Working Diagnosis:
Medial gastrocnemius muscle belly rupture with hematoma formation

Treatment:
The patient was seen for a follow up appointment after one month via telemedicine and reported overall improvement in her pain and denied any functional limitations. She was ambulating without difficulty and the swelling and bruising had significantly resolved in her left lower extremity. Her physical therapy regimen has focused on lower extremity strengthening and proprioception training with approximately 75% of pre-injury function returned.

Outcome:
She has since initiated a gradual return to activity protocol where she is only ambulating on level ground and performing isometric exercise with gradual and graded transition to concentric and eventually eccentric exercise.

Author's Comments:
In this case it was important to rule out a DVT, but avoid empirically anticoagulating due to the risk of compartment syndrome with an expanding hematoma.
The patient suffered a reflex response to a sensation of forward pitch resulting in contraction of the muscles of her posterior chain. Eccentric contraction is the most common etiology of a muscle rupture. The medial gastrocnemius is at greater risk of injury due to a more oblique orientation of fibers versus the lateral gastrocnemius, increased EMG activity when foot is externally rotated, longer muscle belly length versus lateral gastrocnemius, and the bi-articular nature of muscle versus the majority of other muscles.

Editor's Comments:
Calf muscles are indeed high risk for tears because of their location between two joints (knee and ankle). Typically, those with short or tight calf muscles, play sports requiring sudden or repetitive jumping and those generally over 40, with likely weakened calf muscles due to either aging or inflexibility. Some complications from an acute calf muscle tear include compartment syndrome, DVT and superficial thrombophlebitis. When evaluating for calf muscle pathology via point of care ultrasound, it is important to appreciate sonographic anatomy in different positions, particularly in the case of negative sonographic findings. A 2009 case report revealed sonographic pathological features from a calf injury in certain supinated, knee flexed position versus traditional prone position.

References:
Chen CP, Tang SF, Hsu CC, Chen RL, Hsu RCh, Wu CW, Chen MJ. A novel approach to sonographic examination in a patient with a calf muscle tear: a case report. J Med Case Rep. 2009 Jun 25;3:7291. doi: 10.4076/1752-1947-3-7291. PMID: 19830167; PMCID: PMC2726513.

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