CHAPTER 9

Leg

EPIDEMIOLOGY OF LEG PAIN

LEG PAIN IN THE GENERAL POPULATION (1)

Leg discomfort

•  Common complaints in elderly population (up to two-thirds in some studies)

•  Varying characterization by patients: cramps, heaviness, shooting pains etc.

Associated conditions

•  Often related to knee pain, radiating neuropathic pain (sciatic pain), and referred pain from other locations

LEG PAIN IN ATHLETES

Prevalence

•  Common, up to 80% of athletes experience chronic leg pain at some point (2)

•  Lower leg overuse injuries comprise 10% of all overuse injuries in athletes; higher in older athletes and with weight-bearing sports

Common causes

•  Chronic exertional compartment syndrome (CECS; most common cause of exercise-induced anterior leg pain)

•  Medial tibial stress syndrome (MTSS; shin splint)—5% of all athletic injuries, and stress fracture of tibia and fibula (less than half of all musculoskeletal injuries)

DIFFERENTIAL DIAGNOSIS

FLOWCHART 9.1

Differential diagnosis of leg pain.

LS, lumbosacral; MSK, musculoskeletal; MTSS, medial tibial stress syndrome.

DIFFERENTIAL DIAGNOSES BASED ON LOCATION OF PAIN (FLOWCHART 9.1)

DVT, deep vein thrombosis; N, nerve.

FLOWCHART 9.2

Underlying causes of calf cramps.

DIFFERENTIAL DIAGNOSIS OF CALF PAIN AND CRAMPS (FLOWCHART 9.2)

•  Calf cramps (3)

      Definition of cramps: sudden involuntary, painful contractions of skeletal muscles

      Occurs in 30% to 95% of the general population

•  Muscle strain, ischemic or neuropathic claudication, restless leg syndrome, Parkinson’s disease, multiple sclerosis, dystonias, and nocturnal myoclonus (4)

•  Paraphysiologic (occasional cramps that occur in otherwise healthy patients); seen during sports activity or during pregnancy

      Cramps during exercise (recurrent)

  Common causes: serum deficit of magnesium and on medications

  Other causes of cramps: diabetes mellitus, hypothyroidism, vascular disorders, metabolic myopathy, radiculoneuropathy

•  Metabolic: uremia (dialysis), hypothyroidism, hypovolemic hyponatremia (excess perspiration or “heat cramps,” diarrhea, vomiting, diuretic therapy), hypomagnesemia, hypocalcemia, hypoadrenalism, cirrhosis

•  Neurologic

      Peripheral nervous system: motor neuron disease, acute poliomyelitis, radiculopathy, peripheral neuropathies and syndromes associated with antibodies to voltage-gated K⁺ channels (eg, neuromyotonia) (5)

•  Muscle disease: inflammatory myopathies, metabolic, mitochondrial, endocrine myopathy, dystrophinopathies, and myotonia

•  Medications/toxins/supplements: inhaled long-acting β2 agonist, K⁺ sparing and thiazide diuretics, cimetidine, statin medications, lithium, alcohol, Ca²⁺ channel blockers, creatine, and oral contraceptives

DIFFERENTIAL DIAGNOSIS OF LEG SWELLING (6)

Unilateral

•  Acute (<72 hours): deep vein thrombosis (DVT; MC), ruptured Baker’s cyst, compartment syndrome, ruptured medial head of gastrocnemius

•  Chronic: venous insufficiency (MC), secondary lymphedema (tumor, radiation, surgery, infection), pelvic tumor/mass, or reflex sympathetic dystrophy

Bilateral

•  Acute: acute worsening of systemic cause (heart failure or renal disease)

•  Chronic: venous insufficiency, pulmonary hypertension, heart failure, idiopathic edema, lymphedema, drugs, premenstrual edema, pregnancy, lipedema, renal disease, and liver disease

DIFFERENTIAL DIAGNOSIS OF ATROPHY AND PSEUDOHYPERTROPHY

Ipsilateral calf atrophy (7)

•  S1 radiculopathy, tethered cord or meningomyelocele, chronic sciatic neuropathy/tibial neuropathy, motor neuron disease (amyotrophic lateral sclerosis [ALS], progressive muscular atrophy, Kennedy disease), peripheral neuropathy (multifocal motor neuropathy, diabetic amyotrophy), myopathy (Miyoshi, inclusion body myositis), benign focal amyotrophy, and so on.

