The Application Value of MRI in the Training and Physical Rehabilitation of Gastrocnemius with Acute Sports Injury.

The purpose of this study was to analyze the magnetic resonance imaging (MRI) signs of acute gastrocnemius injury and to provide the basis for clinical diagnosis. Thirty-two patients with acute gastrocnemius muscle injury (19 males and 13 females, aged 18-63 years, mean 46 years) were recruited, and MRI scans were performed. The results showed that all the lesions of calf gastrocnemius were detected in 32 patients, including first-degree injury in 15 cases, second-degree injury in 15 cases, and third-degree injury in 2 cases. MRI can display the location and pathological changes of acute gastrocnemius injury, providing good imaging data for clinical diagnosis and treatment.

1. Introduction

The study of skeletal muscle movement has a long history. Its noninvasive and high soft tissue resolution makes it an effective tool for studying skeletal muscle structure and composition, as well as the physiological and pathological changes of skeletal muscle movement, especially imaging and relaxation time measurement [1]. First, the signal of a muscle increases after exercise, and the extent of the increase is related to the intensity of the muscle movement or the force it is subjected to. Images can be used to distinguish between active and inactive muscles [2, 3]. The increased signal of skeletal muscle after exercise is due to the prolonged relaxation time of exercising muscle, which makes it have potential application value in myopathy, exercise training, and physical rehabilitation therapy.

With the development of imaging technology, the application of MRI in the field of muscle movement and rehabilitation has been greatly expanded. Diffusion-weighted imaging (DWI) is the only imaging technique to observe the diffusion of water molecules in vivo. Diffusion-weighted imaging is mainly used in the detection of the axial nervous system, especially in the early cerebral infarction [4]. Diffusion-weighted imaging can reflect the information of water diffusion and microcirculation perfusion in tissues by selecting appropriate B value. At present, most studies believe that the increase of water content in the extravascular space after muscle exercise and the increase of water content in muscle caused by the release of more bound water in cells are the main reasons for the prolonged T2 relaxation time after muscle exercise. DWI can better observe the change of water molecule diffusion after muscle exercise. Early studies have shown that the extension of T2 relaxation time after muscle exercise is closely related to D value. Diffusion tensor imaging is a new technique developed on the basis of DWI. It reflects the change of diffusion in imaging voxel in both quantity and direction [5]. At present, the parameters used in skeletal muscle evaluation mainly include eigenvalue and eigenvector. The eigenvalue reflects the diffusion ability of the ellipsoid in all directions. The eigenvector reflects the direction of diffusion, and the combination of eigenvalue and eigenvector can reflect the detailed information of the diffusion of water molecules in each direction of the ellipsoid. In addition, FA is also a commonly used parameter, which represents the ratio of the anisotropic component of the ellipsoid to the entire diffusion tensor and reflects the shape of the entire diffusion ellipsoid.

Due to the popularity of jumping sports, such as running and basketball, the number of related injuries is also gradually increasing. Among the running-related injuries, lower limb sports injuries are common among which the proportion of knee joint ankle joint and leg injuries is the highest. The lower leg is the main load-bearing joint of the lower limb in jumping sports, such as running and basketball. In the process of running, due to various internal and external factors, it is easy to suffer injuries, such as bone, cartilage, tendon, and ligament [6, 7]. During muscle movement, the blood flow of the muscle is finely regulated. Adequate blood flow can provide nutrients needed for muscle movement and remove metabolites produced by muscle movement. As a new technique, spin proton labeling (SPT) can observe the perfusion information of muscle noninvasively. With the characteristics of multiparameter, multisequence, multidirectional imaging, and high tissue resolution, MRI is helpful for the early detection of soft tissue injuries, such as segmental bone, cartilage, tendon, and ligament of the leg. Therefore, MRI technology has become the first choice for the diagnosis of leg joint injuries. In this study, MRI was used to observe the imaging manifestations of the leg joints of asymptomatic amateur runners, basketball, and other jumping athletes, aiming to analyze the MR characteristics of leg joint injuries and the influencing factors of related injuries, so as to provide scientific basis and guidance for the participants of jumping sports, such as runners and basketball, so as to reduce the occurrence of sports injuries.

