By Prodyut Das

Tennis Leg

The term Tennis Leg refers to an acute medial head of the gastrocnemius muscle tear in the older athlete characterized by sudden onset of severe calf pain and significant disability. The injury is invariably associated with extensive bruising and swelling, and can be mistaken for a deep venous thrombosis. The most common site is the medial head of gastrocnemius, but occasionally the plantaris muscle is involved. Symptoms are a sudden, sharp or burning pain in the leg, sometimes accompanied by an audible sound. In most cases, the player is unable to continue play because of the severe pain. Depending on the severity of the injury, recovery may take between a few days and six weeks.

Risk Factors

This injury occurs commonly in sports activities (e.g, hill running, jumping, tennis), but it can occur in any activity. A medial calf injury is often seen in the intermittently active athlete. Medial calf injuries occur more commonly in men than in women, and these injuries usually afflict athletes and others in the fourth to sixth decade of life. Medial calf injuries are most commonly seen acutely, but up to 20% of affected patients report a prodrome of calf tightness several days before the injury, thus suggesting a potential chronic predisposition.

Sports Biomechanics for Tennis Leg

This condition has been termed "tennis leg" because of its prevalence in this particular sport, but medial calf injury can happen in a variety of sports or other activities. One mechanism that occurs is on the back leg during a lunging shot, in which the knee is extended while the foot is dorsiflexed. This action puts maximal tension on the gastrocnemius muscle as the lengthened muscle is contracted at the "push off," resulting in a tennis leg injury. This is the common position of the back leg in a tennis stroke, and it results in the greatest force to the muscle unit; but tennis leg injury can also occur during a typical contraction of ankle plantar flexion, especially if the athlete is pushing or lifting a large weight or force.

Causes for Tennis Leg

  • Age/activity status: Medial calf injuries occur more commonly in the middle-aged recreational athlete. This population typically continues to be physically active at a moderate to high intensity but not on a regular basis, and these individuals are also likely to have maintained a moderate degree of the muscle mass from their more active days.
  • Deconditioned/unstretched muscles: The cold and unstretched muscles that recreational athletes often use to compete with are very likely to rupture when challenged compared with conditioned and stretched muscles.
  • Previous injury: The athlete with recurrent calf strains is likely to have healed with fibrotic scar tissue, which absorbs forces differently and is thus more likely to result in rupture when the muscle is challenged.

Signs and Symptoms for Tennis Leg

  • An audible pop when the injury to the medial calf occurred is usually reported.
  • The patient complains of calf pain, which also radiates to the knee or the ankle. In addition, the patient complains of pain with ankle movements.
  • The patient complains of a swollen leg that extends down to the foot or ankle, as well as the associated color changes of bruising.
  • Tenderness is noted upon palpation in the entire medial gastrocnemius muscle, but this tenderness is observed to be exquisitely more painful at the medial musculotendinous junction.
  • Palpation of the Achilles tendon should demonstrate an intact tendon.
  • The peripheral pulses should be present and symmetric.
  • Moderate to severe pain is demonstrated with passive ankle dorsiflexion (due to stretching of the torn muscle fibers) in tennis leg, as well as with active resistance to ankle plantar flexion (due to the firing of the torn muscle fibers).

Physical Therapy Management for Tennis Leg

Acute Stage Rehabilitation The following action should be taken as quickly as possible, certainly within 48 hours.

  • Rest (immobilisation). Stop playing tennis and do not lean on the foot.
  • Cool the painful area directly with ice, a cold pack, or cold running water for 10 to 15 minutes and repeat this several times a day. Do not place ice on the bare skin. Place a towel between the skin and the ice pack to avoid injury from the ice pack.
  • Elevate the leg.
  • Apply a compression bandage, as it compresses the small vessels in the calf and limits the bleeding.
  • In severe cases, or if in doubt, the tennis leg injury should be evaluated by a physician, who may make a referral for physiotherapy.

Once the worst pain and swelling have subsided (after 1 to 2 days), start to build-up the training load. During this period, pain is a signal to rest. Do not to cross the pain threshold, as this will slow down the healing process. The training load is built up in three steps. These are described below, with several tips.

