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Available online at www.sciencedirect.com

Computerized Medical Imaging and Graphics 32 (2008) 728–731

Rupture of the medial gastrocnemius muscle during namaz praying:An unusual cause of tennis leg

Cengiz Yilmaz a,∗, Yaman Orgenc b, Ruken Ergenc a, Nazif Erkan c

a Ministry of Health, Izmir Training and Research Hospital, Department of Radiology, Bozyaka, Izmir, Turkeyb Ministry of Health, Izmir Training and Research Hospital, Department of Orthopaedics, Bozyaka, Izmir, Turkey

c Ministry of Health, Izmir Training and Research Hospital, Department of General Surgery, Bozyaka, Izmir, Turkey

Received 17 April 2008; received in revised form 17 September 2008; accepted 19 September 2008

bstract

urpose: The aim of this retrospective study is to report a unique group of patients in whom rupture of the medial gastrocnemius muscle (tenniseg) occurred during namaz praying.

aterial and methods: We reviewed the sonographic and/or MR imaging findings of 543 patients who were referred for the evaluation of leg painnd swelling during the last 7 years. Fourteen patients with a final diagnosis of tennis leg that occured during namaz praying were included in thistudy.esults: Nine of 14 (64.2%) patients had incomplete and the remainder 5 (35.8%) patients had a partial tear at the musculotendinous junction

MTJ). Four of 14 (28.6%) patients were mistaken for deep vein thrombosis (DVT) on the basis of clinical findings and presentation. Associated

uid collection between the gastrocnemius and soleus muscle was noted in 11 (78.5%) patients. Isolated fluid collection between the gastrocnemiusnd soleus muscle without disruption of the gastrocnemius muscle was seen in 1 patient.onclusion: Rupture of the medial gastrocnemius muscle may occur during namaz praying. The clinical presentation is not always characteristicnd may simulate DVT. US and MRI are useful diagnostic tools to establish the correct diagnosis and prompt further treatment.

2008 Elsevier Ltd. All rights reserved.

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eywords: Tennis leg; Gastrocnemius muscle; Namaz praying

. Introduction

Rupture of the medial head of the gastrocnemius muscle,lso known as tennis leg (TL) is a relatively common conditionsually seen in middle-aged veteran tennis or soccer players1–3]. The injury usually occurs during forced dorsiflexion of thenkle and simultaneous extension of the knee [2,3]. We reportunique group of patients who developed TL during namaz

raying.

. Material and methods

The medical records and sonographic findings of 541 patientsith diffuse or focal leg swelling and leg pain who were referred

o our department for US diagnosis between January 2000 andarch 2007 were evaluated retrospectively. Patients were sent

∗ Corresponding author. Tel.: +90 532 475 80 94.E-mail address: cengizyilmaz66@yahoo.com (C. Yilmaz).

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895-6111/$ – see front matter © 2008 Elsevier Ltd. All rights reserved.oi:10.1016/j.compmedimag.2008.09.001

rom different departments, including orthopeadics, emergency,nd vascular surgery. Fourteen patients (8 men, 6 women, meange 61, age range 47–87 years) who met the following two cri-eria were included in this study (1) sonographic and/or MRIvidence of rupture of the medial head of the gastrocnemiususcle and (2) acute pain and/or a snapping sensation in the

osterior calf that occurred during or shortly after namaz pray-ng. Patients with a history of direct trauma to the leg were notncluded in this study.

