Transcript Document
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 • 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 • 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