Calf muscle rupture: symptoms and treatment

Sharp pain, swelling and hematoma are the main symptoms of a rupture of the calf muscle, which is located in the back of the lower leg. The calf muscles bear a heavy load; when it reaches high levels, the muscle fibers rupture. The cause of the injury may be a sharp increase in loads, excessive tension, an unsuccessful fall or push from the ground, poor warming up of the muscle before training, or a strong blow to the shin. Most often, a rupture of the medial head of the gastrocnemius muscle occurs; a little less often, a tear occurs in the area where the muscle passes into the tendon.

Symptoms of a torn calf muscle

Symptoms of a calf muscle injury vary depending on the severity. The main indicator of the severity of the injury is pain in the calf muscle. The more intense the pain syndrome, the more muscle fibers have been torn. If pain occurs, you must immediately stop training, as there is a high probability of tearing the muscle. When such an injury occurs, it is painful for the victim to stand on his leg and make movements. Swelling and hematoma form in the area of the calf muscle. Extensive bruising indicates a complete tear of the calf muscle.

Damage to the calf muscle is classified by severity:

The first degree is a minor strain of the calf muscle - minor damage to the muscle fibers. The injury is accompanied by moderate pain, does not affect the mobility of the leg and does not require special treatment. It is recommended to refrain from training and other stress on the lower leg for 3-7 days.
The second degree indicates a tear of the calf muscle - damage to 20-40% of the muscle fibers. Swelling and hematoma form, the pain is quite severe, and painkillers are required. Treatment involves the use of NSAIDs and providing the muscle with complete rest.
A third-degree injury is a serious injury in which there is a complete rupture of the calf muscle or its tendon (sometimes the tendon is torn from the bone). Symptoms: sharp and very severe pain, rapid swelling of the lower leg, inability to move the muscle, outwardly it is visible that the muscle has gathered into a ball. If such damage occurs, surgery is necessary.

To make a diagnosis, the doctor will prescribe an ultrasound or MRI. These research methods allow you to see damage to soft structures. Sometimes x-rays are needed to detect or rule out a bone fracture. As a rule, these diagnostic methods are sufficient to differentiate injuries to the gastrocnemius muscle.

First aid for sprains, treatment at home

Sprains of the lower leg muscles, as well as ligament ruptures, are within the competence of traumatologists; therefore, in order to avoid possible negative consequences, the victim should be shown to a specialized specialist.

On an outpatient basis, treatment is permitted if there are signs of sprain:

maintaining motor functions of the leg;
moderate severity of pain.

The ankle should not be overloaded. After receiving an injury, he must be kept at rest for at least 48 hours, secured with an elastic bandage and placed in an elevated position. If necessary, crutches can be used for mobility purposes.

In order to relieve swelling, dry ice should be applied to the injured area (in a bag wrapped in cloth) for 2 days for 20 minutes every 4 hours. On day 3 you should refrain from using compresses. From day 4, switch to warm compresses and baths (to stimulate resorption).

Optionally, on the recommendation of a doctor, you can use NSAIDs (non-steroidal anti-inflammatory drugs - Diclofenac, Ibuprofen), including in the form of ointments (Traumel, Apizartron, Voltaren emulgel, Viprosal, Ketonal gel).

Conservative treatment of a calf muscle tear

Stretching and partial rupture of the calf muscle (grade 1 and 2) are treated conservatively. If the injury is assigned the third degree of severity, then only surgical treatment is used.

The doctor prescribes cold compresses to relieve swelling and resolve the hematoma, anti-inflammatory drugs with an analgesic effect (“Ibuprofen”, “Nimesil”, “Diclofenac”, “Ketanov”), ointments for external treatment of injury (“Nise”, “Diclofenac”, “ Dolobene"), as well as vitamins. Three days after the injury, warm applications of wax or therapeutic mud are prescribed, which enhance blood microcirculation and accelerate cell regeneration, promoting the resorption of the hematoma.