Peroneal pseudohypertrophy

•  Hereditary sensory motor neuropathy (Charcot Marie Tooth), spinal muscular atrophy, muscular dystrophy (Duchenne or Becker type), and myopathies

DIFFERENTIAL DIAGNOSIS OF COMMON TIBIAL DEFORMITY

Tibial torsion

•  Medial or lateral tibial torsion (rotation)

•  Medial (intoeing): femoral anteversion, metatarsus adductus, or foot deformity

•  Lateral tibial rotation: normal developmental finding during childhood

Bowing leg

•  Anterolateral bowing: frequently associated with dysplasia of the tibia leading to pathologic fractures and pseudoarthrosis, although a benign form also exists

      Neurofibromatosis type 1 present in ~50% of patients with anterolateral bowing

•  Posteromedial bowing: usually benign

•  Anteromedial bowing: associated with fibular hemimelia (congenital fibular aplasia or hypoplasia)

OTHER HISTORY TO ASK

•  Onset: acute (vascular, trauma > inflammatory) versus gradual (musculoskeletal, nerve entrapment)

•  Associated precipitating or aggravating activities

•  Details of training regimen: any recent change in type/intensity of training, distance of running, or sports activity (lower extremity weight bearing activity, or jumping sports)

      Abrupt increase in activity can lead to overuse or stress injury

•  Duration of pain/timing of pain and relief after the cessation of the activity

      Time until pain resolution is faster in vascular etiologies compared to neuropathic and musculoskeletal etiologies, in which pain is often persistent or presents after the inciting activity

•  Female athletic triads: inadequate nutritional status, amenorrhea or oligomenorrhea, osteoporosis, and excessively thin/lean (8)

•  Claudication

ANATOMY

CROSS-SECTIONAL ANATOMY

Bony and cross-sectional anatomy of the leg (9) (see Figure 1.5B)

BONES

Tibia

•  Main weight-bearing structure, stress reaction to the loading

•  The tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft (narrowest at junction of middle and distal third), and tibial plafond distally

•  Superficial location of the bone (subcutaneous in the anterior–medial aspect): predispose to open fracture

Fibular

•  Not directly involved in transmission of weight

Superior and inferior tibiofibular joint

•  (See Chapters 8 and 10; knee and ankle) with interosseous membrane to bind tibia and fibula

MUSCLES

PHYSICAL EXAMINATION

INSPECTION

Atrophy, edema, deformity, erythema/ecchymosis, wound, hyperpigmentation, and the like

•  Deformity: usually developmental but also occurs secondary to posttraumatic sequelae

      Medial tibial torsion: check femoral anteversion, and foot/ankle inspection

•  Edema

      Hyperpigmentation in the medial ankle (hemosiderin deposition) and pitting edema: venous insufficiency

      Kaposi–Stemmer sign: inability to pinch a fold of skin on the dorsum of the second toe; lymphedema

•  Ecchymosis, focal swelling (hematoma), or mild depression/palpable deficits in muscles occurs with massive muscle tear (MC)

PALPATION

Tibial crest and muscles (anterior, lateral, and posterior)

Evaluate for masses (eg, lipoma, muscle herniation, or bony protuberance or mass)

Palpate arterial pulses with knee in extension and flexion (arterial entrapment syndrome)

•  Absence of both dorsal pedal and posterior tibial pulses strongly suggests peripheral arterial disease (PAD), whereas presence of either pulse suggests PAD is less likely

NEUROLOGICAL EXAMINATION

Motor examination

•  Check ankle dorsiflexion, plantar flexion, eversion, inversion, and knee flexion (gastrocnemius)

Sensory examination

•  Evaluate both dermatomal and peripheral nerve distributions

•  Peripheral nerve distributions

      Proximal lateral calf: lateral sural cutaneous nerve, branches from common peroneal nerve

      Proximal medial leg: saphenous nerve

      Distal anterior: superficial peroneal nerve

      Distal posterior: sural nerve

Palpate over areas of scarring or percuss over common entrapment site to check reproduction of paresthesia or pain in the distribution of peripheral nerves (Tinel sign or Valleix’s phenomenon)

Evaluate sensory symptoms in relation to the inciting activity

EVALUATION OF FOOT FOR PES PLANUS (OVERPRONATION) AND PES CAVUS (WITH SUPINATION)

