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What could swollen calf symptoms mean?

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on how to make sense of common presentations.

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on how to make sense of common presentations.

The GP overview

Such has been the publicity about ‘economy class syndrome' that this presentation – and the closely related symptom, calf pain – has become quite common. The patient's concern about a possible DVT can prove quite infectious with the GP anxious not to miss this significant problem.

In most cases, a careful history, backed up by appropriate examination, should reveal the true cause.

Differential diagnosis

Common

• Cellulitis

• Most causes of swollen ankles

• Muscle strain/rupture (especially rupture of plantaris tendon)

• Ruptured Baker's cyst

• DVT

Occasional

• Ruptured Achilles tendon

• Varicose eczema

• Phlebitis
41193722
Rare

• Muscle herniation through fascia (especially tibialis anterior)

• Muscular neoplasm

• Pseudohypertrophy (as in muscular dystrophy)

Possible investigations

Likely None (unless sent to hospital).

Possible FBC, ESR and other investigations for swollen ankles; in hospital – D-dimer, ultrasound, venography.

Small print Radio-iodine labelled fibrinogen uptake test in hospital.

FBC, ESR Elevated white cell count and ESR in cellulitis.

D-dimer Raised level suggests DVT but is not conclusive.

Ultrasound May help diagnose DVT and useful in confirming ruptured Baker's cyst as the cause.

Venography, radio-iodine labelled fibrinogen uptake test Hospital test that may be used to confirm DVT.

Top tips

• The swelling resulting from a muscle rupture can be impressive – but a typical history with pain preceding the swelling (described as ‘like being shot in the calf') should clinch the correct diagnosis.

• Varicose eczema is often misdiagnosed as cellulitis. Clues are that it is commonly bilateral, itches more than it hurts and is not accompanied by fever.

• Anxiety about possible DVT may cloud the presentation: careful questioning may reveal that swelling is, in fact, longstanding and/or bilateral, making DVT very unlikely.

Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

Red flags

• Patients with unexplained DVT are three to four times more likely than controls to have an underlying malignancy - so once the DVT has been dealt with, consider appropriate investigation
• In high-risk patients – such as those who have just returned from a long-haul flight – your index of suspicion for DVT should be raised
• When the history suggests muscular rupture, ensure that the Achilles tendon is intact

Ready reckoner

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