All sonographic examinations were performed in the proneosition with 5–12 MHz broadband transducers. The contralat-ral medial calf was also imaged in equivocal cases. MRI waserformed in 4 patients in whom sonographic findings werequivocal. The time between the onset of calf pain and sonogra-hy ranged from 8 h to 9 days (mean 2.5 days). Sonographicnd/or MR imaging diagnostic criteria were as follows: (1)

resence of a localized or complete disruption of the regularrrangement of the muscle fibers and fibroadipose septa near ort the musculotendinous junction (MTJ) of the medial gastroc-emius muscle at sonography, (2) increased T2 signal within

C. Yilmaz et al. / Computerized Medical Imaging and Graphics 32 (2008) 728–731 729

Fig. 1. Partial rupture of the gastrocnemius muscle. A longitudinal sonogramof the posteromedial calf in a 62-year-old man with a 4-day history of back legpain who felt like that he was shot in the back of the leg as he stood up fromsajdah during namaz praying. (A) Note the disruption of the regular, alternatingmuscle fibers and fibroadipose septa near the MTJ and a hypoechoic defect(arrows) within the distal gastrocnemius head. (B) The regular arrangement oftcs

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Fig. 2. A 53-year-old woman reported a sudden pop and sharp pain in the backof her leg during standing up from sajdah. She was examined by an orthopaedicsurgeon 36 h after the onset of pain with a clinical diagnosis of rupture of themedial gastrocnemius muscle. A T2W coronal MR image reveals fluid (arrows)b(i

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he muscle fibers and fibroadipose septa ending in the muscle aponeurosis in theontralateral leg is shown for comparison. Note that, without a detailed, carefulonographic examination, small partial ruptures may easily go undetected.

he medial gastrocnemius muscle near or at the MTJ at MRmaging, and (3) fluid collections between the soleus and gas-rocnemius muscles either at sonography or MRI [1,4–7]. Aartial tear was diagnosed in the presence of a localized disrup-ion of the gastrocnemius MTJ, whereas a complete tear wasefined by the involvement of the entire medial head of the gas-rocnemius muscle [1]. Potency of the femoropopliteal veinsas ascertained with color Doppler US and compressibility test-

ng. All patients were treated conservatively with nonsteroidalntinflammatory drugs, leg elevation, ice and rest. Three patientsequired prolonged immobilisation (up to 2 months). Completer near complete clinical healing was observed in 8 of the 10atients within 2 months in whom follow-up was available. Noatient was available for sonographic or MR imaging follow-up.

. Results

Partial rupture of the medial head of the gastrocnemius

uscle was identified in 9 (64.2%) patients (Fig. 1), and com-

lete rupture was seen in the remaining 5 (35.8%) patientsFigs. 2 and 3). Fluid collection between the gastrocnemius andoleus muscle was seen in 11 (78.5%) patients. In one patient,

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etween the gastrocnemius and soleus muscles. Also noted is an increased signalstar) within the medial gastrocnemius head near the MTJ indicating musclenjury.

uid collection between these muscles was the only finding indi-ating muscle rupture (Fig. 4). In 10 of the 14 (71.4%) patientshe clinical presentation and patient history was highly sug-estive of rupture of the medial gastrocnemius muscle. In theemaining 4 (28.6%) patients the clinical presentation was dom-nated by diffuse leg swelling and DVT was suspected on theasis of clinical findings (Fig. 2).

No deep vein thrombosis was identified in 6 patients in whomolor Doppler US was performed. Imaging findings are summa-ized in Table 1.

. Discussion

Rupture of the medial head of the gatrocnemius muscle, alsonown as TL is usually seen in middle-aged tennis or soccerlayers, but TL may also result from daily activities, such asunning to catch a bus, climbing stairs or even hanging curtains4]. Sudden pain is felt in the calf, and patients often report apop” in the calf or a feeling as though someone has kicked theack of their leg.