Overpronation

•  Evaluate hindfoot valgus, tibial internal rotation, tight Achilles tendon (gastrocnemius), and genu valgum

•  Frequently encountered in Achilles tendinopathy, MTSS, tibialis posterior tendon dysfunction

Oversupination

•  Evaluate hindfoot varus, tibial external rotation, and genu varum

•  Frequently encountered in overloading of lateral compartment (peroneus longus and brevis) or proximal tibiofibular joint dysfunction and creates risk of stress related bony injury

DIAGNOSTIC STUDIES

PLAIN RADIOGRAPHS

•  Generally the first diagnostic imaging modality used for lower leg pain (11) (Flowchart 9.3)

•  Specific for fractures if fracture line or displaced fracture is present

Limitations

•  Insensitive for early-stress–related bony injuries: may need to repeat in 2 weeks or MRI if suspicious

Bone scan

•  Sensitive for early bony injury but is not specific

MRI

•  Imaging modality of choice for leg pain

•  Fat-suppressed fluid-sensitive sequences (T2-weighted, proton density): best for detecting edema

•  T1-weighted images: used for better depiction of anatomy, muscle atrophy, fatty infiltration

•  Marrow edema: intermediate or low signal intensity in T1-weighted and high signal intensity on fat-suppressed fluid-sensitive sequences

•  Muscle edema (eg, in compartment syndrome): high signal intensity on T2-weighted sequences

FLOWCHART 9.3

Diagnostic workup for leg pain in an outpatient clinic.

CRP, C-reactive protein; Dx, diagnosis; EMG, electromyography; ESR, erythrocyte sedimentation rate; Tx, treatment; US, ultrasound.

Source: Adapted from Ref. (12). Edwards PH, Jr, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med. 2005;33(8):1241–1249.

POINT-OF-CARE ULTRASONOGRAPHY (US)

Indications

•  Diagnostic evaluation of acute tendon or muscle injury or tear, tendinosis; anatomical evaluation of nerve trunk

•  Needle guidance for injections

Advantages

•  Allows for dynamic maneuvers/evaluation, such as evaluation of muscle/tendon impingement (rotator cuff), tendon instability, or muscle herniation (occurs upto 40% in CECS)

Limitations

•  Operator dependant, inadequate penetration/resolution of deep structures

•  Intracortical (marrow) lesion: tumor, cyst, osteochondritis dissecans, avascular necrosis

CT SCAN

•  Useful in differentiating stress reactions from stress fracture versus other bony abnormalities

•  Able to detect osseus cortical findings as osteopenia, resorption cavities, and striations

•  Limitations: insensitive in the early stages of bony stress injury (normal). Unable to detect cancellous bone marrow edema or bone bruise

VASCULAR STUDY AND OTHER TESTS

Venous studies: venous duplex to rule out DVT

Arterial studies: ankle brachial index (ABI), duplex US, and angiography (CT or MR angiography) used to evaluate PAD

•  ABI: systolic blood pressure (SBP) in ankle divided by SBP in arm, correlates well with findings on angiography. ABI values ≤0.9; PAD >1.4; noncompressible/calcified vessels

Compartment pressure study: gold standard for CECS

TREATMENT

NONOPERATIVE MANAGEMENT

General guidelines

•  Initial relative rest (from prolonged lower extremities weight bearing or any symptom provocation activities and/or decreasing activity duration depending on the condition) with use of modalities (eg, therapeutic US) as needed, and gradual return to exercise as symptoms improve

    º  Maintain upper extremity endurance exercise during period of recovery

      Water based exercise often useful for maintaining limited weight bearing

      Cross-training can be considered after initial rest period

•  Clarify weight-bearing status (on specific condition, based on follow-up imaging)

•  Identify biomechanical culprit in overuse injury

      Intervene faulty biomechanics, for example, pes planus (hindfoot eversion), hyperpronation, tight Achilles cord (gastrocnemius), pes cavus (hindfoot inversion) with appropriate foot orthotics: heel lift, medial or lateral heel wedge

      Footwear education: for example, roomier (wider and longer) shoe with higher toe box

  Clarify utility and proper fit of anti-supinator and anti-pronator shoe options; patient often confused.

