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Rehabilitation of Plantaris Tendon Rupture in an Elite Triathlete: a Case Report

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Rehabilitation of Plantaris Tendon Rupture in an Elite Triathlete: a Case Report Dar et al., J Athl Enhancement 2013, 2:2 http://dx.doi.org/10.4172/2324-9080.1000108 Journal of Athletic Enhancement Case Report a SciTechnol journal during stair climbing and level walking suggests that the plantaris Rehabilitation of Plantaris muscle assists the function of the knee in loading situations [3]. Tendon Rupture in an Elite Palpation of the plantaris muscle belly is possible in the popliteal fossa as well as along the medial aspect of the common tendon of the Triathlete: A Case Report triceps surae group [4]. Dar G1,2*, Dolev E2,3, Kots E4 and Cale’-Benzoor M1,2 Calf muscle injuries are common among athletes, with rupture of the medial head of gastrocnemius being the most diagnosed entity [5]. In contrast, isolated rupture of the plantaris muscle is a rare condition Abstract with limited documentation in the literature [6-8]. Most plantaris Calf muscle injuries are common among athletes. While rupture of injuries occur in association with tears of the gastrocnemius, soleus the medial head of the gastrocnemius muscle is the most diagnosed or anterior cruciate ligament [4,7]. Clinical symptoms of plantaris entity, isolated rupture of the plantaris muscle is a rare condition with limited documentation in the literature. The plantaris assists ankle rupture are considered to be less severe than those of injuries involving plantar flexion, and is an important contributor to proprioceptive other calf muscles [2]. Signs and symptoms include local swelling, in mechanisms vital for normal athletic function of the ankle and proportion to the severity of soft tissue damage. Swelling in case of knee. This case study reports of an elite triathlete who complained plantaris involvement will usually appear at the upper posteromedial of proximal right calf pain without any specific trauma. The pain calf, whereas swelling due to gastrosoleus injury would be located in appeared during running and following practice and prevented him the medial mid- calf, closer to the musculotendinous junction [2]. from carrying out his scheduled training. Diagnostic ultrasound examination revealed a fluid collection between the gastrocnemius Pain will limit full dorsi flexion. Isolated, resisted plantar flexion or and the soleus indicating a partial rupture of the plantaris tendon. slight knee flexion in standing will be painful, while calf rising may A rehabilitation program was designed to address specific aspects still be possible. This observation may aid in the differential diagnosis relevant to plantaris muscle roles as outlined above. The patient of gastrosoleus tear, which is usually characterized by inability to was able to resume full athletic activity following this six week execute a fully controlled calf raise. program. The following case report describes the successful rehabilitation This case report shows that isolated rupture of the plantaris muscle may occur and should be considered as a possible etiology of a male triathlete with an isolated rupture of the plantaris muscle. in patients with calf muscle complains. Moreover, the specific Ultrasound imaging assisted in obtaining early correct diagnosis and diagnosis will allow the clinician to design appropriate treatment in implementing a safe rehabilitation protocol, designed to allow an that will assure full anatomical and functional recovery. early as possible return to running. Keywords Case Report Calf muscle injury; Tendon tear; Sport injury; Ultrasound A 32-year-old male elite level triathlete with 16 years of competitive experience presented to the clinic with complain of proximal right Introduction calf pain. Review of his medical history dating back 10 years indicated The plantaris muscle is an accessory plantar flexion muscle in several episodes of low back pain. In light of this complaint, diagnostic the calf. It originates from the postero-superior aspect of the lateral imaging consisting of computerized tomography skenogram (2006) femoral condyle and it inserts into the posterior surface of the had identified a leg length discrepancy of 1 cm (left side longer) and calcaneus via the Achilles tendon. It is characterized by a small, short, the athlete was fitted with corrective orthotics which he had been thin muscle belly averaging 1.5×10 cm in size, and a long tendon using for several years. varying highly in size and form between individuals. The plantaris Two weeks prior to the current visit, the patient had resumed tendon merges with the inner border of the Achilles tendon 10-15 running following 3 months rest due to a stress fracture of his left cm above the calcaneous [1,2]. Together with the gastrocnemius, and ala of sacrum. During those 3 