To the best of our knowledge, rupture of the medial head ofhe gastrocnemius during namaz praying has not been reportedreviously. Namaz, which is the method of praying to God in the

slamic world, is performed five times a day on a regular basisnd is composed of different postures. During sajdah, a posturen namaz, one sits on his knees and places his face on groundor prostration. Following this, one stands up from sajdah up by

730 C. Yilmaz et al. / Computerized Medical Imaging and Graphics 32 (2008) 728–731

Fig. 3. Tennis leg simulating DVT. A 49-year-old woman presented with diffuse leg swelling and pain in the back of the leg that began shortly after namaz praying.Three days after the onset of pain, she was seen in the emergency room because of increasing pain and swelling. The emergency physician who examined the patientordered Doppler sonography to rule out DVT. At Doppler US, the femoropopliteal veins were patent and compressible with no sign of DVT (not shown). Thereafter,gray scale sonography (A) targeted to the area of maximal pain and tenderness was paspect of the leg (between cursors). The image quality was degraded due to obesity awithin the gastrocnemius muscle (star) consistent with interstitial edema/hemorrhage

Fig. 4. Isolated fluid collection between the gastrocnemius and soleus muscles.A 57-year-old male patient reported sudden sharp pain at the back of the leg thatoccurred during standing up from sajdah during namaz praying. A longitudinalsonogram reveals isolated fluid collection between the gastrocnemius and soleusmuscles (arrows) with no sonograhic evidence of muscle injury. It should be keptin mind that this finding is nonspecific and, besides tennis leg, may also be seenin ruptured Baker’s cysts. In our patient, the popliteal fossa was normal, thusexcluding a ruptured Baker’s cyst.

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erformed which showed an ill-defined hypoechoic lesion at the posteromedialnd edema. (B) A T2W transverse MRI demonstrates diffusely increased signaland fluid within the gastrocnemius and soleus muscles (arrows).

lacing his hands on his knees, putting pressure on the knees andegs without putting his hands on the ground to assist to standp. We believe extension of the knee during standing up fromajdah without support was the cause of muscle rupture in ourelatively elderly patients, in whom even a moderate amount of

orced extension of the knee could have caused rupture of theastrocnemius muscle. Indeed, 6 of our 14 patients reported thathe sudden, sharp snapping sensation occured at the moment oftanding from sajdah. Atrophy and weakness of the muscles, an

able 1onographic and MRI findings of 14 patients with tennis leg.

Number of patients (n = 14)

artial rupture of the medial gastrocnemiusmuscle at or near the musculotendinousjunction

9 (64.2%)

omplete rupture of the gastrocnemius muscle 5 (35.8%)luid collection between the gastrocnemius andsoleus muscle with sonographic or MRIevidence of muscle rupture

11 (78.5%)

solated fluid collection between thegastrocnemius and soleus muscles with noevidence of muscle rupture

1 (7.1%)

ssociated deep vein thrombosis 0 (0%)

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xpected finding in with increasing age, as in our patients, mightave been a contributing factor. The hypothesised mechanism ofuscle rupture is quite different from that of the usual TL, where

atients are middle-aged tennis or soccer players who preserveheir muscle mass to a large extent.

Fluid collection between the medial gastrocnemius andoleus muscles, thought to represent blood, is a frequent findingn patients with TL. Kwak et al. reported that TL was associ-ted with fluid collection between the gastrocnemius and soleususcles in 19 of 22 (90.2%) of their patients [6]. Delgado et al.

lso reported 141 patients with TL. With 89 (63%) having fluidollection between the medial head of the gastrocnemius musclend the soleus muscle [4]. Collection between the gastrocnemiusnd soleus muscles was also a frequent finding in our study andas seen in 11 of our 14 (78.5%) patients. In one of these patientsuid collection between the gastrocnemius and soleus muscleas an isolated finding without sonographic or MRI evidencef disruption of the medial gastrocnemius muscle (Fig. 4). Onehould keep in mind that isolated fluid collection between theastrocnemius and soleus muscles is a nonspecific finding anday represent either a ruptured Baker cyst, a torned plantaris ten-

on or rupture of the gastrocnemius muscle [4,8,9]. Therefore,solated fluid collection without an associated imaging evidencef gastrocnemius injury should be interpreted carefully in theight of clinical findings and presentation. Imaging the poplitealossa may be helpful to exclude a Baker cyst, whereas the moreroximal location of a fluid collection in plantaris tendon ruptureay aid in the differential diagnosis.TL may be mistaken for deep venous thrombosis on the basis

f clinical findings and presentation [10,11]. In fact, in 4 of 1428.5%) patients in this present study the clinical presentationf TL simulated DVT. Although there was no patient with DVTn our study, it has been reported that TL may also be associatedith DVT [4].The limitations of our study are as follows. None of our

atients underwent surgery to confirm the diagnosis and noatient was available for imaging follow-up. Also, rupture of thelantaris tendon, which is reported to be an associated findingn some patients with TL [4], was not evaluated in our patients.

