Medial Gastrocnemius Strain: Clinical Aspects and Algorithmic Approach

Medial gastrocnemius strain (MGS), is the most common cause of mid-calf pain in athletes due to the stretch of the gastrocnemius muscle when the knee is in extension and the ankle is in dorsiflexion. Chronological age and previous calf injury are the most substantial risk factors for MGS, including high body mass index, previous lower limb injuries, L5 radiculopathy, and inadequate warm-up. The dominant presentation of MGS is a pain that can be diverse from acute to latent, which is felt in the posteromedial aspect of the calf and is often preceded by a feeling of a pop. The signs of MGS include antalgic gait, ecchymosis, swelling, local tenderness, and sometimes a palpable gap felt along the muscle. Passive dorsiflexion of the ankle or resistive ankle plantarflexion with knee extension can indicate a more severe injury, while functional tests can illicit milder injuries of calf muscles-including gastrocnemius. The diagnosis of MGS is usually made by clinical evaluation. However, imaging modalities-including magnetic resonance imaging and ultrasound-can be helpful in case of suspicion. In most cases of MGS, the cornerstone of treatment is nonoperative rehabilitation, which can be performed as a 4-phase program and should be tailored individually. Some instances of MGS are referred for early or later surgical treatment if indicated. In this article, we review the literature about various aspects of MGS, from diagnosis to treatment and rehabilitation, and propose a structured approach to this injury.