off with the foot. The medial head of the gastrocnemius tears from its bony origin or from the musculotendinous junction. A medial calf injury is often seen in the intermittently active athlete, often referred to as the weekend warrior. This muscle is injured when pushing off the front of the foot or when the knee is extended while the foot is flexed. This happens when running on an incline or during a lunging shot on the tennis court. This action puts maximum tension on the gastrocnemius as the lengthened muscle is contracted. My friend who is an orthopedic surgeon diagnosed me with a Grade II muscle strain of the medial head of my left gastrocnemius. I argued my plantaris tendon tear theory, but he won. Instead of taking two weeks to heal, it would take about eight weeks for me to recover. I would be in a big, ugly CAM boot for six weeks. No cute shoes for me!
What Are Signs and Symptoms of a Muscle Strain?
- Swelling, bruising or redness known as a hematoma will occur at the muscle strain site. Tearing to the muscle fibers causes bleeding to pool under the skin.
- Initially, pain in the affected muscle will be present even at rest. Gradually pain at rest will go away, but pain will persist when the damaged muscle is used.
- Weakness of the associated muscle or tendons
- Inability to use the damaged muscle. This occurs when there is a complete tear or rupture of the involved muscle.
How Do Physical Therapists Diagnose a Muscle Strain?
The Physical Therapist (P.T.) will take a medical history and perform a physical exam. A thorough history will help determine the mechanism of injury. Range of motion of the involved extremity and palpation to the anatomy will help establish which muscle is injured. There are special orthopedic tests that the Physical Therapist will also perform. For example, the Thompson Test will help the P.T. diagnose an Achilles tendon rupture. The PT will assess circulation by palpating distal pulses and capillary filling time. The test for deep vein thrombosis, Homan’s Sign, will assist the PT in determining circulation status of the patient.
The examination is generally all that is needed for diagnosis and can help to establish whether the muscle is partially or completely torn. A higher degree of grade of strain (grades 1-3) can involve longer healing, possible surgery, and a more complicated recovery. If a higher degree of strain is suspected, the patient should follow-up with their medical doctor. X-rays or laboratory test are often not necessary, unless there was a history of trauma or evidence of infection. Infrequently, the physician may order a CT or MRI to better asses the diagnosis of the injury.
What Are the Grades and Recovery Times for Muscle Strains?
- Grade I Muscle Strain: This is the most minor of muscle strains, affecting only a minimal percentage of the muscle fibers of the affected muscle. Compete recovery is expected within weeks.
- Grade II Muscle Strain: This is a partial tear of a significant percentage of the muscle fibers of the affected muscle. Complete recovery can occur but can take months and require Physical Therapy.
- Grade III Muscle Strain: This a complete tear, or rupture, of the affected muscle. This can require surgical repair, and sometimes recovery is incomplete, even after many months of substantial Physical Therapy.
What is the Physical Therapy Treatment for Acute Muscle Strains? (P.R.I.C.E.)
- Protect the strained muscle from injury by using a CAM walking boot or using axillary crutches for a minimum of two weeks.
- Rest the strained muscle. Avoid activities that caused the strain and any activities that cause pain at the injury site.
- Ice the muscle area at least four times per day. Ice is a very effective anti-inflammatory and pain relieving agent. Ice should not be applied to bare skin. Always use a protective covering such as a towel between the ice and the skin. Heat can be applied to further relax the muscle when the swelling has decreased. I recommended waiting 48 hours from the time of injury to apply heat. The early application of heat can increase swelling and pain.
- Compression can be gently applied with an Ace or other elastic bandage. I am a big fan of Juzo compression stockings to treat swelling and routinely fit my patients with a Juzo medical grade compression stocking. The Juzo stocking can provide both support and decrease swelling.
- Elevate the injured area to decrease swelling. Keep the involved extremity up while sitting.
How Can Physical Therapy Accelerate Recovery Time?
Every patient is interested in getting better quicker, but there is a normal physiological rate of healing. It takes about six weeks for the a muscle strain to be 40% healed and twelve weeks for 100% of primary healing to occur. During this time frame it is important to protect the muscle and to maintain overall fitness level. This is what I do best as a Physical Therapist. While I was recovering from my Grade II gastrocnemius muscle strain I used several treatment strategies to optimize healing time.
I immediately started a P.R.I.C.E. protocol. I used crutches until I got my CAM boot for ambulation. I ordered Juzo compression stockings and wore them religiously for the next six weeks. I treated the tear using laser therapy, which accelerates cell regeneration and improves tissue healing time. I treated my leg with Ultrasound, a form of deep heat, massage and contrasted with ice several times per day. Contrasting heat and cold aids in improving circulation and reducing swelling. I exercised daily using a Modified Pilates Method of core stabilization. Two weeks after my injury I started riding a stationary bike and performing gentle stretching to the affected limb. Five weeks after the injury I could walk without pain, and six weeks after the injury I was back to light jogging without pain.
I had a fantastic time at the concert despite being in an ugly CAM boot. I was chauffeured around in a wheelchair by my awesome husband. We had a wonderful dinner and I caught a Hank William’s Junior guitar pick. I sang out loud to Chris Stapleton’s “Tennessee Whiskey”. I got to cut to the front of the bathroom line in my wheelchair. I got upgraded seats and drank a beer or two. I did not get to wear my cute shoes, but I was rocking my boots. I am an aging athlete that will never give up.