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      A novel approach to sonographic examination in a patient with a calf muscle tear: a case report

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          Rupture of the distal musculotendinous junction of the medial head of the gastrocnemius, also known as "tennis leg", can be readily examined using a soft tissue ultrasound. Loss of muscle fiber continuity and the occurrence of bloody fluid accumulation can be observed using ultrasound with the patient in the prone position; however, some cases may have normal ultrasound findings in this conventional position. We report a case of a middle-aged man with tennis leg. Ultrasound examination had normal findings during the first two attempts. During the third attempt, with the patient's calf muscles examined in an unconventional knee flexed position, sonographic findings resembling tennis leg were detected.

          Case presentation

          A 60-year-old man in good health visited our rehabilitation clinic complaining of left calf muscle pain. On suspicion of a ruptured left medial head gastrocnemius muscle, a soft tissue ultrasound examination was performed. An ultrasound examination revealed symmetrical findings of bilateral calf muscles without evidence of muscle rupture. A roentgenogram of the left lower limb did not reveal any bony lesions. An ultrasound examination one week later also revealed negative sonographic findings. However, he still complained of persistent pain in his left calf area. A different ultrasound examination approach was then performed with the patient lying in the supine position with his knee flexed at 90 degrees. The transducer was then placed pointing upwards to examine the muscles and well-defined anechoic fluid collections with areas of hypoechoic surroundings were observed.


          For patients suffering from calf muscle area pain and suspicion of tennis leg, a soft tissue ultrasound is a simple tool to confirm the diagnosis. However, in the case of negative sonographic findings, we recommend trying a different positional approach to examine the calf muscles by ultrasound before the diagnosis of tennis leg can be ruled out.

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          Most cited references 7

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          Tennis leg: clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US.

          To evaluate the ultrasonographic (US) findings in patients with a referring diagnosis of tennis leg and to explore the relative importance of the plantaris tendon and gastrocnemius muscle in the pathogenesis of this condition. A cadaveric study was performed to outline the normal anatomy of the posterosuperficial compartment of the calf. Magnetic resonance (MR) imaging and US were performed, followed by gross anatomic correlation. US findings in 141 patients referred with a clinical diagnosis of tennis leg were retrospectively reviewed by means of consensus of two radiologists. Images were analyzed with respect to the integrity of the lower-leg musculotendinous units, presence of fluid collection, and deep venous thrombosis. MR imaging and US enabled distinction of the musculotendinous unit of the plantaris from the remaining muscles of the lower extremity in cadaveric specimens. US findings in the 141 patients included rupture of the medial head of the gastrocnemius muscle in 94 patients (66.7%), fluid collection between the aponeuroses of the medial gastrocnemius and soleus muscles without muscle rupture in 30 patients (21.3%), rupture of the plantaris tendon in two patients (1.4%), and partial rupture of the soleus muscle in one patient (0.7%). Deep venous thrombosis was seen in isolation in 14 patients (9.9%). In patients with clinical findings of tennis leg who undergo US, abnormalities of the medial gastrocnemius muscle appear to be more common than those of the plantaris tendon.
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            Sonographic findings in muscle strain injury: clinical and MR imaging correlation.

            Both sonography and magnetic resonance imaging were performed in 57 patients with clinically suspected strain injury in lower extremity muscles. Sonography demonstrated normal findings in nine patients (16%), hyperechoic infiltration in 31 patients (54%), mass in nine patients (16%), and compound lesions of infiltration and mass in eight patients (14%). Clinically grade 2 lesions ranged from small infiltration to large compound lesions on both sonography and magnetic resonance imaging. Hyperechoic infiltration was not demonstrated on T1-weighted magnetic resonance images and with less than 50% cross-sectional muscle involvement. The mass and compound lesions were ascertained to be moderate or severe injury because the masses of the lesions had obvious hemorrhage or hematoma on magnetic resonance images.
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              Sonographic evaluation of tears of the gastrocnemius medial head ("tennis leg")

              Rupture of the medial head of the gastrocnemius muscle, or tennis leg, is a common lesion affecting middle-aged persons. An imaging examination may be needed to rule out other diseases and assess the severity of the tear. We reviewed the sonographic images of 65 patients with clinically suspected tennis leg. Fifty-one partial and 14 complete tears were diagnosed. Twenty-five patients had follow-up examinations (15 days to 24 months; mean, 45 days). The torn muscle fibers, hematoma, and the reparative process were appreciated by ultrasonography. Ultrasonography may be a useful noninvasive, low-cost modality for diagnosis and follow-up of tennis leg.

                Author and article information

                J Med Case Reports
                Journal of Medical Case Reports
                BioMed Central
                25 June 2009
                : 3
                : 7291
                [1 ]Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan County 333, Taiwan
                [2 ]Pharmaceutical Sciences Research Division, King's College, Hodgkin Building, Guy's Campus, London SE1 1UL, UK
                [3 ]Department of Medicine, Chang Gung University, College of Medicine, Tao-Yuan County 333, Taiwan
                Copyright ©2009 licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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