Leg joint is the most common part of jumping sports injuries, such as running and basketball, and the common injuries include bone, cartilage, tendon, and ligament injuries. The latest domestic research shows that the leg joint injuries of amateur jumping athletes, such as running and basketball, include ligament injuries, hydrops, and injuries around tendons, synovitis hydrops, cartilage injuries, bone marrow edema, and stress fracture, and there is a close relationship between the leg joint injury and running form in jumping sports such as running and basketball. Landing on the back of the foot is more likely to cause ligaments damage to the joints of the legs than landing on the front middle foot, while landing on the front middle foot is more serious than landing on the back foot. In foreign studies. Han et al. reported whether jumping sports, such as running and basketball would cause acute injuries to leg joints [8]. The results showed that jumping sports, such as running and basketball, would not cause serious acute injuries to articular cartilage, ligament, meniscus, or bone marrow of normal people's leg joints. Slight changes, such as joint effusion or changes in signals in the meniscus, can only be observed after jumping sports, such as running and basketball. However, there is no literature to support the acute injury of leg joints after jumping sports, such as running and basketball. The study of Rabusin and Kappert et al. showed that bone marrow edema could be found on MRI during long-distance running, and this phenomenon mainly appeared in leg joints and feet [9, 10]. In addition, Weber et al. found that 69% of the lesions of bone marrow edema occurred in the ankle and foot in the study on the lesions of bone marrow edema in professional runners. For MRI changes of ankle bone marrow in asymptomatic normal subjects [11], Zhang et al. observed the feet and ankles of asymptomatic volunteers using MRI short time inversion recovery (STIR) sequence and found that the occurrence rate of bone marrow changes was the highest with edematous bone marrow changes [12]. Johnson et al. studied the leg of asymptomatic nonprofessional runners, basketballers, and other jumper athletes, mainly focused on the presence of edema in the bone marrow of the leg, injury in the muscle and Achilles tendon, joint effusion, and the effusion around the tendon sheath (tibial posterior tendon, flexor longus tendon, flexor digitorum longus tendon, etc.), and so on [13]. The results suggest that pathological MRI findings of leg joints and feet caused by jumping sports, such as running and basketball, seem to occur with similar frequency in people who are physically active. Other studies that compared MRI of runners' legs with those of sedentary subjects showed that running on STIR images in the absence of any clinical symptoms resulted in enhanced signals of abnormal bone marrow. Studies on leg articular cartilage are rarely reported. Wang et al. found in the study on the biochemical changes, thickness, and lesions of leg articular cartilage in ultralong-distance running (4486 km ultramarathons) that T2 value of leg articular cartilage increased during 2000–2500 km and then decreased during the race [14]. The results showed that the normal cartilage matrix of the leg joint had the ability to partially regenerate under the load of multi-stage jumping sports, such as hyperrunning and basketball, and no significant changes of cartilage morphology or thickness were observed during the process.

As a noninvasive examination method, MRI technology can be used to analyze and evaluate bone, cartilage, tendon, ligament, and so on, which has a good value for early clinical diagnosis. This study using MRI to observe asymptomatic amateur jump athletes leg joints images, such as running and basketball, aims to sum up the leg joint damage characteristics of MR and analyze the related factors influencing the leg joint damage and is conducive to prevent injury and guidelines to science amateur jumping athletes, such as running and basketball training and competition, to make due contributions to the development of jumping sports, such as running and basketball.

2. Materials and Methods

2.1. General Information

A total of 32 cases of gastrocnemius muscle injury clinically confirmed in a hospital from December 2016 to April 2018 were collected, including 19 male patients and 13 female patients, aged 18–63 years, with an average age of 46 years. The clinical manifestations include obvious swelling of the calf leg after exercise, tenderness at the medial head of calf gastrocnemius muscle, aggravation of local pain when affecting the toes, and scattered ecchymosis under the skin [15, 16]. The clinical manifestations and imaging signs were observed, analyzed, and summarized. Sports injuries main reasons are running, walking, jumping, such as playing cross movement, and logging. 22 patients complained that their hind legs felt hard. After the heavy impact on their lower legs, they made a “click” sound and then felt pain and swelling in their legs, unable to walk normally. MR examination time after calf sports injury was 6 h–20 d after injury, and DR or CT examination was performed in all patients within 1 week of injury.

2.2. Equipment and Inspection Method

The Simens Avanto 1.5 T MR device typically adopts trim panorama 8-channel phased array coil. The scanning sequence includes Fset1WI, T2WI, and T2WI + FS that were performed on sagittal and coronal planes parallel to the long axis of the tibia and fibula, supplemented by transverse planes perpendicular to the long axis of the tibia and fibula, with layer thickness of 4.0 mm and layer spacing of 0.4 mm [17, 18].