After completing the main course of treatment, rehabilitation is prescribed - physiotherapy, massage and exercise therapy to restore the elasticity and strength of the muscle. Full treatment of first and second degree gastrocnemius muscle rupture requires from ten days to two months.

Diagnostics

An external examination of a patient with muscle fiber rupture is not very informative due to the similarity of symptoms of almost all ankle injuries. Differential diagnosis is carried out to exclude a fracture of the tubular bone, dislocation or damage to the Achilles tendon. What diagnostic tests can be performed:

radiography. An X-ray examination reveals fractures and cracks in the bones;
MRI or CT. The study is informative for establishing damage to any connective tissue structures: muscles, ligaments, tendons, soft tissues.

Diagnostics is also necessary to identify the inflammatory process that occurs during injury, the degree of its intensity and localization. The victim is also shown general blood and urine tests, the results of which make it possible to assess the general state of health.

Surgical treatment of a torn calf muscle

Surgery is necessary if there is a complete rupture of the fibers of the calf muscle. As a rule, it is carried out in an open way and consists of connecting the torn ends of the muscle. After repairing the damage, a suture is applied and immobilization is done with a plaster cast. The doctor prescribes a course of medication and prescribes physiotherapy and exercise therapy. Ultrasound and magnetic therapy accelerate local metabolism and trigger active regeneration in tissues, which allows the calf muscle to recover faster.

Exercise therapy for the calf muscle begins with light movements of the toes and feet to prevent muscle tissue atrophy. After the cast is removed, physical therapy is performed to improve elasticity and restore full range of motion. Recovery time after a calf muscle rupture and subsequent surgery takes several months, depending on the individual characteristics of the patient.

Achilles tendon rupture

Introduction

The calcaneal (Achilles) tendon, tendo calcaneus (Achillis), is the common terminal tendon of the triceps surae muscle, m. triceps surae, which in turn consists of two muscles - the gastrocnemius, m. gastrocnemius, located superficially, and soleus, m. soleus lying underneath it. In 93% of cases, the calcaneal tendon is supplemented by the tendon of the plantaris muscle, m. plantaris The insertion point of the Achilles tendon is the posterior surface of the calcaneal tuberosity. At the point of attachment between the tendon and the bone there is a very permanent synovial bursa, bursa tendinis calcanei. The Achilles tendon has a round top and a relatively flat distal end.

Achilles tendon tissue consists of 70% collagen (mainly type I), 2% elastin, acidic polysaccharides (hyaluronic acid, chondroitin sulfate) and water. Collagen fibers are grouped into primary bundles, from which large secondary bundles or fascicles are formed, which are surrounded by endotenon - loose connective tissue containing nerves, blood and lymphatic vessels, and allowing some sliding of the bundles relative to each other. The bundles group together to form a tendon surrounded by the paratenon. The paratenon consists of two layers: visceral - epitenon, covering the entire tendon, and parietal - peritenon, bordering the surrounding tissues. The paratenon sheets are separated by a capillary layer of fluid to reduce frictional forces during tendon movements.

Arterial blood supply is carried out in the proximal sections due to the branches of a. tibialis posterior, and in the distal ones - from the arterial network of the calcaneus, which is formed by the fusion of the communicating branches of a. tibialis posterior and a. fibularis. Blood flow in the Achilles tendon is carried out mainly by vessels penetrating through the mesentery of the paratenon. The vessels penetrating the tendon at the muscle-tendon junction or at the site of attachment of the tendon to the heel bone play a subordinate role. The number of vessels supplying the tendon decreases from the calcaneus proximally and reaches a minimum at 2-5 cm from the calcaneal tubercle. Venous outflow is carried out through communicating veins into the superficial and deep venous systems.

The relevance of the problem of Achilles tendon ruptures is due to the increased frequency of this injury in recent years. This injury occurs most often in men (according to various authors, the ratio ranges from 1.7:1 to 30:1), which is probably due to both the greater involvement of men in sports activities and their higher susceptibility to injury. A typical rupture of the Achilles tendon occurs in a man who is professionally or occasionally involved in sports, between the ages of 30 and 50 years.

