What is the appropriate treatment for an adult athlete diagnosed with a medial gastrocnemius strain (Tennis leg)?

Treatment of Tennis Leg (Medial Gastrocnemius Strain)

Begin immediate conservative management with relative rest, ice application, and early mobilization followed by progressive eccentric strengthening exercises, as this approach successfully resolves 80% of cases within 2-6 weeks, with surgery reserved only for chronic cases failing 3-6 months of appropriate conservative therapy. 1, 2, 3

Acute Phase Management (First 2 Weeks)

Immediate Interventions

• Implement relative rest by reducing activities that reproduce pain (running, jumping, pushing off), but critically avoid complete immobilization which accelerates muscle atrophy and deconditioning 1, 4
• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief 1, 4
• Initiate compression bandaging of the calf to limit hematoma formation and provide support during ambulation 3

Pain Management

• Prescribe NSAIDs for short-term pain relief, recognizing they provide symptomatic relief but do not alter long-term outcomes 1, 4
• Consider topical NSAIDs as preferred when treating localized muscle injuries, as they provide similar pain relief with fewer systemic side effects 4, 5
• Paracetamol up to 4g/day can be used as first-line oral analgesic due to favorable safety profile 4, 5

Rehabilitation Protocol (Weeks 2-6)

Progressive Exercise Program

• Initiate eccentric strengthening exercises as soon as pain allows, as they reverse degenerative changes, reduce symptoms, and increase strength by stimulating collagen production and guiding normal alignment of newly formed collagen fibers 1, 4, 6
• Implement deep transverse friction massage to reduce pain and promote healing 1, 4
• Progress from passive stretching to active range of motion exercises, advancing to weight-bearing activities as tolerated 2, 3

Expected Timeline

• Significant pain relief occurs within approximately 2 weeks with appropriate conservative management 2, 3
• Full return to sport typically requires 2-6 weeks for straightforward cases, with more severe injuries (>50% gastrocnemius aponeurosis width involvement or free gastrocnemius aponeurosis injury) requiring 3-4 months 7, 2, 3

Prognostic Ultrasound Classification

The severity of injury directly correlates with recovery time based on ultrasound findings 7:

• Type 1 (myoaponeurotic junction injury): Shortest recovery
• Type 2A (<50% gastrocnemius aponeurosis width affected): Moderate recovery time
• Type 2B (>50% gastrocnemius aponeurosis width affected): Prolonged recovery, associated with intermuscular hematoma
• Type 3 (free gastrocnemius aponeurosis tendinous injury): Longest recovery period
• Type 4 (mixed injury): Worst prognosis, often with gastrocnemius-soleus asynchronous movement 7

Critical Pitfalls to Avoid

• Never completely immobilize the calf, as this causes rapid muscular atrophy and deconditioning that delays recovery 1, 4, 5
• Avoid corticosteroid injections into the muscle or tendon substance, as they inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1, 4
• Do not rush return to sport before adequate healing, as premature loading increases reinjury risk 2, 3

Surgical Management

• Surgery is indicated only for chronic cases (>12 months) that have failed 3-6 months of well-managed conservative treatment 1, 4, 8
• Surgical techniques include reverse flap reconstruction from the musculotendinous junction aponeurosis, potentially augmented with fascia lata allograft for chronic injuries 8

Occupational Considerations

Recognize that tennis leg is not exclusively a sports injury and should be considered as potentially work-related trauma in occupational settings, particularly in workers performing repetitive plantarflexion or sudden push-off movements 9