  For example, anti-pronator (medial hindfoot reinforcement) shoes will aggravate pain from peroneal tendinopathy due to resultant varus positioning of hindfoot

Therapeutic exercises

•  Stretching of gastrocnemius (Achilles stretching with neutral subtalar placement), hamstring (knee extension and flexion), flexor hallucis longus (FHL), and flexor digitorum longus (FDL; stretch with toe dorsiflexion)

•  Evaluation of proximal (knee and hip) and distal segment (foot and ankle) deformity: assessment of biomechanics and address it

•  Aerobic endurance exercise (upper body ergometer) to avoid deconditioning

Oral medication

•  First line: acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or short duration of muscle relaxant

•  Second line: weak opioid medications

Orthotic

•  Check foot and ankle orthoses part

Injection

•  Trigger point injection with lidocaine ± steroid injection used for myofascial pain syndrome and fascial tear

•  Cutaneous nerve block (sural, saphenous nerve, and superficial peroneal nerve) used most often for focal entrapment neuropathy or neuroma

      Can be used as an adjunct treatment for complex regional pain syndrome (superficial peroneal nerve and posterior tibial nerve blocks) or diffuse pain syndrome

•  Botox for exertional compartment syndrome (13)

MUSCULOSKELETAL PATHOLOGY

MEDIAL TIBIAL STRESS SYNDROME

Introduction (10)

•  Commonly used definition: pain and tenderness along the posteromedial border of the tibia resulting from exercise (14)

      Traction induced periostitis of tibia secondary to dysfunction of the tibialis posterior, FDL, and medial soleus

      Excess tibial stress results in remodeling of the tibial cortex with resultant osteopenia

•  Common in physically active population; 4% to 35% depending on the studies

Etiology and risk factors (15)

•  Increased hindfoot (calcaneal) eversion and pes planus (tibialis posterior dysfunction results in a biomechanical disadvantage)

•  Weakness or inflexibility/tightness of the calf muscle (gastrocnemius) results in impaired biomechanics and diminished shock absorption capability

History and physical examination

•  Intermittent or continuous pain on the medial side of the lower leg

      Described as dull or intense and is exacerbated by repetitive weight-bearing activity

•  Tenderness over the distal two-thirds of the posterior medial tibial crest

•  Reproduction of tibial pain/symptoms on provocative maneuvers (not specific)

      Passive ankle dorsiflexion and active ankle plantar flexion against resistance

      Bilateral or unilateral standing toe raises and jumping

Diagnosis

•  Clinically diagnosed with imaging study to rule out other etiologies

•  Imaging studies

      X-ray to rule out stress fracture (may have to repeat in 1–2 weeks)

      Bone scan: may be positive in MTSS and stress fractures

      MRI: equivocal in MTSS. Positive in stress fracture and chronic compartment syndrome

•  Compartmental pressure testing for evaluation for chronic compartment syndrome

Treatment (14)

•  Ice, NSAIDs, activity modification, tibialis posterior strengthening, closed kinetic chain functional exercise, and graded running program of interval training with increasing duration and intensity

•  Custom made foot insole can be considered in pes planus (16,17)

•  Extracorporeal shockwave therapy has been shown to result in a faster return to running (18)

CHRONIC EXERTIONAL COMPARTMENT SYNDROME (CECS)

Introduction (19)

•  Reversible ischemia occurring secondary to a noncompliant osseofascial compartment that is unaccommodating to the expansion of muscle volume that occurs with exercise

•  Location: most commonly in anterior compartment (45%), followed by deep posterior (40%), lateral (10%), and superficial posterior (5%)

      Occurs bilaterally in 75% to 90% of cases

•  Female > male and mean age of presentation: 20 years old

•  Etiology and risk factors (20)

      Aberrant biomechanics (rear foot landing or overpronation)

      Anabolic steroid and creatine use

      Training errors with excessive eccentric exercise

History and physical examination

•  Recurrent exercise-induced leg discomfort occurring at a well defined and reproducible point in the run or training time (gradual onset of discomfort)

      Characterized as tight, cramp-like, or squeezing pain

      Relief of pain with discontinuation of inciting activity

•  Often accompanied by nerve irritation (superficial peroneal nerve in the anterolateral compartment, tibial nerve in the deep posterior compartment)

•  Physical examination: muscle firmness and tenderness to palpation and pain with passive stretching of the muscle

