Vascular causes of calf pain
Most causes of lower leg pain presenting to MSK and orthopaedic clinics musculoskeletal in aetiology. However, it is important to consider neurological and vascular causes and leg and calf pain in our clinical assessment and differential work up.
When it comes to calf pain, most MSK practitioners will be viligant for vascular pathologies such as Deep Vein Thrombosis and Popliteal Artery Entrapment that may be mascarading as musculoskeletal pain. Chronic venous insufficiency (CVI) on the other hand, affects 1 in 20 adults and is often overlooked as a differential diagnsosis. This case study presents a runner with calf pain from CVI.
Chronic Venous Insufficiency (CVI)
Chronic venous insufficiency (CVI) is a form of venous disease that occurs when veins are damaged and become incompetent. As a result, blood pooling occurs in the leg veins, leading to high pressures in the venous system and capillary damage and leakage. This causes;
- Local tissue inflammation
- Haemosiderin (iron) deposition
- Tissue damage
- Venous stasis ulcers
CVI can happen due to damage in the (see diagram below);
- Deep venous system. Femoral vein, Popliteal vein
- Superficial venous system. Great Saphenous vein, Small Saphenous vein
- Perforating or communication veins.
- Venous Junctions. Sapheno-femoral, Sapheno-popliteal
Although Deep vein thrombosis (DVT) is a cause of chronic venous insufficiency (with the thrombosis damaging to the innermost layer, tunica intima, of the vein), the most common cause comes from age related valve and venous junction failure.
Case Presentation
Clinical history;
- 51-year old lady presenting with right calf and shin past 2 years
- Describes a dull ache around inside of calf and along medial border, deep in location
- Experiences dull calf pain and cramping sensations particularly overnight after long runs
- Worse after running, with onset usually a few hours after ceasation of run
- Not symptomatic during the run itself
- No obvious or visible calf swelling
- No risk factors for DVT
Previous treatment and investigation
- Sent to A+E on four separate occasions to rule out DVT, all ultrasound doppler and D-dimer tests came back normal
- Seen by orthopaedic team who diagnosed mild tibialis posterior tendinitis, through MRI.
- Treated by physiotherapy with tibialis posterior exercises which had miild improvement in symptoms.
Past Medical history;
- BMI 24
- Non-smoker
- No history of ill health
- No family history of poor health
Exercise history;
- Recreational club runner, preferred distance half marathon (PB sub 1h30min)
- Good variation of training but now unable to run due to calf pain post running, particularly on longer runs
Social history;
- Accountant
- Non drinker or smoker
Clinical examination;
- Mild discomfort on palpation of tibialis muscle and tendon activation (both sides equally)
- Mild discomfort across medial tibia
- Varicose veins and varicosities more prominment on right than left leg (see diagram below)
- Small increase in mid calf diameter (by 8mm R>L)
- Good pulses in foot and ankle
- Buerger’s test for arterial disease negative
- Mild haemosiderin deposition
- No venous ulcers
- Ankle Brachial Pulse Index (ABPI) normal
Point of Care Ultrasound
Normal appearences of right tibialis posterior tendon and calf musculature.
Clincial suspicions, differentials and reasoning;
- Venous insufficiency related calf pain. The increased varicosities indicate venous congestion on right (symptomatic side) compared to left. Symptom onset is also delayed to after running when the calf pump has become inactive and venous pooling occurs.
- Popliteal artery entrapment syndrome. No clinical signs of arterial disease. No classical claudication symptoms occurring with running.
- Compartment syndrome of the lower leg. Patient does not report classical compartment syndrome symptoms including onset during exercise with no paraesthesia, pain and foot slap.
- Tibialis posterior tendinits. Tenderness along tibialis posterior most likely muscle tension related and previous MRI and US shows no real evidence of this.
- Shin splints/Tibial stress. Previous MRIs discounted and no further increase in training volumes since then
Imaging
Vascular Duplex scan right leg
Duplex scanning demonstrates significant reflux at the right sapheno-femoral junction.
A duplex ultrasound combines;
- Traditional ultrasound with sonographic waves that bounce off blood vessels to create images
- Doppler ultrasound which records sound waves reflecting off moving objects, such as blood, to measure its speed and flow.
Sample image from the patient’s Duplex scan below.
Diagnosis
Chronic Venous Insufficiency related calf pain, primarily due to reflux at the right sapheno-femoral junction, with secondary varicose veins and calf cramping post exercise
Management
Medical
- Patient asked to wear exercise skins during runs and medical grade compression stockings after runs. Patient experienced vast improvement in symptoms
- Also asked to elevate the legs as much as possible after exercise
- Patient offered radiofrequency ablation of the right saphenous vein as definitive medical treatment, but declined as symptoms had significantly improved
Rehabilitation
- Focus placed on developing calf pump strength
- Alteratation of running training and patterns to reduce “time on feet” with more short interval training and variation of speed, distance and gradient
Patient Self monitoring tools
- LBSM pain and symptom diary
- LBSM load monitoring diary
Key Summary and learning points
- Chronic venous insufficiency is very common above the age of 50 and should be considered as a cause for calf pain
- Patient under the age of 50 with CVI should have other medical causes excluded e.g. DVT, compression masses
- The most common cause of CVI is age related vein incompetence commonly at the sapheno-femoral and sapheno-popliteal junctions
- DVT must always be considered
- Diagnosis is usually made clinically but can be confirmed with Vascular Duplex ultrasound scanning
- Compression stocks that measured and medical grade 1/2 are very effective in the treatement calf related pain due to CVI
- Medical inverventions such as vein stripping and ablation are usually reserve for the more severe cases
- Consider “time on feet” of your patients (particularly with runners) and try to adapt their exercise routines to reduce this
What are the signs and symptoms of chronic venous insufficiency?
Look out for the following signs and symptoms of Chronic venous insufficiency when assessing patients with lower leg and calf pain;
- Achy or tired legs
- Burning, tingling or “pins and needles” sensation in legs
- Cramping in legs at night
- Discolored skin reddish-brown
- Oedema in lower legs and ankles, especially after standing a while or at the end of the day
- Flaking or itching skin in legs or feet
- Full or heavy feeling in legs
- Leathery-looking skin in legs
- Ulcers (open sores)
- Varicose and varocosities veins