Etiology and pathology

The etiology of Achilles tendon rupture has been extensively studied but remains unclear. It is based on many factors, such as poor vascularization of the tendon, degenerative processes, dysfunction of the gastrocnemius muscle, age, gender, previous injuries, changes in the training regimen and improper exercise performance, and the type of shoes worn. It may also be associated with processes such as inflammation, autoimmune processes, hyperuricemia, genetic predisposition, renal dysfunction and atherosclerosis.

Theory of degeneration.

The events leading up to the breakup are unclear. A normal tendon does not rupture even when great stress is applied. Arner et al. first noted degenerative changes in all 74 patients with Achilles tendon rupture and suggested that these changes preceded the rupture. However, about 2/3 of the samples were obtained more than 2 days after rupture. Davidsson and Salo reported noted degenerative changes in 2 patients with Achilles tendon rupture who were operated on on the day of injury. Therefore, the identified degenerative changes should be considered as having developed before the rupture. Most of these deviations have no etiological explanation. It is possible that changes in blood flow with subsequent hypoxia and metabolic disorders are a factor in the development of the observed degenerative changes.

Physical activity interspersed with periods of low physical activity (weekend sports) can lead to degenerative changes in the tendons. Sports activities lead to additional stress on the Achilles tendon, which leads to the accumulation of microtraumas, which, although below the threshold level of rupture, can nevertheless lead to secondary intratendinous degenerative changes.

Kannus and Jozsa evaluated biopsy samples from patients with spontaneous Achilles tendon rupture taken during surgery. Only 1/3 of the control group samples had the same changes, but to a significantly lesser extent. They also noted that only a small proportion of patients reported any symptoms prior to rupture. They suggested that there is clear evidence that, at least in urban populations, tendon degenerative changes are widespread in people over 35 years of age, and these changes may be associated with spontaneous tendon rupture.

Mechanical theory.

Tendon damage can occur even under loads within the physiological threshold with frequent cumulative microtraumas that do not leave enough time for regeneration.

McMaser believes that a completely healthy tendon is not susceptible to rupture even under significant overload. However, Barfred showed that complete rupture can occur in a healthy tendon when maximum muscle contraction is applied to the initially stretched tendon. Similar factors are present in many sports that require fast take-off. A healthy tendon can thus be torn due to excessive muscle tension.

Inglis and Sculco suggested that failure of the mechanisms that inhibit excessive or uncoordinated muscle contraction may also lead to rupture in a normal tendon. Thus, athletes who return to training too quickly after a period of inactivity are at increased risk. The risk of Achilles tendon rupture continues to increase if tangential stress is accompanied by supination or pronation at the subtalar joint.

In a study of 109 runners, Clement showed that Achilles tendon injuries can result from structural or dynamic disturbances in normal lower extremity biomechanics, such as overtraining, functional overpronation, and soleus or gastrocnemius muscle weakness. It has also been suggested that repetitive microtrauma caused by eccentric loading of a fatigued muscle may play an important role in tendon injury. A complete rupture is the consequence of several micro-tears that lead to tendon rupture after reaching a critical point.

LA-associated tendon ruptures.

The use of anabolic steroids and fluoroquinolones has been associated with Achilles tendon rupture. Both groups of drugs cause dysplasia of collagen fibers, which reduces the ability of the tendon to stretch.

The use of systemic and topical corticosteroids has previously been associated with tendon rupture. However, studies on the quadriceps tendon have shown that the normal tendon is not damaged by intratendinous corticosteroid injections. However, most of the available evidence suggests that intra- and peritendinous injection of corticosteroids into the injured tendon may precipitate tendon rupture.