Step 1. Improvement of General Condition

  • If the pain allows it, you may put weight on the foot, if necessary using elbow crutches during the first week. The foot should be used in a normal fashion.
  • A heel lift (with shock absorption) in both shoes for one to two weeks may help to ease the load on the calf muscles during walking. ‘Viscoheels’ are very useful for this purpose.
  • Stretching the long calf muscles. Step forward with the unaffected leg, keeping the heel of the back leg on the floor. The knee of the affected leg is kept straight. Shift the weight of the back leg to the front leg and press the heel of the back leg firmly into the floor. Rest with your hands on a stationary object. The stretch is felt high up in the calf. Hold the stretch for 15 to 20 seconds without bouncing, followed by a rest period of 10 to 20 seconds. Repeat 3 times.
  • Stretching the short calf muscles. Start from the same position as described above, but now bend the knee of the hind leg, while keeping the heel on the floor. The stretch is felt low in the calf. Again, hold the stretch for 15 to 20 seconds (no bouncing), followed by 10 to 20 seconds rest, and repeat 3 times.
  • Strengthening the foot muscles. Sit on a chair. Write the alphabet in the air with the foot of the injured leg. Fold a towel by grasping it with the toes of the injured leg. Perform this for 15 to 20 seconds, followed by 10 to 20 seconds rest, and repeat 10 to 20 times.
  • Swimming or cycling for 30 minutes every day increases the blood flow to the calf muscles and enhances recovery after tennis leg injury.

Step 2. Build-up

  • As soon as all the above exercises can be performed and walking is possible without pain, a return to tennis and other sports can be considered.
  • Start by strengthening the calf muscles. Slowly rise onto your toes and hold this position for 10 to 20 seconds. Then return to the starting position. Perform this exercise with both feet at the same time, then when leaning on the injured leg only. If using body weight is too painful or difficult, elastic tubing may be used to work the plantar flexors (i.e. push the toes and forefoot down against the resistance of the elastic tubing).
  • Take small, quick steps on the spot, alternating the left and the right leg.
  • If this goes well, you can begin jogging. Start with an easy jog, then include some sprints and straight running, followed by quick turns, starts, and stops.
  • Finally, you can include jumping exercises.

Step 3. Return to Play

  • A return to the tennis court should now be possible. Start against the practice wall or with minitennis and gradually increase the distance to the wall or your opponent on the court. Make sure you position yourself well for the ball by taking small steps.
  • In this phase you can also include volley exercises.
  • Gradually (in the course of one to two weeks) include more exercises that involve moving longer distances towards the ball.
  • Next, include low volleys, followed by overheads and services.
  • As soon as you can hit a smash with footwork without problems, you are ready to start playing points, games and a practice match.
  • Once you have played practice matches for two weeks in succession without problems, you can start playing matches again.

Medical Management for Tennis Leg

Pain management should include analgesics as indicated. Caution should be used with nonsteroidal anti-inflammatory drugs (NSAIDs) during the acute injury phase, as these agents can predispose the patient to increased bleeding and hematoma formation in the initial days after an injury. Theoretically, cyclooxygenase-2 (COX-2) inhibitors may provide pain control without the risk of bleeding in acute injuries, which is a concern with traditional NSAIDs.

Ankle/foot bracing should be used to keep the ankle in a position of maximal tolerable dorsiflexion. Studies have shown an increased rate of healing with this intervention.

Preventing Re-injury

Read research articles about Tennis leg on Pub Med

  • Perform a complete warm-up before play and a cool down afterwards, for approximately 10 to 15 minutes each. Pay close attention to correct stretching exercises. Stretching exercises for the calf muscles are particularly important.
  • Build up training gradually, so that the body can slowly adapt to the increased load.
  • Wear properly fitting tennis shoes with good shock absorption, sideways stability, feeling with the playing surface (grip) and optimal comfort.
  • Massage calf muscles if they feel stiff and tense.
  • Adapt clothing to the weather conditions. Particularly at the start of the season or if there is a biting wind, it may be wise to keep the track suit or running tights on during the warm up. Well-warmed muscles and tendons are better able to withstand pulling and traction forces than cold muscles.
  • Maintain strong calf muscles, with adequate rest in your training programme. Steps, cycling and running are ideal exercises for calves.

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