miguel khoury. m.d. university of buenos aires

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