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Return to Play in Gastrocnemius and Soleus Injuries. From Scientific to Practical Experience
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Dr. Miguel Angel Khoury
Buenos Aires - Argentina
5th MuscleTechNetwork From Scientific Evidence to Clinical Practice. 14-15 Oct. 2013
Return to Play in Gastrocnemius and Soleus Injuries. From Scientific to Practical Experience
Return to play : gastrocnemius and soleus injuries
From scientific to practical experience
At present: What do we know?
Optimal decision-making
When and why they go wrong?
“How Doctors Think”
How Doctors think?
1. Experts Studying misguided care have concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes.
2. The quality of our practice is highly influenced by the way we think.
How Doctors Think
DECISIONS ARE MADE ON THE BASIS OF:
-INTUITION: System I (Unconscious process of making decisions on the basis of experience and accumulated judgment)Automatic, fast, emotional. Limbic, Heuristics
-RATIONALITY: System II (Problem is clear, alternatives are known, evidence based practice )slow, logic progressive and mainly conscious process, cortical
Cognitive Traps: Heuristics
ü Availability
ü Anchoring
ü Attribution
ü Satisfaction Search
ü Confirmation Bias
ü Commission Bias
ü Affective error
ü 31% of all injuries
ü 27%of total injury absence
ü Hamstring 37%
ü Adductor 23%
ü Quadriceps 19%
ü Calf Muscles 13%
Epidemiology of Muscle Injuries in Professional Football (Soccer)
AJSM 2011 Jan Ekstrand, MD, PhD*† Martin Hägglund, PT, PhD† arkus Waldén, MD, PhD†
Gastrocnemius vs. soleus strain injury
MTJ grastrocnemius
SIMULTANEOUS GASTROC-SOLEUS TEARS
• Koulouris G. et.al. similar incidence in gastrocnemius and medial soleus injuries. Skeletal Radiol.2007
• Balius R. et.al. reported six cases of dual lesions. Skeletal Radiol.2012
• Most likely dual lesions are under-reported
US longitudinal view Normal Gastroc-Soleus muscle unit
GASTROCNEMIUS APONEUROSIS SOLEUS-GASTROC.
SOLEUS
DISTAL PROXIMAL
They Look Like Twins!!
The Gastrocnemius-Soleus Unit (Non-Identical Twins)
Gastrocnemius Muscle Soleus Muscle
Predominant Type I fibers
One Joint muscle
Aerobic
Resistant
Type II Fibers
Tow Joints Muscle
Anaerobic
Fatigue
Different personality (Non-Identical Twins)
• The Soleus muscle accounts for 70% of the total area of the triceps surae (Fukunaga T. et al, JOR, 1992)
The Gastrocnemius-Soleus Unit
ü Myotendon-junction:Proximal medial strains: 25.5%, Proximal Lateral strains 12.7% and central tendon strains 12.7%
ü Myofascial sites: anterior 21.8%, posterior 21.8%
The soleus muscle: MRI, anatomic and histologic findings in cadavers with clinical correlation of strain injury distribution
Balius R., Alomar X, Rodas G. et. al. Skeletal Radiol. 2012,
Soleus muscle contraction
ü Primary plantar flexor of the foot
ü Invertor of the foot
ü Acts as an agonist for the ACL (Elias J.J., AJSM, 2003)
Gastrocnemius - Soleus Unit
ü With knees flexed 90 degrees the gastrocnemius are virtually inactive.
ü The load is borne almost entirely by the soleus.
The Gastrocnemius-Soleus Muscle Unit
Dorsiflexion of the foot during take off phase or jumping
• Silverskiöld test: pain with dorsiflexion of the foot with knee flexion
Effect of Increased Excursion of the Ankle on the Severity of Acute Eccentric Contraction-Induced Strain Injury in the Gastrocnemius An In Vivo Rat Study
Hongsun Song, MS Koichi Nakazato, PhD*, and Hiroyuki Nakajima, MD AJSM, 2007.
