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

2. 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

3. 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

4. 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

5. 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

6. Questions on History or Physical Exam?

7. 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

8. Questions?

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

10. Final Working Diagnosis
 DVT right popliteal and peroneal vein

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

12. 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 mg of Coumadin daily. INR therapeutic  

13. 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 should only do extremely light exercise

14. 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 

15. Thank You

16. 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