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A Venous cause of calf pain – Musculoskeletal case of the month

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
calf pain

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
calf pain

Point of Care Ultrasound 

Normal appearences of right tibialis posterior tendon and calf musculature. 

Clincial suspicions, differentials and reasoning;

  1. 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. 
  2. Popliteal artery entrapment syndrome. No clinical signs of arterial disease. No classical claudication symptoms occurring with running. 
  3. 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. 
  4. Tibialis posterior tendinits. Tenderness along tibialis posterior most likely muscle tension related and previous MRI and US shows no real evidence of this. 
  5. 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;

  1. Traditional ultrasound with sonographic waves that bounce off blood vessels to create images
  2. 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. 

calf scan

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
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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.