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 assists the function of the in loading situations [3]. Rupture in an Elite Palpation of the plantaris muscle belly is possible in the as well as along the medial aspect of the common tendon of the Triathlete: A Case Report surae group [4]. Dar G1,2*, Dolev E2,3, Kots E4 and Cale’-Benzoor M1,2 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 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 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 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 via the . 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 . 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 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 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 the orthopedic physician, the patient restoration, utilizing active stretching, soft tissue progressive was referred to an ultrasound imaging. Ultrasound imaging has been mobilization, and initiation of active plantar flexion exercise. gaining acceptance as a primary diagnostic tool for evaluation of Isometric plantar flexion exercise utilizing limited weight bearing non- specific posterior lower leg pain 4[ ]. It is a simple, low cost and (seated posture) was combined with unstable surfaces (foam cushion, easily accessible evaluation method [9]. The diagnostic ultrasound rocker board, and slant board) to facilitate proprioceptive receptors examination was performed by a professional musculoskeletal abundant within the plantaris muscle. Once tolerated well, exercises radiologist (E.K) using GE Voluson machine, with 12 MHz linear were progressed to full weight bearing with additional function - transducer. resembling components, such as running swing phase simulation while standing on the affected side. All exercises were initially The examination revealed a hypoechoic lesion indication ona performed in a slow and controlled manner. fluid collection between the gastrocnemius and the soleus muscles in the anatomical position. The of these muscles was found to The following sequence is an example of a graded proprioceptive routine performed by the athlete twice a day during week two: 1. be intact. The lesion size was of 7 cm in length, 2 cm width and 0.3 Single stance on a flat surface, eyes opens, 3 sets × 30 seconds; 2. cm in depth (Figure 1). The examination indicated a partial rupture Single stance on a flat surface, eyes closed 3 sets × 30 seconds; 3. Single of the plantaris tendon. Differential diagnostic tests for Baker’s cyst, stance on a flat surface, eyes open, trunk rotations slowly performed or involvement of other calf muscles and were found to be from side to side 3 sets × 30 seconds (this added a degree of stretch negative. The radiologist indicated that initial tissue healing was in to plantaris muscle- tendon unit, which courses obliquely from the progress. For comparison, an ultrasound examination was made to lateral knee aspect down to the medial side of the Achilles tendon); 4. the other leg. Single stance on a flat surface, eyes open, and trunk rotations while standing on a slant board, foam cushion etc. 3 sets × 30 seconds. As the athlete reported feeling no pain at all, concentric plantar flexion and inversion exercise were also initiated. Heel raises were commenced, as the athlete was instructed to touch the doorway, reaching up while maintaining good balance, posture and stability. This was performed in dual stance, and progressed to single stance. To facilitate muscle endurance 30 repetitions were performed × 3 sets. Varying knee angles promoted the stabilizing role of plantaris while loading the knee. Phase 3 Figure 1: Ultrasound imaging of the plantaris rupture: A. Transverse scan: measurement of the hypoechoic lesion; B. Longitudinal scan: the hypoechoic Goals for this final phase consisted of increasing calf muscle lesion is seen between the gastrocnemius and the soleus muscles while the strength and endurance, establishing dynamic control of the ankle in fascia of these muscles is intact. final preparation for the return to running program. Rope skipping

Volume 2 • Issue 2 • 1000108 • Page 2 of 3 • 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 was introduced as a warm up/ endurance activity, starting bilaterally treatment and activity modification needed to allow the patient to and progressing to alternate toe skipping. Several sets of 1 minute obtain full recovery and resume athletic activity. each were performed, combined with single leg balancing activities References on various surfaces. Phase 2 activities were progressed to running 1. Moore KL, Dalley AF, Agur AMR (2010) Clinically Oriented Anatomy (6th stride simulation while standing on a Bosu, performing left leg quick edtn), Lippincott Williams & Wilkins, Philadelphia 597–600. swing activity while maintaining right stance balance. 