The role of corticosteroids in the etiology of Achilles tendon rupture remains unclear. However, the available data do not allow us to recommend prolonged oral use and repeated peritendinous administration of corticosteroids. The anti-inflammatory and analgesic effects of corticosteroids may mask the symptoms of tendon injury, allowing a high level of activity to be maintained. Corticosteroids interfere with repair, and intratendinous corticosteroid injections result in tendon weakening for up to 14 days after injection. The destruction is directly related to collagen necrosis and the restoration of tendon strength is associated with the formation of a cellular amorphous collagen mass. For this reason, you should avoid activity for 2 weeks after a corticosteroid injection near the tendon.

Fluoroquinolone antibiotics such as ciprofloxacin have also recently been recognized as an etiological factor in tendon injury. In France, from 1985 to 1992, degenerative tendon changes were noted in 100 patients taking fluoroquinolones, including 31 ruptures. Many of them also received corticosteroids, which does not allow us to draw a clear conclusion about the exclusive effect of fluoroquinolones on the identified disorders. Szarfman et al. reported an animal study of fluoroquinolones at near-human doses that showed cartilage extracellular matrix destruction, chondrocyte necrosis, and collagen depletion. Deviations identified in animals can also occur in the human body. The authors recommend supplementing the list of unwanted side effects with a warning about the possibility of tendon rupture.

Hyperthermia and tendon rupture.

Up to 10% of the elastic energy stored in the tendon can be released as heat. Wilson and Goodship assessed in vivo temperatures generated by flexion in the flexor digitorum superficialis tendons during exercise. A peak temperature of 45°C, at which tenocytes can be damaged, was measured in the center of the tendon after 7 minutes of jogging. Exercise-induced hyperthermia may contribute to tendon degeneration. Good tissue perfusion should prevent overheating, but tissues such as the Achilles tendon with areas of poor perfusion may be more sensitive to the effects of hyperthermia.

Breaking mechanism.

Arner and Lindholm classified the mechanism of Achilles tendon rupture in a group of 92 patients into 3 main categories:

- 53% occur during weight bearing, pushing off with the forefoot and extending the knee joint. This movement is often found during sprint starts and during jumps in sports such as basketball. This explains the fact that rupture of the left Achilles tendon predominates in right-handed people.

- 17% of ruptures occur during sudden flexion of the ankle joint, which occurs, for example, when falling into a hole or as a result of a fall on the stairs.

- in 10%, the tendon was torn as a result of forced flexion of the straightened foot, which can happen when falling from a height.

In the remaining cases, the authors were unable to determine the exact mechanism of injury.

Diagnostics.

A detailed history and thorough physical examination are extremely important in diagnosing Achilles tendon ruptures. Although the diagnosis seems simple, 20 to 25% of Achilles tendon ruptures are missed during the initial examination. There are a large number of diagnostic tests and signs - both clinical and instrumental. Clinical examination is usually sufficient to diagnose acute Achilles tendon injuries, while establishing a diagnosis of chronic injuries can be difficult. Ultrasound and MRI significantly complement clinical diagnosis; they are more sensitive and less invasive compared to “soft” radiography or xeroradiography.

A patient with an Achilles tendon rupture usually reports sudden pain in the leg, often reporting that at the time of the injury they had a sensation of a blow to the back of their shin. Some patients report that the injury was accompanied by an audible clicking sound. They are often unable to bear body weight and experience weakness or stiffness in the affected limb. However, they may be capable of plantar flexion using the flexor pollicis longus, flexor digitorum longus, tibialis posterior and peroneus muscles. Patients with chronic Achilles tendon rupture often have difficulty pinpointing the time of injury and first notice the injury when they are unable to perform everyday tasks, such as climbing stairs.

During the examination, diffuse swelling and bruising may be detected and, if the swelling is small, palpation reveals retraction along the tendon. The site of rupture is usually 2-6 cm proximal to the tendon insertion.

Inspection and palpation should be supplemented by other tests to confirm the diagnosis. And although the Thompson test is usually quite reliable, it can sometimes be questionable. In such cases, it should be supplemented by the O'Brien and Copeland tests. Also, the patient may be asked to rise on his toes.

