Injury scientist, Dr. Alexander Jimenez looks at a case of a sore and swollen calf...
The Patient
A 25-year-old Muay Thai kick boxer with a three-week history of calf swelling and ankle soreness following an acute ankle sprain while training. The patient had been on a training camp in Thailand when he had twisted his ankle and sensed an audible snap. He stopped hammering and coaching the ankle aggressively and the ankle swelled and rested on a sofa sofa.
He returned home to Australia the next week (on a seven-hour flight) and post-flight noticed the calf continued to swell and felt a deep ache from the calf. He decided to rest after his return home from coaching for a further five days. He felt the pain had subsided he did notice that the crab was swollen and tight. After he resumed training again, he underwent additional swelling and a redness in the calf. He had no history of heavy calf tears previously and had 'wrapped' but had recovered.
Upon evaluation, he had a clear swelling at the lateral gutter of their consistent with a tier that is high ankle sprain to the ligaments that are lateral. He was tender to palpate along the anterior talofibular ligament (ATFL) and his anterior draw test for ATFL instability demonstrated a grade two laxity. He had decreased knee-to-wall dorsiflexion on that side in contrast to another hand (5cm vs 12 cm). What was evident was that the gross of the muscle on that side.
Considering the nature of the primary injury, the swelling he'd struck soon after, the competitive intervention he had experienced in Thailand and the current extended flight flight, it had been suspected that he may be suffering a post-traumatic deep vein thrombosis (DVT) in that calf. This was clarified to also an urgent referral to his GP was organized. The GP referred him to get a Doppler ultrasound study that confirmed blood clots in four little veins in the calf.
He had been treated with compression stockings and a course of blood thinning medicines (Heparin). He was told to prevent any contact into the calf for six months.
He recovered without any additional incident and returned to training six months.
Pathophysiology
A deep vein thrombosis (DVT) is the formation of a blood clot in the deep vein of the calf. It had been postulated by Rudolf Virchow in 1856 that a 'barbarous triad' must happen in order to get a DVT to occur (Dickson 2004):1. Hypercoagulability. A inclination to clot that might follow injury (like an ankle sprain).
2. Hemodynamic stasis. Reduced blood flow due to swelling, era, or extrinsic factors such as decompression (aviation) resulting in decreased external hemostatic pressure.
3. Endothelial dysfunction. Damage to the vessel from trauma.
In the case it might be postulated that the hypercoagulability followed the severe trauma. Such an accident could create a cascade of the two compounds and chemicals that are coagulating . This followed by calf massage may have exacerbated the coagulation factors. Stasis might have eventuated to shield dormant as well as sitting and allowing blood. Damage might have been the result of injury to the veins in the sprain or damage to vessels due to over- massage into the calf muscles.
Common Symptoms & Signs
The most signs and symptoms that a clinician should look out for are:1. Pain and tenderness in the calf;
2. Swelling in the calf;
3. Warmth and redness.
Diagnosis
Duplex Doppler ultrasound has become the most frequent tool to diagnose a DVT. A radiologist performs this and the investigation is able to highlight areas where the blood flow in the veins is compromised.Treatment
Treatment for DVT:1. Anticoagulation medication such as low molecular weight heparin to prevent blood clot formation. This may be continued for up to six months.
2. Vitamin K antagonist. These prevent the recycling of Vitamin K.
3. Compression stocking to increase pressure that is hemostatic that is external. These should ideally be than stockings which might obstruct the popliteal vein in the back of the knee. The 'stability' of this compression should be rated at the ankles and diminishing towards the knees. This will produce a pressure gradient to move blood up the veins in the calf.
4. Rest and avoidance of activity. Preventing any increase is crucial to prevent blood pooling and venous status.
5. Avoid long haul flights. Due to this decompression of cabin pressure at 30,000 feet altitude, the pressure in the surrounding atmosphere is reduced. This will allow the veins to dilate and blood pressure may result.
Literature Review of DVT Following Lower Limb Trauma
Although a very rare condition following lower limb injury, DVT has been described in the literature following injury:- Post-ankle fracture. Patil et al (2007);
- Popliteal artery contusion. Echlin et al (2004);
- Gastrocnemius tear and calf injury. Slawski (1994) and Watson et al (1991).
Conclusion
Deep vein thrombosis is an unexpected consequence following lower limb sports trauma. However, it is a rare possibility that sports medicine professionals must think about in the presence of calf swelling and swelling. Misdiagnosis may result in devastating consequences such as a clot causing a pulmonary embolism and linking to the lungs. If detected early, they can be managed with compression stockings, anti- coagulation treatment and activity modification.References
1. Dickson R (2004) Venous thrombosis. On the history of Virchow’s triad. University of Toronto Medical Journal. 81; 166-171.
2. Echlin et al (2004) Traumatic deep vein thrombosis in a soccer player. A case study. Thrombosis Journal 2(8);
3. Patil et al (2007) Incidence of deep vein thrombosis in patients with fractures of the ankle treated in a plaster cast. The Bone and Joint Journal. 89(10); 1340-1343.
4. Slawski D (1994) Deep vein thrombosis complicating rupture of the medial head of gastrocnemius. J Ortho Trauma. 8; 263-264
5. Watson et al (1991) Deep vein thrombosis following sports injury to the calf – a potentially dangerous complication. Sports Training Med and Rehab. 2; 273-278.