hese limitations are largely due to the retrospective nature of

his study.In summary, TL should be suspected in patients who report

udden onset of pain in the back of their legs during namaz

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ging and Graphics 32 (2008) 728–731 731

raying. The clinical presentation may simulate DVT and, afterxcluding thrombosis of the deep veins of the leg, sonogra-hy and/or MR of the gastrocnemius musculotendinous junctionhould be performed for the correct diagnosis.

eferences

[1] Bianchi S, Martinoli C, Abdelwahab IF, Derchi LE, Damiani S. Sono-graphic evaluation of tears of the gastrocnemius medial head (“tennis leg”).J Ultrasound Med 1998;17:157–62.

[2] Froimson AE. Tennis leg. JAMA 1969;209:415–6.[3] Gilbert TJ, Bullis BR, Griffiths HJ. Tennis calf or tennis leg. Orthopedics

1996;19:179–84.[4] Delgado GJ, Chung CB, Lektrakul N, Azocar P, Botte MJ, Coria D, et al.

Tennis leg: clinical US study of 141 patients and anatomic investigation offour cadavers with MR imaging and US. Radiology 2002;224:112–9.

[5] Lee JC, Healy J. Sonography of lower limb muscle injury. AJR2004;182:341–51.

[6] Kwak HS, Han YM, Lee SY, Kim KN, Chung GH. Diagnosis and follow-upus evaluation of ruptures of the medial head of the gastrocnemius (“tennisleg”). Kor J Radiol 2006;7:193–8.

[7] Kwak HS, Lee KB, Han YM. Ruptures of the medial head of the gastroc-nemius (“tennis leg”). Clinical outcome and compression effect. Clin Imag2006;30:48–53.

[8] Jamadar DA, Jacobson JA, Theisen SE, Marcantonio DR, Fessell DP, PatelSV, et al. Sonography of the painful calf: differential considerations. AJR2002;179:709–16.

[9] Leekam RN, Agur AM, McKee NH. Using sonography to diagnose injuryof plantaris muscles and tendons. AJR 1999;172:185–9.

10] Liu SH, Chen WS. Medial gastrocnemius hematoma mimicking deep veinthrombosis: report of a case. Taiwan Hsueh Hui Tsa Chih 1989;88:624.

11] McClure JG. Gastrocnemius musculotendinous rupture: a condition con-fused with thrombophlebitis. South Med J 1984;77:1143–5.

r. Cengiz Yilmaz was born in Berlin, 1966. He received his medical degree in990, Uludag School of Medicine, Bursa, Turkey and completed his radiologyesidency in 1995. He is currently working in Izmir Teaching Hospital, Turkey.e is specially interested in color Doppler sonography and musculoskeletal

maging.

r. Yaman Orgen was born in 1960. He received his medical degree in 1983,gean School of Medicine, Izmir, Turkey and completed his residency in 1989.e is currently working as an orthopaedist in Izmir Teaching Hospital.

r. Ruken Ergenc was born in 1972. She received her medical degree fromegean School of Medicine, Izmir, Turkey and is currently working as a senior

adiology resident in Izmir Teaching Hospital.

r. Nazif Erkan was born in 1969. He received his medical degree fromhe Hacettepe School of Medicine, Ankara, Turkey. He completed his generalurgery residency in 9 Eylul School of Medicine, Izmir, Turkey. He is currentlyorking as an associated professor of general surgery in Izmir Teaching Hospital.