Thompson (Simmonds) test or calf compression test

The patient is in a prone position, the feet hang freely, the doctor compresses the soft tissues of the upper third of the leg. If the Achilles tendon is damaged, contraction of the calf muscle does not lead to movement of the foot. A comparative study of both limbs should always be performed to avoid the false negative result that can occur with incomplete rupture.

Matls test

With the patient lying on his stomach, he is asked to bend his legs at the knee joints 90*. If the foot on the affected side is in dorsiflexion during this movement, the test is considered positive.

O'Brien test

A needle from a medical syringe is inserted into the place where the aponeurosis passes into the tendon, move the foot and watch how the needle deflects.

Copland test.

A sphingmomanometer cuff is placed on the lower leg. It is inflated to a pressure of 100 mmHg and the doctor begins to move the foot. If the pressure increases to 140 mmHg, then the Achilles tendon is not torn.

Radiography

Lateral ankle radiographs have previously been widely used to diagnose Achilles tendon rupture. When ruptured, Kager's triangle (the fat-filled triangular space anterior to the Achilles tendon and between the back of the tibia and the top of the heel bone) loses its proper configuration. Currently, radiography is losing its relevance in the diagnosis of fresh and old ruptures of the Achilles tendon due to the increasingly widespread use of ultrasound diagnostics and magnetic resonance imaging, but its use is justified to determine changes preceding the rupture (Haglund's disease, ossification of the Achilles tendon) and to exclude traumatic damage to the foot skeleton.

Ultrasound diagnostics

The introduction of ultrasound into clinical practice has made significant changes in the treatment tactics of subcutaneous rupture of the Achilles tendon, since it has become possible not only to confirm or refute the presence of a rupture, but also to determine parameters important for choosing a treatment method: the degree of disintegration of the tendon ends, the size of diastasis, the degree of contact of the ends tendons in different positions of the foot; and also monitor the condition of the tendon at the stages of treatment.

During an ultrasound examination, the patient is positioned on the couch on his stomach, first the feet are placed freely in a neutral position over the edge of the table, then, if necessary, the examination is performed during movements of the foot (dorsal/plantar flexion). For comparison, both Achilles tendons are always examined. During the study, the sensor should be positioned strictly parallel to the tendon to ensure the optimal amount of returned energy and avoid artifacts in the form of false hypoechogenicity. It is preferable to use high-frequency linear sensors (7.5 - 10.0 megahertz), which provide the greatest image clarity.

In longitudinal section, the Achilles tendon appears as a hypoechoic band, which is bounded ventrally and dorsally by the echo-dense paratenon. The internal structure of the tendon is presented in the form of alternating hyper- and hypoechoic stripes, separated when the tendon is relaxed and more compact when it is stretched. The musculotendinous junction is determined proximally, and the attachment of the tendon to the calcaneus is determined distally. The tendon is fusiformly woven into the calcaneus, whose dorsal surface represents an echo-dense line slightly curved posteriorly. Due to the spindle-shaped course of the tendon fibers in the area of attachment, the reflection of sound waves loses its uniform character, and the tendon in this area often looks hypoechoic. Ventral to the tendon is fatty tissue with irregular echo density, which corresponds to the radiographic triangle of Kager. In addition, the deep flexors, the posterior surface of the tibia with Volkmann's triangle and the posterior part of the ankle joint are visualized. The sagittal size of the tendon is easily measured between the peritenon layers. Features of tendon gliding are determined during foot movements.

On transverse sonograms at the heel bone insertion, the tendon appears as a crescent-shaped structure located just under the skin. Further proximally, the tendon gradually takes on the shape of an ellipse. At approximately a distance of 3-6 cm from the calcaneal tubercle, the tendon has an almost round outline and then flattens out again. When examining a tendon in cross section, it is almost always possible to measure its dimensions (thickness and width).

When a tendon ruptures, the following changes in the ultrasound picture occur:

- disruption of tendon continuity

- visible limited ends of the tendon

- hypoechoic fluid accumulation (hematoma in the area of the rupture)

— loosening of parallel-tensioned structures.