months, the athlete had been able to soleus, they are collectively referred to as the triceps surae muscle. continue pain free swimming, was using a bone stimulator and Plantaris is in fact a two- joint muscle, thus its action could influence performing static core strengthening exercises. Running was resumed both joints involved, extending the ankle if the foot is free, or bending gradually following orthopedic approval. The athlete reported that the knee if the foot is fixed [3]. The plantaris is very active when upon return to running he started using a right heel lift, thinking this plantar flexion occurs in full knee extension. As flexion of the knee was appropriate in lieu of his leg length discrepancy. On average, his increases, the amplitude of activity falls progressively, apparently due training load after resuming training consisted of a 4 cycling hours to mechanical insufficiency. Moderate plantaris activity observed per week, 40 Km of running per week and 4 hours of swimming. *Corresponding author: Gali Dar, Department of Physical Therapy, Faculty of Two weeks later the athlete developed proximal right calf Social Welfare & Health studies, Haifa University, Mount Carmel, Haifa 31905, Israel, Tel: 972-50-5662054; E-mail: [email protected], [email protected] pain and presented for evaluation at the clinic. He reported initial pain onset during running, with cessation at rest. He attempted to Received: January 03, 2013 Accepted: March 19, 2013 Published: March 22, 2013 continue running practice without the heel lift, but experienced All articles published in Journal of Athletic Enhancement are the property of SciTechnol, and is protected by copyright laws. International Publisher of Science, Copyright © 2013, SciTechnol, All Rights Reserved. Technology and Medicine Citation: Dar G, Dolev E, Kots E, Cale’-Benzoor M (2013) Rehabilitation of Plantaris Tendon Rupture in an Elite Triathlete: A Case Report. J Athl Enhancement 2:2. doi:http://dx.doi.org/10.4172/2324-9080.1000108 gradual worsening of his symptoms. When pain persisted during With the confirmed diagnosis of a plantaris tendon tear, in its level walking the athlete requested medical advice. early- stage healing, a three phase, three week rehabilitation program was devised. Following successful completion the athlete was to Symptoms were aggravated with running or jumping, calf rising initiate a return to running program for three more weeks, and fully and resisted plantar flexion. The physical examination revealed resume running at six weeks total. The following rationale guided our focal tenderness during palpation of the upper posterior-medial phases of rehabilitation. calf area and medial belly of gastrocnemius muscle. Slight soft tissue thickening was readily palpable over the tender area but without any Phase 1 ecchymosis. Full ankle range of motion was observed but the pain Acute stage management (one week) designed to prevent further increased with free active and resistive plantar flexion. The patient damage, control pain, swelling and inflammation. The athlete managed to perform functional tasks such as tip toe walking, step up was strongly advised against any running activity. NSAIDs were and down activities within a normal pattern but reported discomfort. utilized sparingly to minimize interference of tissue regeneration. Thompson test was negative. Knee joint range of motion, strength Therapeutic ultrasound and electrotherapy modalities were added and stability testing were within normal limits. for pain control, circulation and muscle stimulation. Soft tissue Clinical reasoning process following this assessment determined mobilization techniques were used to promote collagen streaming, that while an intra-articular problem (either knee or ankle) was an prevent adhesions and alleviate painful trigger point formation. Treatment was administered three times per week, and the athlete was unlikely diagnosis, pain during active plantar flexion of the ankle encouraged to perform a home program of gentle self mobilization joint and during weight bearing functions may indicate muscular with a foam roller. To promote normal ambulation without limping, injury. The conclusion of the physical examination was that there was rigid taping was used for a few days. He was encouraged to continue a high likelihood of soft tissue damage to one of the plantar flexor calf swimming practice and core strengthening exercises, while avoiding muscles. The therapist was particularly concerned since overtraining cycling for one week, to minimize stress on healing tissues. or muscle overuse were not a likely possibility in light of the long period of rest due to the stress fracture. A sudden biomechanical Phase 2 stressor due to the heel lift was considered a possible precursor. Progression of this second week emphasized soft tissue mobility Following consultation with
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