•  Foot overpronation or possible weakness of involved muscle (not striking)

•  Muscle herniation (through facial defects) may be noted on examination in 40% to 60% of cases (commonly in anterior compartment)

Diagnosis

•  Clinical suspicion confirmed by intracompartmental pressure measurement criteria as noted in the following. Application of these criteria with a history suggestive of CECS: <5% false-positive rate in the diagnosis of CECS (21)

      Pressure value interpretation by Stryker intracompartmental pressure monitor:

  0 to 8 mmHg: normal; 30 to 50 mmHg: equivocal; >50 mmHg: surgical emergency

      Three criteria by Pedowitz et al. (22)

  Pre-exercise resting intracompartmental pressure: ≥15 mmHg

  1-minute postexercise pressure: ≥30 mmHg

  5-minute postexercise pressure: ≥20 mmHg

      Intracompartmental pressure increase >10 mmHg from baseline pressure with exercise

•  Differential diagnosis

      Stress fracture: commonly coexist (up to 30%)

      MTSS, periosteitis or tenosynovitis/tendonitis

      Nerve entrapment, lumbosacral (LS) radiculopathy, or neurogenic claudication

      DVT, vascular claudication, or popliteal artery entrapment

      Infection, myopathy, or tumor

Treatment

•  Conservative treatments

      Limit activities to the level of minimal symptom, NSAIDs, soft tissue release, stretching and strengthening, and foot orthotic (for overpronation)

      Forefoot running (23), gradual increase (no greater than 10%/wk) in duration and intensity

      Heel lift and medial wedge if significant Achilles tightness present or pes planus

      Botox injection (13); good pain relief and mild weakness without functional decline

•  Surgical fasciotomy: indicated for persistent symptoms despite 6 to 12 weeks of conservative treatment

      Endoscopic release site should be distal from location where superficial peroneal perforates the fascia (7–10 cm above ankle)

      Success rate greater than 80% for anterior/lateral and 50% for posterior compartment fasciotomies

      Complications occur in about 10% of surgeries

  Females are generally less responsive to fasciotomy compared to males

      Postoperatively, return to activity as soon as possible is recommended with no limitation of activity

STRESS FRACTURE (OF TIBIA)

Introduction (24)

•  Most common location of stress fracture is the tibia (50% of stress fracture in athletes). Posteromedial tibia is the most common location within tibia

      Anteromedial tibial stress fractures result from tension type stress and have a high risk for nonunion. Posteromedial tibial stress fractures present like shin splints

      High risk of delayed healing and nonunion

•  Risk factors: young and healthy adults who participate in activities that involve significant amounts of walking, running, or jumping such as seen in certain sports (most commonly in running, though also seen in dancers and basketball and soccer players) and military recruits, impaired bone mineralization

History and physical examination

•  Little discomfort even in the setting of nonunion

•  Gradually progressive (weeks to months) anterior leg pain or vague discomfort that occurs with activities

•  Localized tenderness, swelling, and palpable callus

      Percussion of the bone away from the site of the fracture may produce the pain

Diagnosis

•  Clinical suspicion (suggestive history and examination) confirmed by imaging study

•  X-ray: negative for first 2 to 3 weeks. Findings suggestive of stress fractures include evidence of a periosteal reaction, cortical thickening, sclerosis, or a true fracture line

      “Dreaded black line” refers to a transverse fracture line in the anterior tibial shaft

•  MRI: grading of tibial stress injuries (25)

      Grade 1: periosteal edema on fat-suppressed T2 images (shin splints)

      Grade 2: grade 1 + marrow edema on fat-suppressed T2 images

      Grade 3: grade 2 + marrow edema on T1 images

      Grade 4: grade 3 + clearly visible fracture line

•  Differential diagnosis

      MTSS: relief of symptoms with rest or daily ambulation, pain is nonfocal, shorter time course to symptom onset, rarely cause proximal tibial pain

      Stress reaction, muscle strain, and neoplasm

      CECS

Treatment

•  6 to 8 weeks of non–weight bearing

      Radiologic union at 3 months and return to play at 4 months (pain and tenderness has to be resolved)

    º  Typical return-to-running program for a non-elite athlete after the initial period of rest with uncomplicated stress fracture (24)

  a: Runs on softer surfaces during the initial return-to-running phase

  b: Nonimpact activity on off days, which can be the same form of cross-training that the athlete was performing before resuming running

  c: Gradual increase in distance and intensity depending on the runner’s goals over 4 to 6 weeks.