The listed signs are regularly detected with the accumulation of appropriate experience, however, there are various options for ultrasound imaging of fresh Achilles tendon ruptures. In some cases, a clear diastasis between the ends of the tendon and an accumulated hematoma are not observed, then a dynamic study is necessary to make a final diagnosis. When the foot is dorsiflexed, divergence of the ends of the tendon is almost always observed.

Important information is obtained by plantar flexion of the foot, which clarifies the possibility of adaptation of the ends of the tendon. During plantar flexion, the integrity of the paratenon is also determined: if the sheath is damaged, the tendon ends overlap each other.

Magnetic resonance imaging

If the clinical and ultrasound picture of the injury is questionable, MRI of the Achilles tendon can be successfully used.

In sagittal sections, the healthy Achilles tendon appears as a long, thin, hypointense structure originating from the distal gastrocnemius muscle and inserting at the posterior aspect of the calcaneal tuberosity. On axial sections, the tendon appears slightly flattened, with rounded outer and inner edges. The anterior surface is usually flat or slightly concave, the posterior surface is convex. The surrounding fat layer is quite pronounced and emphasizes the tendon structures. There may be slight variations in the size, shape and appearance of the tendon, and sometimes some lobulation of the structure of the anterior tendon is visible. Intratendinous signals are not normally observed.

Any increase in intratendinous signal intensity should be considered abnormal. To evaluate a tendon with suspected rupture, its structure should be examined in T1 and T2 modes. In T1 mode, a complete rupture of the Achilles tendon is defined as the disappearance of signal within the tendon; in T2 mode, the rupture appears as a generalized increase in signal intensity, swelling and hemorrhage at the site of the rupture are also visible as an area of high signal intensity. The study allows you to clearly assess the level of rupture and the degree of divergence of the ends of the tendon.

Treatment of acute Achilles tendon ruptures

Treatment of acute Achilles tendon ruptures is still largely dependent on surgeon and patient preference. Surgery is the treatment of choice in athletes and young adults, while fresh tears in non-athletes can be treated conservatively.

Conservative treatment

Some authors oppose surgical treatment, citing the high incidence of complications as its main drawback. However, recent studies in larger populations report significantly lower complication rates. These complications include skin necrosis, wound infection, sural neuromas, adhesions, and the usual anesthetic risks. Postoperative wound healing problems remain the most common and most difficult to manage, given the poor vascularity of the Achilles tendon area. Adherents of the conservative method of treatment indicate that the possibilities of covering the Achilles tendon area with soft tissue are limited. Unfortunately, skin flaps cannot be grafted onto an exposed tendon, and grafting with local tissue may lead to an unsatisfactory result. Therefore, these defects often require closure with free flaps.

Despite the constant improvement of surgical techniques and experience, wound problems cannot be completely eliminated when using an open method of surgical treatment, which most often uses a longitudinal incision passing through an area of poor blood supply. Aldam used a transverse incision passing immediately distal to the site of tendon rupture and reported 1 case of postoperative wound complications in 41 patients.

In elderly patients with chronic Achilles tendon damage, whose biological age is more than 70 years, only physiotherapeutic treatment is acceptable. Typically, these patients complain of weakness in plantar flexion and gait disturbance. They often adapt well to their illness.

Immobilization

The most commonly used form of non-surgical treatment is plaster immobilization, usually for 6-10 weeks. Good clinical results comparable to those of surgical treatment were reported.

Although function after conservative treatment is generally good, the high risk of re-rupture is considered unacceptable. Lea and Smith, in a study of 66 patients treated conservatively, reported 7 re-ruptures (13%), Persson and Wredmark reported a figure of 35%. Recently, based on work on functional postoperative bracing, McComis et al. in a study of 15 patients with Achilles tendon rupture treated conservatively, reported achieving good functional results.

Thus, in selected cases, bracing and plaster immobilization may be a viable alternative to surgery.

