PM R XXX (2015) 1-2
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Ultrasound Imaging of Torn Soleus Muscle ¨ zc Chen-Yu Hung, MD, Ke-Vin Chang, MD, Levent O ¸akar, MD A 51-year-old man was referred for ultrasound (US) examination because of persistent left calf swelling for 3 months. The swelling developed abruptly after he had stumbled against a stone, sustaining an inversion injury to his ankle. He described calf pain and swelling but no ecchymosis. Three months after injury, active and passive range of motion of the ankle and toes were not limited, including ankle plantar flexion and toe flexion. Skin color and sensation also appeared normal over the swollen area (Figure 1). US imaging revealed a hyperechoic, homogeneous mass originating beneath the mid-portion of the Achilles tendon and ending at the posterior proximal tibia, with an intact distal musculotendinous junction of the medial gastrocnemius muscle (Video and Figure 2A). The mass was observed to occupy the space between both heads of the gastrocnemius and deep plantar flexors (tibialis posterior, flexor digitorum profoundus and flexor hallucis longus), with overlying anechoic fluid (Video and Figure 2B). The patient was eventually diagnosed with tear of the soleus muscle and an organized hematoma. The soleus muscle, originating from the fibula and medial border of the tibia, merges with the gastrocnemius muscle, forming the Achilles tendon and attaching on the calcaneus. Tear of the medial head of the gastrocnemius muscle at the musculotendinous junction (ie, “tennis leg”) is the more common calf muscle tear, and is typically caused by abrupt extension of the knee and simultaneous forced dorsiflexion of the ankle [1,2]. In this patient, there had been a severe ankle sprain with simultaneous knee buckling. As such, although his gastrocnemius muscle had been protected from overload, the soleus muscle had become vulnerable to the twisting force. In addition, we conclude that the lack of ecchymosis could be attributed to the intact gastrocnemius muscle wrapping the hematoma inside the soleus muscle.
Differentiating soleus rupture from the more commonplace tennis leg is paramount [3]. Rapid accumulation of blood between the gastrocnemius and deep ankle/foot flexors may result in compartment syndrome [4] and compress the posterior tibial nerve and vessels that course right beneath the soleus muscle. Aspiration under US guidance should be performed once the diagnosis is confirmed. On the other hand, because the hematoma had already been organized in this case, surgical intervention was considered to be the best option [4]. Although we suggested that the patient receive further surgical removal, he preferred observation and waiting for spontaneous resolution of the hematoma. Finally, it is noteworthy that the coagulation profile should be examined in case of a large uncommon hematoma. Although our patient had normal prothrombin and partial thromboplastin time, compromised platelet function (due to antiaggregant
Figure 1. In comparison with the normal side, the left calf appeared markedly swollen, without noticeable ecchymosis.
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.05.008
2
US Imaging of Torn Soleus Muscle
Figure 2. In the long-axis view (A), the ultrasound image revealed a large hyperechoic, homogeneous mass located inside the soleus with intact gastrocnemius muscle and Achilles tendon (asterisks). In the short-axis view (B), the mass occupied/filled the space between the 2 heads (g) of the gastrocnemius muscle and the deep plantar flexors. Also note the superficial anechoic fluid (f).
medication after coronary stenting) may have predisposed him to his soleus tear/hematoma.
References
URL: http://www.pmrjournal.org/article/ S1934-1482(15)00236-1/fulltext
1. Ozc ¸akar L, Solak HN, Yo ¨ru ¨bulut M. Tennis leg: A look from the geriatric side. J Am Geriatr Soc 2005;53:356-357. 2. Russell AS, Crowther S. Tennis legda new variant of an old syndrome. Clin Rheumatol 2011;30:855-857. 3. Aydog ST, Ozc ¸akar L. A handball player with a tennis leg: Incentive for muscle sonography and intermittent pneumatic compression during the follow up. J Back Musculoskelet Rehabil 2007;20:181-183. 4. Bryan Dixon J. Gastrocnemius vs. soleus strain: How to differentiate and deal with calf muscle injuries. Curr Rev Musculoskelet Med 2009;2:74-77.
C.-Y.H. Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Chu-Tung Branch, Hsinchu, Taiwan Disclosure: nothing to disclose
¨ . Department of Physical and Rehabilitation Medicine, Hacettepe University L.O Medical School, Ankara, Turkey Disclosure: nothing to disclose
Video Gallery: To view the online videos, use your smartphone camera QR Reader App to scan and capture this QR Code or visit www. pmrjournal.org to locate this video content.