2.3. Image Evaluation

The injury of muscle and tendon can be divided into 3 degrees clinically: first degree is traction injury, second degree is partial tear, and third degree is complete tear. Generally speaking, the injury of muscle and tendon is manifested as abnormal shape and MR signal. In first-degree injury, MRI showed normal shape of muscle and tendon, equal or slight hypointensity on T1WI and hyperintensity on T2WI + FS lesions. In second-degree injury, MRI showed partial discontinuity, absence or thinning and flabbiness of muscle and tendon, and intralesion edema and bleeding were more obvious than those in first-degree injury. In third-degree injury, MRI showed discontinuity of muscles and tendons, with extensive edema and hemorrhage at the fracture site. After the leg MR examination of all patients, 2 radiologists (1 chief physician and 1 associate chief physician) who had experience in MRI diagnosis jointly read the film and made the diagnosis report [19, 20].

3. Results and Discussion

3.1. Results

All the 32 patients in this group were diagnosed with calf gastrocnemius injury lesions, including 15 cases of first-degree injury, 15 cases of second-degree injury, and 2 cases of third-degree injury. The edema and bleeding in the lesions of gastrocnemius injury showed uneven patch-like or feathery high signal on T2WI + FS, as shown in Figures 1 and 2. The edema presented slightly lower signal on T1WI, and the bleeding lesions presented equal or slightly higher signal. The patients with degree 1 or 2 gastrocnemius injury were correctly diagnosed clinically and symptomatic management was performed. After 6-month follow-up, 26 patients basically recovered after conservative treatment, and 4 patients developed calf muscle contraction, walking weakness, and other symptoms. Surgical suture was performed in 2 cases of third-degree injury, and congestion and swelling of torn muscle tissue, fiber bundle rupture, and broken end contracture were observed during the operation, which was consistent with MRI findings.

Figure 1

The feathery edema signal of the medial head of the gastrocnemius muscle is visible, suggesting a strain of the gastrocnemius muscle and clearly showing the formation of an intermuscular hematoma in the gastrocnemius and soleus muscle.

Figure 2

A tear of the aponeurosis of the medial head of the gastrocnemius muscle and local subcutaneous soft tissue edema.

3.2. Discussion

3.2.1. Anatomical Characteristics and Injury Mechanism of Calf Gastrocnemius Muscle

The calf muscle can be divided into three groups, of which the latter has a strong calf three-head muscle from the inner side and outer side and the outer side of the gastrocnemius muscle. The gastropolis is provided with a driving force of walking, running, and jumping, which is the curved knee and foot buckling. Human body after the knee joint is straight, and then fast push, jump, serious valuation, and internal rotation can cause the posterior contraction of the gastrocnemius muscle laceration; both the inside and the outside of the gastrocnemius muscle are strength type muscle. The medial head produces more tension than the lateral head, but the lateral head has a higher potential of shorting speed than the medial head, so the medial head is prone to injury. The severity of an acute injury depends on the speed, magnitude, and duration of the stress. The structure of muscle and tendon intersection is the most special among the three. This part is connected by muscle cells and tendon fibers. After muscle tendon injury, local muscle fiber tearing, bleeding, and necrosis occur, tissue edema and infiltration of inflammatory cells occur, and its function will be immediately affected. The degree of function decline depends on the degree of injury, and the function may be completely lost when the injury is serious. Mild injuries to muscles and tendons may be treated conservatively, while complete or proximal tears require early surgical treatment to avoid retracting, atrophy, shortening, and scarring of the muscles, making the surgery more complicated. The complete tear of muscle and tendon often shows retraction, which is easy to be determined clinically. However, the clinical diagnosis of partial tear or complete tear without retraction is difficult, and it is easy to cause misjudgment. MRI can provide the part of the muscle tendon injuries and severity information, can identify with other diseases with similar symptoms, can plan treatment in guidance and tracking the change of the lesion, and can judge the prognosis of patients with (especially the athletes' recovery time), and can predict late-onset complications, such as muscle atrophy and fibrosis, the trend of development.

3.2.2. MR Scanning Technique of Calf Gastrocnemius Muscle

All cases in this group performed coronal and sagittal comparison scans of both legs using body coil. The scanning field (FOV) was 400 mm, and the scanning sequence was Fset1WI, T2WI, and T2WI + FS. The layer thickness was 4.0 mm, and the layer spacing was 4 mm. T1WI could clearly display the anatomical details of calf gastrocnemius muscle and tendon, while T2WI + FS could clearly display the anatomical details of calf gastrocnemius muscle. It is very important to show and judge the location and range of the lesion. Large FOV scan can fully display the outline of the lesion area, which is convenient for observation. It is more accurate to judge the injury length, contraction, and tear of gastrocnemius tendon. When lesions are found in sagittal and coronal planes, scanning along the horizontal axis perpendicular to the long axis of the tibiofibular surface, FOV is relatively small, which can improve the image resolution and help to see the tear of gastrocnemius fascia. Contrast-enhanced scans of soft tissue injuries are rarely performed unless solid or cystic lesions are identified or if muscle necrosis is present.