Surgical treatment

Over the past two decades, surgery has been the treatment of choice for Achilles tendon rupture in young patients. Advances in surgery and new postoperative rehabilitation programs have led many surgeons to opt for surgical treatment. In addition, surgical treatment reduces the risk of re-rupture from 13-20% to 1-4%, allows for greater tendon strength, causes fewer cases of calf muscle atrophy, and helps more athletes return to their previous level of physical activity.

Surgical technique.

Various surgical techniques can be used to repair the Achilles tendon, ranging from simple end-to-end matching with Bunnel or Kessler suture to more complex ones using fascial reinforcement or the use of tendon grafts and artificial tendon implants of various materials. However, there is no evidence that for acute Achilles tendon ruptures these techniques provide better results than a simple end-to-end connection without lengthening.

Open Achilles tendon suture

The patient is on the operating table lying on his stomach, with his head lowered to 20* and both legs hanging from the edge of the table. A longitudinal incision 8-10 cm long is made immediately medial to the medial edge of the tendon, centered at the site of palpable retraction. The subcutaneous fatty tissue is cut sharply without damaging the skin edges of the wound. The paratenon is incised longitudinally along the midline to the length of the skin incision. Often the paratenon is swollen and the torn ends of the tendon in the classic version have the appearance of a horse's end or a mop. After matching the ends, they are sutured together with a strong absorbable suture (for example, Vicryl 2) using the Kessler method. Before tying the ends, the assistant performs plantar flexion at the ankle joint to better align the ends. Next, a wrapping suture is applied with thinner absorbable suture material to further strengthen the connection. After closing the paratenon with thin vicryl, the subcutaneous tissues are sutured with a continuous suture. The skin wound is closed with strips to minimize tension. Next, plaster immobilization is applied in the equinus position of the foot. Limited exercise under the supervision of a physiotherapist is possible already on the day of surgery. The patient is advised to maintain an elevated position of the operated limb whenever possible. Immobilization is removed 2 weeks after surgery by moving the foot to a physiological position and wearing a brace. Full body weight loading is allowed.

Percutaneous repair

In 1977, Ma and Griffith described the technique of percutaneous Achilles tendon repair as a compromise between open surgery and conservative treatment. The technique involves making 6 small punctures along the lateral and medial border of the tendon and then passing a suture through these incisions. The authors report on 18 patients in whom this technique was used. There were 2 minor non-infectious complications and no cases of re-rupture. FitzGibbson reports 14 good results with one complication of sural nerve injury. Rowley and Scotland describe 24 patients with Achilles tendon rupture, 14 of whom were treated conservatively and 10 treated with percutaneous Achilles tendon repair. One patient in the latter group subsequently developed sural nerve injury. In addition, a faster recovery of working capacity was noted in patients of the second group.

Other authors report less success with this technique. Klein et al. reported sural nerve entrapment in 13% of 38 patients. Hockenbury and Johns compared in vitro percutaneous Achilles tendon suture with open Achilles tendon repair in 10 fresh-frozen cadaveric specimens and reported better results in the first group. Overall, most studies demonstrate a higher success rate for open Achilles tendon repair compared to closed Achilles tendon repair.

Recently, Webb and Bannister described a new closed Achilles tendon suture technique performed under local anesthesia using 3 transverse 2.5 cm incisions over the posterior surface of the tendon. They reported no sural nerve injury or re-rupture in 27 patients in whom this technique was used.

It is also worth noting the emergence of special guiding systems, such as Achillon, which minimize the risk of damage to the sural nerve.

Treatment of old Achilles tendon injuries

In more than 20% of patients with an Achilles tendon rupture, the injury goes undetected. It is usually possible to suture the ends of the tendon end-to-end within 72 hours of the rupture. In the case of an old injury, the ends of the tendon cannot be approximated without excessive tension. It is unknown when acute damage becomes chronic, but it is usually considered to be 4-6 weeks.

In the case of an old rupture, the ends of the tendon can be brought together using a single central (Chernavsky technique) or 2 (medial and lateral – Lindholm technique) myofascial flaps of the gastrocnemius muscle. If possible, plantaris tendon should be used to strengthen the sutured tendon.

