What is the recommended treatment for a gastrocnemius (calf muscle) tear?

Treatment of Gastrocnemius Tear

Conservative management with RICE principles (rest, ice, compression, elevation) followed by progressive rehabilitation is the recommended treatment for the vast majority of gastrocnemius muscle tears, with surgical repair reserved only for complete tendinous avulsions in patients requiring forceful plantar flexion for their activities. 1, 2

Initial Management (First 48-72 Hours)

Apply the PRICE protocol immediately:

• Protection: Avoid weight-bearing activities that provoke pain 1
• Rest: Discontinue aggravating activities but avoid complete immobilization to prevent muscle atrophy 3
• Ice: Apply through a wet towel for 10-minute periods for short-term pain relief and to reduce swelling 3, 1
• Compression: Use compression bandaging to control edema 1
• Elevation: Elevate the affected limb to reduce swelling 1

Pharmacological Management

NSAIDs are the first-line medication for pain control:

• Oral NSAIDs effectively relieve tendon and muscle pain 3
• Topical NSAIDs can be used to eliminate gastrointestinal hemorrhage risk while maintaining analgesic benefit 3
• Analgesics (acetaminophen) can be added for additional pain control 3

Avoid corticosteroid injections into the muscle substance as their effects on muscle healing are unknown and may have deleterious effects on tendon tissue 3

Diagnostic Confirmation

Ultrasound is the preferred imaging modality:

• Provides real-time, dynamic confirmation of the tear location and severity 4
• Can identify the specific injury pattern (myotendinous junction injuries are most common, occurring in two-thirds of cases at the gastrocnemius-soleus fascial junction) 4
• MRI can be used if ultrasound is inconclusive or to rule out complications 1, 5

Progressive Rehabilitation (Weeks 2-6)

Follow a structured progression once acute pain subsides:

1. Stretching phase: Begin gentle gastrocnemius and soleus stretching exercises 1
2. Strengthening phase: Progress to resistance exercises for plantar flexion 1
3. Proprioception training: Incorporate balance and coordination exercises 1
4. Conditioning phase: Gradually return to sport-specific activities 1

Eccentric exercises are particularly beneficial for tendon healing as they stimulate collagen production and guide normal alignment of newly formed collagen fibers 3

Surgical Indications (Rare)

Surgery should be considered only for:

• Complete tendinous avulsions (not myotendinous tears) 2
• Patients requiring forceful plantar flexion for their occupation or desired activities 2
• Only after failed conservative management 2

Surgical technique when indicated:

• Two suture anchor repair of the tendinous avulsion 2
• Postoperative bracing with graduated therapy progression 2

Critical Complications to Monitor

Be vigilant for acute compartment syndrome:

• This is a rare but potentially devastating complication of gastrocnemius rupture 6
• Monitor for progressive pain, paresthesias, and tense compartments 6
• Requires emergent fasciotomy if present 6

Watch for sural nerve entrapment:

• Can develop from scar tissue formation after injury 5
• Presents with progressive calf pain, paresthesias in sural nerve distribution, and positive Tinel's sign 5
• May require surgical release if conservative management fails 5

Expected Outcomes

Most patients achieve full recovery with conservative management:

• Complete resolution of symptoms typically occurs within 6-9 weeks 1
• No residual impairment in gastrocnemius function at long-term follow-up when properly managed 1
• Serial ultrasound can monitor tissue healing and guide return-to-activity decisions 4

Key Clinical Pitfalls

• Do not confuse gastrocnemius tears with DVT: The muscular veins of the calf (soleus, gastrocnemius) have lower risk of thrombosis extension, but DVT must be excluded in the differential diagnosis 3
• Avoid premature return to activity: Tensile loading is beneficial but must be graduated to prevent re-injury 3
• Do not inject corticosteroids into the muscle substance: This may impair healing 3