           –  1st week: a for 5 minutes b 10 minutes b 15 minutes b × 2 days

           –  2nd week: a for 15 minutes b 20 minutes b 25 minutes b × 2 days

           –  3rd week: for 25 minutes 30 minutes b 30 minutes 35 minutes 40 minutes b

           –  4th week: 45 minutes c

•  Anterior tibial fracture may need surgical referral for intramedullary nailing given risk for nonunion

•  For improvement of bone mineralization: vitamin D supplementation, improved nutritional intake, and smoking cessation

MEDIAL GASTROCNEMIUS TEAR

Introduction (26,27)

•  Medial gastrocnemius tears are a common location of muscle tears in the leg

•  “Tennis leg”: leg pain caused by tear of the medial gastrocnemius (MC), followed by, in order of decreasing incidence, soleus tear, both gastrocnemius and soleus tears, tears of both heads of gastrocnemius and lastly, plantaris tear

      Isolated tear of the lateral head of the gastrocnemius occurs in ~15% of cases involving gastrocnemius tears.

•  Peak incidence in middle age men

Etiology and mechanism of injury

•  Ankle dorsiflexion while the knee is extended, short/abrupt sprints, climbing stairs, sudden forceful eccentric contraction of the muscle (eg, lunging forward by pushing off of leg while in a crouched position as seen commonly in tennis)

History and physical examination

•  Sudden intense calf pain, as if the calf has been kicked or struck by a ball or racket followed by swelling, cramping, and discolorization or ecchymosis within 24 hours

•  Visible depression of the musculature in distal leg and proximal migration of muscle bulk

Diagnosis

•  Clinical diagnosis confirmed by imaging study

•  US

      Common findings

  Disruption of the normal fiber alignment at the musculotendinous junction

  Hematoma and fluid collection between the gastrocnemius and soleus muscles

      Longitudinal views are obtained to evaluate the size and extent of muscle retraction and transverse scans are used to evaluate the degree of tear (partial vs complete tear)

•  MRI: helps to further characterize the lesion, distinguish hemorrhage versus hematoma at musculotendinous junction, and evaluate for any concurrent bony pathology (ie, stress fracture and intracortical structure abnormalities)

•  Differential diagnosis: ruptured Baker’s cyst, hematoma without muscle tear, DVT, plantaris, or Achilles tendon tear and intracortical lesion of the bone

Treatment

•  First employ the RICE method

      Rest until able to walk without a limp

      Ice, Compression, and Elevation until swelling subsides

•  Initially, also beneficial to use gentle stretch, massage, and cryotherapy

•  Pain medications (acetaminophen, NSAIDs) can be used as needed

•  One- to two-centimeter heel lift (to decrease calf stretch) initially and/or Unna boot for 2 weeks can help with pain.

      Three-dimensional (3D) walking boot and crutches can be used in severe strains.

•  Progress to eccentric strengthening, heel raises/dropping exercise, proprioception exercises and closed kinetic chain exercises with core and general conditioning

•  Running, jumping, and cutting activity can be initiated in 6 to 12 weeks

•  Prognosis: benign prognosis with no significant difference in strength compared to the contralateral leg after about 2 years

PLANTARIS TENDON AND SOLEUS MUSCLE TEAR

Introduction (27)

•  Rare; even existence of plantaris tendon tear has been disputed in the past

•  Plantaris tears occur at the musculotendinous junction (mid-calf level), similar to the gastrocnemius

•  Soleus tears occur when the ankle is passively dorsiflexed while the knee is flexed (eg, position of foot landing while uphill running). Tears can occur throughout the extent of the muscle

History and physical examination

•  Patients complain of painful weight bearing

•  Inspection shows swelling (less than what is seen with other muscle tears) ± ecchymosis

•  Pain can be elicited with active dorsiflexion of affected ankle and point tenderness is noted on palpation

•  Often difficult to distinguish from gastrocnemius or proximal Achilles tendon injury

Diagnosis

•  Clinical suspicion based on history and exam confirmed by imaging study

•  US and MRI evidence of fluid between the gastrocnemius and soleus

Treatment

•  Similar to the gastrocnemius tendon tear

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