In case of tears that cannot be directly sutured, other tendons can be used. Perez-Teuffer describes cutting the peroneus brevis tendon from the base of the fifth metatarsal and then attaching it to the calcaneus. This modified technique was later applied by Turco et al. in 40 patients. Both authors do not report any functional limitations after this operation. Mann et al. reports excellent to good results in 6 patients treated with the flexor digitorum longus muscle as a graft. Wapner et al. reports experience with the use of the flexor hallucis longus muscle as a graft.

Carbon and polyester implants can also be used to connect the ends of the tear. Ozaki et al. report successful experience with Marlex mesh in 6 patients. Bugg et al. used a fascia lata graft and reported good results in 10 patients.

Conclusion

With the recent rise in popularity of outdoor activities, Achilles tendon ruptures continue to become a growing concern. And despite extensive research in this area, the etiology of Achilles tendon damage still remains unclear. However, it is clear that treatment for Achilles tendon ruptures must be individualized for each patient.

Rehabilitation after a torn calf muscle

Before exercising, it is appropriate to massage the calf muscle to fully warm it up before exercise. Gymnastics are selected by the doctor individually, depending on the characteristics of the injury and the victim’s body.

An approximate set of exercises for the calf muscle:

Sit on the floor or on the bed, straighten your legs. Without bending your knees, place the heel of your healthy leg on the ball of your foot under the toes of your injured leg. Apply moderate pressure and pull your fingers towards you. In this case, there should be no pain in the lower leg. Stay in this position for 15-30 seconds.
Stand in front of a wall, lean on it with your arms extended at chest level. Place the injured leg back without lifting the heel off the floor. Bend the other leg at the knee and transfer your body weight to it. The heel of the injured leg remains pressed to the floor. Stay in this position for up to 30-40 seconds. Do 8-10 approaches.
Stand on your toes, raising your heels as much as possible. Stand on your toes for 5 seconds, then lower your entire foot. Repeat 15 times.

During exercise therapy exercises, overstrain of the calf muscle, pain and other discomfort are not allowed. If any discomfort occurs, you should notify your doctor.

Pathogenesis and prevention[edit | edit code]

The triceps surae muscle is commonly injured during sprinting and jumping. Muscle injuries account for 30% of all sports injuries and their treatment poses a challenge for the sports physician. Most muscle injuries are bruises and sprains, and they can sideline an athlete for a long time.

Athletes who have suffered a muscle injury in the past have an increased likelihood of re-injury, and the shorter the interval between injuries, the higher the likelihood. Additionally, the likelihood of damage increases with age.

Fatigue may play a key role in triceps surae injury, as the injury appears to occur late in training or competition. It was shown that a tired muscle could absorb much less energy before contractility was exhausted than a control muscle. Therefore, an essential part of prevention should be maintaining fitness to reduce or delay fatigue.

Due to the elastic properties of muscles, they can be influenced by stretching and warming up. Cyclic (interrupted by relaxation) stretching of muscles to 50% of the elastic limit has a positive effect on the amount of energy absorbed by the muscle before contractility is exhausted. Stretching more than 50% of the limit reduces the amount of energy absorbed by the muscle before exhaustion. Therefore, light stretching exercises are advisable before sports activities. Elastic properties also depend on the temperature of the muscle. Consequently, warm-up exercises (warm-up) help improve the elastic properties of the muscle.

A set of exercises for a torn calf muscle

Ankle exercises after a torn calf muscle
Exercises for the knee joint after a torn calf muscle

Conclusion

Treatment for a calf muscle tear is quick if only part of the fibers are damaged. In this case, it is important to consult a doctor in a timely manner, because an old injury to the calf muscle requires longer treatment and does not always respond successfully to therapy. An integrated approach - drug therapy, physiotherapy, exercise therapy and massage - contributes to the complete restoration of lower leg function and prevents the risk of complications. To further prevent ruptures, it is necessary to thoroughly warm up the calf muscles before physical activity and avoid excessive tension.