Soleus strain injury Clinical Manifestation
M. Khoury, E. Santa Coloma, A. Rolon From Cleveland Sports Medicine, Buenos Aires, Argentina 10.1177/0363546511415619 Am J Sports Med August 2011 vol. 39 no. 8 1800-1802
Soleus Muscle Strain Injuries: Clinical and Magnetic Resonance Imaging Study 1. Early vs. Delayed diagnosis 2. Myofascial vs. MTJ injuries 3. Acute vs. Chronic injuries
T1 STIR
Soleus Anatomy Mio-tendon junctions MRI
Soccer Player Degree II
strain aedema Perifascial fluid
Acute soleus muscle strain injuries
Post gadolinium
Soleus muscle strain injury
37 years old – tennis player - Rerupture
fibrosis
Chronic soleus muscle strain injury
28 years old – Tennis player
Chronic soleus muscle strain injury
calcification
Ca++
Chronic exertional compartmental syndrome
Post-exercise
Soleus muscl
e
Soleus muscl
e
Return to Competitive Play After Hamstring Injuries Involving Disruption of the Central Tendon
ü Longer rehabilitation when the central tendon was disrupted, enclosed within the muscle belly
ü Lower time in: only muscle fiber, epimisial or muscle tendon junction strains
ü 21 vs. 72 days (p<0.001)
Jules Comin, MBBS*,†, Peter Malliaras, PhD†, Peter Baquie, MBBS‡, Tim Barbour, MBBS‡ and David Connell, MBBS†§ AJSM 2013
L R
L
R
Central Tendon
Acute soleus muscle strain injuries
Soleus Muscle Injuries: Special Considerations
ü Untrained or returning to play injury
ü Delayed diagnosis and reruptures are common
ü Increased rehabilitation time
ü Chronic injuries: should be considered in evaluating leg pain
Medial Gastrocnemius
Muscle-tendon junction
Medial Gastrocnemius
Relationship between sports trauma and muscular injury
Grade II – Medial Gastrocnemius
Dynamic US
Gastrocnemius strain injury
Chronic Tear Organized Haematoma
Haematoma Aspiration
PRP Aplication
PRP after injection
Medicine: Imperfect Science
Are you Ready to Play? Stop and Think Again!
HEALING RESPONSE EVALUATION
Healing response
COMPARATIVE VIEW REINJURY
NORMAL GASTROCNEMIUS
GASTROCNEMIUS INJURY
The Balance: Intuition vs. Rationality
The Grastrocnemius – Soleus Unit
When and why they go wrong?
Gastrocnemius muscle
Bleeding or fluid
collecction
Delayed cicatrization
Rerupture
Soleus muscle
Underdiagnosis or
Underestimation
Rerupture, chronic pain
How to Get Better
¤ Multiple Inteligences. The theory in practice: Howard Gardner. Seven types of inteligence
¤ “Improve our medical
Inteligence”
¤ Thinking better: What make us powerfull is the way we think!
Thank You!!!!
drmiguelkhoury@gmail.com
Comparative View Acute Tear
NORMAL GASTROCNEMIUS
GASTROCNEMIUS TEAR
Gastrocnemius special concerns
ü Fluid colection or organized haemathoma
ü Moist heat and massage should be avoided the first week
ü Compression
Soleus Anatomy
Axial View Lateral View Coronal View
Soleus Anatomy Mio-tendon junctions
Fat Sat T1 W
30 years old – Tennis Player
Medial Tendon
Acute soleus muscle strain injuries
28 yearlL old – Runner
Lateral Tendon
Acute soleus muscle strain injuries
Flexor hallucis longus strain injury
Soleus
FHL
GL
TP
HL
Soleus
GL
Longitudinal View
GASTROCNEMIUS
FLUID COLECTION
PRP Treatment
Grade II – Medial Gastrocnemius
Summary
ü Non-Identical Twins
ü Soleus Muscle Strains: Early diagnosis, Tendon rupture
ü Gastrocnemius Muscle Strains: Haematoma, Fluid Colection
ü Aspiration and PRP Treatment
Judgment Rationality: Is rarely a calculating weighing of all options, but rather a form of pattern recognition
Objective:
¤ How to improve our thinking about gastrocnemius and soleus strains
We all develop conclusions from a very incomplete body of information
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