top of page

Case study 2: 23yo elite soccer player presenting with an acute on chronic gastrocnemius musculotendinous junction strain 1.5/52 ago

The goal of these case studies is not to create an extensive program for specific injuries. Rather, it is to provide examples with potential progressions with explanations to allow a physiotherapist/physiotherapy student to prescribe appropriate exercise by understanding core principles and clinical reasoning.

Subjective and objective assessment;

Subjective assessment;

  • Body chart

  • History of presenting condition

    • Acute, grade 2 gastrocnemius musculotendinous junction strain following a sprinting effort

    • Acute management in first 5 days included periods of ice, isometric contractions and range of motion exercise

    • Full ROM of the ankle has been achieved 

  • Symptom behaviour

    • 24hour pattern: Worse in mornings and end of day

    • Aggravated by stairs, running and jumping

    • Eased by heat and elevating leg

    • Average 4/10 pain

  • Special questions

    • Not waking at night

  • Past medical history

    • Recurrent L) hamstring strains

    • Otherwise general health good

  • Social and family history

    • Offseason soccer player

    • Regular interactions with physiotherapist up to 3x per day​ at club

Step 1.

Consider;

WHO-ICF:

Participation limitations:

  • Unable to participate in soccer trainings or games

​

Activity limitations

  • Unable to go up/down stairs at home without pain

  • Unable to run

​

Physical assessment;

  • Decreased hip extension L) during late stance/late swing confirmed by modified Thomas Test

  • Decreased endurance in L) hip extensors and external rotators compared with R)

  • Decreased strength & endurance in L) single leg hamstring bridge compared with R) (L = 17, R = 22)

  • Decreased endurance during L) heel raises (straight knee and bent knee) compared with R) (L = 5 limited by pain, R = 25)

  • Knee to wall test: L) 6cm; R) 10cm

  • Impaired dynamic standing balance on L) lower limb compared with R) 

​

Irritability;

  • Pain lingers for 30minutes following irritation

​

Skeletal muscle tissue healing principles;

  • According to principles of tissue healing, similar to other types of tissue, skeletal muscle undergoes an inflammatory, proliferative and remodelling phase. 

  • In the first 10 days of injury, the newly formed scar tissue is at its weakest.
  • Initial healing takes 6-8 weeks and continues for 12-14 weeks, when the muscle tissue demonstrates almost normal strength. Remodelling can take from 6 months to a year following it's injury. 
  • Early active muscle contraction is imperative to;
    • induce capillary growth
    • muscle fibre regeneration and orientation of new fibers
    • regaining normal tensile strength and,
    • improves return to sport timeframes (Bayer, Magnusson, & Kjaer, 2017).
  • Immobilisation should be avoided and progressively loading to increase strength, prevent atrophy and extensibility is important

Step 2.

Identify level of framework

Considering that the athlete has progressed through the peak of the inflammatory phase, but is yet to achieve full ROM in the talocrural joint, we can assume that he is currently in the mobility phase of the framework.

However, remembering we must consider other impairments found during assessment such as the decreased hip extension ROM, which may later contribute to further injury, these need to be addressed, too. 

Step 3.

Consider Blanchard & Glasgow's model, identify patient goals and prescribe exercises based on tissue healing and optimum dosages

​

Goal = Return to soccer in 2/12

​

Goal A: Improve ROM in L) ankle

​

Goal B: Improve strength in L) plantarflexors

​

Goal C: Improve endurance in L) hamstring

​

Goal D: Improve power in L) plantarflexors

Step 4.

Goal A

Improve ROM in L) ankle

  • Mobility should be achieved before we progress to the later stages of rehabilitation, but loading a tissue can begin within pain free ROM before full mobility is gained. 

  • With knowledge of tissue healing timeframes, it can be reasoned that the exercises should not be too aggressive to reinitiate the inflammatory response, but concomitantly remembering that skeletal muscle responds most appropriately early muscle contraction while avoiding immobilisation

  • AROM is preferred over PROM/A-AROM

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

  • Later during rehabilitation, the ROM exercises and strengthening can be combined to complete in one exercise i.e. eccentrics to increase fascicle length and load at the same time

  • Note the inclination of the (1) triangle - this is to appreciate the healing timeframe of skeletal muscle

​

​

​

​

Goal B

Improve strength in L) plantarflexors 

  • We can start to introduce strength training within pain free ROM early in rehabilitation, but remember to monitor signs of inflammation 

  • Consider strength dosages 

Improve endurance in L) hamstring

Goal C

 Improve power in L) plantarflexors

  • Consider power dosages 

  • NB: this may not begin until later in rehabilitation until sufficient strength has been established, denoted on the graph by the first triangle further along the 'time' axis

  • Patients should have sufficient strength before progressing to power based activities!

Goal D

Understanding the concomitant demands of a rehabilitation:

  • The multicoloured triangles represent the integration of multiple aspects of the rehabilitation combined into single exercise to more closely replicate the demands of the sport

Step 5.

Step 5: Consider most appropriate motor learning principles for each exercise 

Practice, feedback, instruction, modelling or manual guidance.

bottom of page