Disclosure
K.-V.C. Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, BeiHu Branch and National Taiwan University College of Medicine, Taipei, Taiwan. Address correspondence to: K.-V.C., National Taiwan University Hospital, Bei-Hu Branch, Physical Medicine and Rehabilitation, No.87, Neijiang St., Wanhua Dist., Taipei City 108, Taiwan (R.O.C.), Taipei City 10845, Taiwan; e-mail: [email protected] Disclosure: nothing to disclose
Submitted for publication April 17, 2015; accepted May 6, 2015.
www.pmrjournal.org
Images
Ultrasound Imaging of Torn Soleus Muscle ¨ zc Chen-Yu Hung, MD, Ke-Vin Chang, MD, Levent O ¸akar, MD A 51-year-old man was referred for ultrasound (US) examination because of persistent left calf swelling for 3 months. The swelling developed abruptly after he had stumbled against a stone, sustaining an inversion injury to his ankle. He described calf pain and swelling but no ecchymosis. Three months after injury, active and passive range of motion of the ankle and toes were not limited, including ankle plantar flexion and toe flexion. Skin color and sensation also appeared normal over the swollen area (Figure 1). US imaging revealed a hyperechoic, homogeneous mass originating beneath the mid-portion of the Achilles tendon and ending at the posterior proximal tibia, with an intact distal musculotendinous junction of the medial gastrocnemius muscle (Video and Figure 2A). The mass was observed to occupy the space between both heads of the gastrocnemius and deep plantar flexors (tibialis posterior, flexor digitorum profoundus and flexor hallucis longus), with overlying anechoic fluid (Video and Figure 2B). The patient was eventually diagnosed with tear of the soleus muscle and an organized hematoma. The soleus muscle, originating from the fibula and medial border of the tibia, merges with the gastrocnemius muscle, forming the Achilles tendon and attaching on the calcaneus. Tear of the medial head of the gastrocnemius muscle at the musculotendinous junction (ie, “tennis leg”) is the more common calf muscle tear, and is typically caused by abrupt extension of the knee and simultaneous forced dorsiflexion of the ankle [1,2]. In this patient, there had been a severe ankle sprain with simultaneous knee buckling. As such, although his gastrocnemius muscle had been protected from overload, the soleus muscle had become vulnerable to the twisting force. In addition, we conclude that the lack of ecchymosis could be attributed to the intact gastrocnemius muscle wrapping the hematoma inside the soleus muscle.
Differentiating soleus rupture from the more commonplace tennis leg is paramount [3]. Rapid accumulation of blood between the gastrocnemius and deep ankle/foot flexors may result in compartment syndrome [4] and compress the posterior tibial nerve and vessels that course right beneath the soleus muscle. Aspiration under US guidance should be performed once the diagnosis is confirmed. On the other hand, because the hematoma had already been organized in this case, surgical intervention was considered to be the best option [4]. Although we suggested that the patient receive further surgical removal, he preferred observation and waiting for spontaneous resolution of the hematoma. Finally, it is noteworthy that the coagulation profile should be examined in case of a large uncommon hematoma. Although our patient had normal prothrombin and partial thromboplastin time, compromised platelet function (due to antiaggregant
Figure 1. In comparison with the normal side, the left calf appeared markedly swollen, without noticeable ecchymosis.
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.05.008
2
US Imaging of Torn Soleus Muscle
Figure 2. In the long-axis view (A), the ultrasound image revealed a large hyperechoic, homogeneous mass located inside the soleus with intact gastrocnemius muscle and Achilles tendon (asterisks). In the short-axis view (B), the mass occupied/filled the space between the 2 heads (g) of the gastrocnemius muscle and the deep plantar flexors. Also note the superficial anechoic fluid (f).
medication after coronary stenting) may have predisposed him to his soleus tear/hematoma.
References
URL: http://www.pmrjournal.org/article/ S1934-1482(15)00236-1/fulltext
1. Ozc ¸akar L, Solak HN, Yo ¨ru ¨bulut M. Tennis leg: A look from the geriatric side. J Am Geriatr Soc 2005;53:356-357. 2. Russell AS, Crowther S. Tennis legda new variant of an old syndrome. Clin Rheumatol 2011;30:855-857. 3. Aydog ST, Ozc ¸akar L. A handball player with a tennis leg: Incentive for muscle sonography and intermittent pneumatic compression during the follow up. J Back Musculoskelet Rehabil 2007;20:181-183. 4. Bryan Dixon J. Gastrocnemius vs. soleus strain: How to differentiate and deal with calf muscle injuries. Curr Rev Musculoskelet Med 2009;2:74-77.
C.-Y.H. Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Chu-Tung Branch, Hsinchu, Taiwan Disclosure: nothing to disclose
¨ . Department of Physical and Rehabilitation Medicine, Hacettepe University L.O Medical School, Ankara, Turkey Disclosure: nothing to disclose
Video Gallery: To view the online videos, use your smartphone camera QR Reader App to scan and capture this QR Code or visit www. pmrjournal.org to locate this video content.
Disclosure
K.-V.C. Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, BeiHu Branch and National Taiwan University College of Medicine, Taipei, Taiwan. Address correspondence to: K.-V.C., National Taiwan University Hospital, Bei-Hu Branch, Physical Medicine and Rehabilitation, No.87, Neijiang St., Wanhua Dist., Taipei City 108, Taiwan (R.O.C.), Taipei City 10845, Taiwan; e-mail: [email protected] Disclosure: nothing to disclose
Submitted for publication April 17, 2015; accepted May 6, 2015.