3.2.3. MRI Findings of Gastrocnemius Muscle Injury

Gastrocnemius skeletal muscle, under normal circumstances such as signal in T1WI, T2WI in low signal, gastrocnemius after acute injury, damage caused by diffuse muscle tissue congestion, edema, hemorrhage, with or without muscle fiber bundle torn, muscular tissue contracture, deformation, displacement, and the pathological changes is difficult to show on X-ray plain film. As a chemical imaging method with high resolution for soft tissue, MRI is currently the best imaging method for displaying soft tissue contusion and edema. MRI can clearly show the location, scope, and degree of muscle tendon injury and can also observe whether the adjacent bone is involved.

Most of the injuries of muscles and tendons are located at the junction of muscles and tendons. Clinically, they can be divided into three degrees: first degree is tensile injury, second degree is partial tear, and third degree is complete tear. In this study, 15 of the 32 patients had first-degree injury (see Table 1). At first-degree injury, the muscles and tendons were normal in shape, often showing isosignal on T1WI, presenting a “false appearance of complete normalcy.” On T2WI + FS, the area of injury showed hypersignal due to edema and bleeding and extended to adjacent muscles and developed feathery along the fascia surface of the muscles. There are no sequelae in this type of lesion, so the clinical manifestations and magnetic resonance manifestations will return to normal after the lesion healing. In second-degree injury, a total of 15 cases were in this group. MRI findings were the following. The medial head of the gastrocnemius muscle was diffused with patchy and feathery long T1 and T2 edema signal shadow, the edge was blurred, and the continuity of some muscle bands was interrupted. The tear of the muscle bands was filled with edema signal shadow, and there were small patchy and filiform short T1 and T2 bleeding lesions locally, among which 3 cases were accompanied by soleus injury, and the feathery edema signal shadow was observed inside. Hematoma signal shadow appeared between the medial head of gastrocnemius muscle and soleus muscle in 11 cases; in this group of 15 cases, different forms of bleeding signal shadow could be seen in the irregular muscle bundle tear, which was reported as the characteristic MRI manifestation of second-degree injury of muscle and tendon. In border in 3 degrees of damage, muscle tendon was totally torn, MRI performance was as follows. The muscle tendon interruption, breaking muscle tendon retraction, enlargement, and contracture crumb may be accompanied by extensive hemorrhage, edema, the clinical manifestation, limb pain, loss of function, physical examination leg lesions in patients with subcutaneous soft tissue limitations sag, and the proximal soft tissue swelling bulge. Surgical repair was performed in both cases, and the intraoperative findings were completely consistent with MRI findings.

Table 1

Degree of gastroenteral muscle injury.

Degree of muscle injury	Number of examples
One degree of strain	15
Pardegrees degree partial tear	15
Three degrees completely 3 degrees	2

3.2.4. Diagnosis of Prognosis of Acute Gastrocnemius Muscle Injury by MRI

MRI can make a correct judgment of the prognosis of muscle tendon injury. Muscle tendon injury recovery time and its damage are related to the range of the axial images; muscle abnormal signal area accounts for 50% of a single muscle or a set of more, needing a long time (at least 3 months) to recover, such as muscle completely torn and retraction, hemorrhage, and tendon sheath cyst, which are the effusion or distal involvement, and the poor prognosis of patients.

4. Conclusions

To sum up, running, basketball, and other jumping sports are not only an exercise to temper the will and test the endurance but also a kind of dangerous sports. Jumpers, such as runners and basketballers, are prone to leg joint injuries in daily training and competitions without any clinical symptoms. The main MR characteristics are bone marrow edema, increased fluid accumulation around the tendon sheath, and partial injury of the lateral collateral ligament. Early application of MRI technology can timely detect, evaluate, and intervene in leg joint injuries. Age, running age, weekly running amount, and landing pattern are the related factors affecting leg joint injury. Correctly understanding these injury factors can effectively prevent injury and guide jumping athletes, such as runners and basketballers, to carry out scientific training and competition. MRI characteristic shows the site and pathological changes of acute fibular muscle injury, providing good imaging data for clinical diagnosis and treatment.