Bilateral Lower Extremity Pain Kristina DeMatas, D.O. Sports Medicine Fellow Mayo Clinic Jacksonville 2/11/12

History 35 yo female Federal law enforcement officer & competitive power lifter Noticed bilateral leg pain after a hard workout Treated with massage and stretching for gastrocnemius muscle spasm by her Physical Therapist x 1 week

History Continued Presented to the ER 1 week later Traveling from Georgia to Austin, TX Felt fatigued and dehydrated from a strenuous workout Slept the entire 5 hr flight Upon standing she felt severe pain in her bilateral calves Presented to the ER

Past Medical History Past Medical Hx: GERD, Anxiety, hx of PFO Family Hx: Mother-end stage lung cancer, PE Home medications: Loestrin 24 (started 4 months ago) Prozac 20mg daily ASA 81mg daily Allergies: PCN Social Hx: single, non-smoker, no EtOH or drug abuse

Physical Exam Gen: Young healthy female, NAD Vitals: BP 160/83, repeat 120/70, HR 86, RR 18, O2 sat 100% RA, wt 57.6 kg  HEENT: WNL  CV: S1, S2, regular rhythm, no murmur  Lungs: CTA bilaterally Extremities: negative for swelling or discoloration, positive for bilateral calf tenderness with palpation MSK: Knee and ankle ROM WNL, no joint effusion Neuro: WNL

Questions on History or Physical Exam?

Differential Diagnosis 1. Gastrocnemius/Soleus strain or tear   2. Achilles tendonitis 3. DVT   4. Rhabdomyolysis  5. Ruptured Baker’s cyst 6. Calf hematoma 7. Compartment Syndrome 8. Cellulitis

Questions?  

Tests and Results CBC, BMP WNL BNP WNL TSH WNL INR-1.03 CK- 87 US-DVT right popliteal vein and peroneal vein 

Final Working Diagnosis  DVT right popliteal and peroneal vein

Treatment and Outcomes Admitted to telemetry  Started on Lovenox and Coumadin Discharged the next day Oral contraception discontinued Hypercoagulable workup negative

Treatment and Outcomes 1 month after Dx Presented for clearance and recommendations about activity while on Coumadin Demoted to a desk job, gun confiscated, told she was unable to drive a vehicle at work  Anxious and tearful about her lifestyle changes  Currently taking 12.5-15 mg of Coumadin daily. INR therapeutic  

Treatment and Outcomes Gradual return to activity but at a low level No heavy weights while on coumadin Watch for signs of bleeding Cleared to operate a motor vehicle, maintain firearms proficiency, teach officer response tactics -including searching, defense, and weapons confiscation  Refrain from activity that causes head, body or extremity blows  Restrict all exercise if INR 4 or higher. If 3.5 - 4 should only do extremely light exercise

Treatment and Outcomes   Treatment and Outcomes Repeat B/L US 1 month after diagnosis showed resolution of right popliteal DVT, positive for left peroneal vein DVT   Complained of significant side effects from Coumadin including muscle aches and pain in areas of previous injury Rheumatologic workup negative   Coumadin discontinued   Started on Lovenox 60mg q12   Anticoagulation for 6 months 

Thank You

Are Athletes at risk for DVT? Return to Play Guidelines?  Risk Factors Orthopedic trauma Postinjury immobilization Frequent & Prolonged travel Hemoconcentration No consensus that elite athletes are at higher risk for DVT No return to play guidelines currently exist for athletes with venous thrombosis No RCT or large cohort studies documenting safe timing of exercise