Acute Achilles Paratendinopathy following Major Injury of the Crural Fascia in a Professional Soccer Player: A Possible Correlation?

Hindawi Publishing Corporation Case Reports in Orthopedics Volume 2016, Article ID 1830875, 5 pages http://dx.doi.org/10.1155/2016/1830875 Case Report Acute Achilles Paratendinopathy following Major Injury of the Crural Fascia in a Professional Soccer Player: A Possible Correlation? Gabriele Mattiussi, Michele Turloni, Pietro Tobia Baldassi, and Carlos Moreno Medical Staff, Udinese Calcio SPA, 33100 Udine, Italy Correspondence should be addressed to Carlos Moreno; Received 24 March 2016; Revised 14 April 2016; Accepted 18 April 2016 Academic Editor: John Nyland Copyright © 2016 Gabriele Mattiussi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. The anatomy and mechanical properties of the Crural Fascia (CF), the ubiquitous connective tissue of the posterior region of the leg, have recently been investigated. The most important findings are that (i) the CF may suffer structural damage from indirect trauma, (ii) structural changes of the CF may affect the biomechanics of tissues connected to it, causing myofascial pain syndromes, and (iii) the CF is in anatomical continuity with the Achilles paratenon. Consistent with these points, the authors hypothesize that the onset of acute Achilles paratendinopathy may be related to histological and biomechanical changes of the CF. Case Presentation. A professional male football player suffered an isolated injury of the CF, interposed between the soleus and medial gastrocnemius (an atypical site of injury) with structural connective integrity of the muscles. After participating in the first official match, two and a half months after the trauma, he has unexpectedly demonstrated the clinical picture of acute Achilles paratendinopathy in the previously injured limb. Conclusions. Analysis of this case suggests that the acute Achilles paratendinopathy may be a muscle injury complication from indirect trauma of the calf muscle, if a frank and extensive involvement of the CF were to be ascertained. 1. Introduction The distal myotendinous junction of the medial gastrocnemius (MG) is the typical site for muscle injuries to the calf. This particular injury is also known as a “tennis leg” calf injury and is widely known and extensively written about in literature [1]. Balius et al. [2] have recently described the injuries of the soleus (SL). The authors emphasise the fact that the rate of accidents against this muscle is likely to be underestimated, due to the anatomical complexity of the muscle and due to the low sensitivity of the ultrasound examination to detect abnormalities [3]. The involvement of the Crural Fascia (CF) is also possibly underestimated. It is the ubiquitous connective tissue of the posterior region of the leg that interfaces and connects the calf muscles. The CF does not integrate into the connective tissues forming the skeletal muscle extracellular matrix [4]. The CF is viewable through the use of ultrasound (Figure 1) and appears as a thick lamina of connective tissue similar to an aponeurosis [5]. The mean thickness of the (superficial) CF is estimated to be 1.1 mm in healthy subjects [6]. The close anatomical relationship of the CF with the Achilles paratenon (AP) has recently been described. The CF and AP join together at about 4 cm proximal to the posterior superior calcaneal tubercle [7, 8]; Webborn et al. [7] were also the first to describe the acute tear of the CF at the attachment to the Achilles tendon, making it an attributing factor to the etiopathogenesis of achillodynia. These new findings have a significant impact in the diagnostic study of calf muscle injury and in the evaluation of their complications. In this study, the case of a professional football player who suffered a rare and isolated injury to the CF interposed between MG and SL is presented. The case is particularly complex because the football player, at complete sporting recovery, demonstrated the clinical picture of acute 2 Case Reports in Orthopedics MG LG MG ∗ SL Figure 1: Ultrasound image of Crural Fascia (CF) in a 24-yearold male volunteer. The CF is easily distinguishable by the epimysia of the medial gastrocnemius (MG) and soleus (SL) being between these three structures (hyperechoic) interposed by two layers of hypoechoic connective tissue. Achilles paratendinopathy in the same leg. Paratendinopathy is defined by inflammation and/or degeneration of the paratenon. Exercise-induced pain and local swelling around the tendon’s mid-portion are the most important symptoms [9]. In light of the recent findings above, the hypothesis of the authors is that acute Achilles paratendinopathy may be related to the previous injury of the CF, representing a complication. To the best of the authors’ knowledge, this possible correlation has never been presented in literature. 2. Case 2.1. Acute Calf Injury. A male professional football (soccer) player suffered an injury to his right calf muscle during an official match. He described his injury mechanism as a sudden “kick” from the back in his calf during a jump. He had to leave the game. On initial examination, he had localised tenderness at the middle of his right calf. Passive and active movement of the ankle exacerbated the pain. No palpable defect was noted in the gastrocnemius muscle mass. The Achilles tendon was freely movable and Thompson test was negative for Achilles tendon tear. No other injury was reported and the initial clinical diagnosis of gastrocnemius strain was established. After elastic taping in neutral ankle flexion he was sent for an emergency MRI investigation. The MRI reported very generally “gastrocnemius and soleus muscle strain with presence of fluid between the two muscles.” Two days later, an ultrasound examination was performed to assess what structures were actually damaged. All the ultrasound examinations presented in this study were carried out using an ultrasound GE Logiq S7 Expert (GE Healthcare, Milwaukee, WI) with a 50 mm linear footprint matrix probe (5–15 MHz). Contrary to what was expected, the pictures show a rare non-tennis leg calf injury: the epimysia of the MG and of the SL were, in fact, ecostructurally intact. However, a considerable enlargement of the connective component interposed between the muscles was observed, compatible with structural injury and retractions of the CF (Figure 2). The framework was aggravated by the presence of SL Figure 2: Isolated injury of the Crural Fascia, with considerable thickening of same (asterisk). Note the structural integrity of the medial gastrocnemius (MG) epimysium and of the soleus (SL), indicated by the arrows, and the absence of intramuscular edema. The muscle belly of the MG and Lateral Gastrocnemius (LG) are observable, a sign that the injury is not at muscle-tendon junction level. ∗ Figure 3: Interfascial blood (...truncated)