2. Allard JC, Bancroft J, Porter G (1992) Imaging of plantaris muscle rupture. Perturbation exercise was added as well, with the therapist Clin Imaging 16: 55-58. tipping a rocker board while the athlete maintained balance. For 3. Basmajan JV, De Luca CJ (1985) Muscles alive: their functions revealed by further eccentric control, rocker board lunges were performed, with electromyography, Williams & Wilkins, Baltimore MD. the right leg serving both as the stance, as well as the moving limb. 4. Spina AA (2007) The plantaris muscle: anatomy, injury, imaging, and An Elastic tubing cord tied to both shin areas created an additional treatment. J Can Chiropr Assoc 51: 158-165. dynamic force. To promote dynamic plantar flexor strength a 5. Delgado GJ, Chung CB, Lektrakul N, Azocar P, Botte MJ, et al. (2002) Tennis hopping sequence between two mini- trampolines was initiated, with leg: clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology 224: 112-119. Thera tubing added as a resistive device. At the conclusion of the third week the athlete had not experienced any pain during exercise bouts, 6. Biedert RM (2005) Surgical treatment for persistent complaints following rupture of the fascia of the plantaris longus muscle: a case report. Knee Surg had resumed cycling and was able to complete 30 repetitions of single Sports Traumatol Arthrosc 13: 335-337. toe raises to full height. He was then cleared to progress to the final 7. Harmon KJ, Reeder MT, Udermann BE, Murray SR (2006) Isolated rupture of phase of return to running progression. the plantaris tendon in a high school track athlete. Clin J Sport Med 16: 361- 363. The return to running program was initiated at the beginning of the fourth week. It included four sets of five minute blocks. Each 8. Helms CA, Fritz RC, Garvin GJ (1995) Plantaris muscle injury: evaluation with MR imaging. Radiology 195: 201-203. five minutes consisted of some walking and some jogging, starting with 4.5 minutes walking, 0.5 minute jogging. The balance gradually 9. Bianchi S, Sailly M, Molini L (2011) Isolated tear of the plantaris tendon: ultrasound and MRI appearance. Skeletal Radiol 40: 891-895. shifted in favor of full course running, assuring no pain or limping occurred. This progression was performed on alternate days during week four, commenced to daily sessions on week five, with increased running pace on week six. The progression was tolerated well without any symptom exacerbation. The final goal of the rehabilitation program was thus successfully achieved. Discussion This case report presents an isolated rupture of the plantaris muscle in an elite triathlete. The pain started without specific trauma; the attempted use of a right heel lift may have provided the particular stress, causing increased eccentric loading of the right plantaris. While not causing major pain, it resulted in disruption of normal function such as walking, and prevented the athlete from carrying out his scheduled training. Plantaris muscle involvement was confirmed using diagnostic Author Affiliations Top ultrasound imaging. Shown to be a reliable diagnostic tool for 1Department of Physical Therapy, Faculty of Social Welfare & Health studies, plantaris injury, comparable to MRI imaging, [2,4], it identified the University of Haifa, Mount Carmel, Haifa 31905, Israel 2Ribstein Center for Research and Sports Medicine, Wingate Institute, existence of alternation in the normal linear echogenic septations Netanya 42902, Israel between different tissues [2]. Ultrasound imaging allowed for accurate 3Department of Orthopedics, Meir Hospital Sapir Medical Center, Kfar Saba, identification of this rare condition, and correctly distinguished 44281, Israel 4Department of Radiology, Meir Hospital Sapir Medical Center, Kfar Saba, it from gastrocnemius muscle injury. There are several significant 44281, Israel clinical implications to the accurate diagnosis of plantaris tear: (1) Conservative treatment is usually very effective; (2) As plantaris is known to contain a high density of muscle spindles, functioning as an Submit your next manuscript and get advantages of SciTechnol important proprioceptive organ [4], great emphasis should be put on submissions proprioceptive exercises during rehabilitation; (3) The estimated time ™™ 50 Journals for healing and returning back to training is shorter than other calf ™™ 21 Day rapid review process ™™ 1000 Editorial team muscles injuries and the prognosis is good [7]. ™™ 2 Million readers ™™ More than 5000 Conclusion ™™ Publication immediately after acceptance ™™ Quality and quick editorial, review processing Isolated rupture of the plantaris muscle may occur, and should be considered as a possible etiology in patients with calf muscle Submit your next manuscript at ● www.scitechnol.com/submission complains. Plantaris muscle rupture can be diagnosed via ultrasound imaging. Early specific diagnosis will allow for the appropriate

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