A 67-year-old man presented with spontaneous left-calf pain and swelling of 2-days duration. Four weeks prior, he had undergone percutaneous angioplasty of the left anterior descending artery (LADA), and was discharged on aspirin, warfarin, and clopidogrel. On examination, the left calf was swollen and tender with subtle erythematous changes. Posterior tibial and dorsalis pedis pulses were palpable. There were no ecchymoses or petechiae noted. A venous duplex showed a large, complex, mostly hypoechoic fluid collection beginning at the proximal posteromedial aspect of the calf, with distal extension to the medial mid calf (Figures 68-1 and 68-2). The collection was below the muscular fascia and consistent with an intramuscular hematoma. Due to progressive swelling and pain, he was taken to the operating room where a moderate amount of coagulum was removed from the gastrocnemius muscle. Although acute deep vein thrombosis (DVT) should be the predominant concern when anyone presents with acute unilateral pain and swelling, this was unlikely in this patient since he was therapeutically anticoagulated.

Acute unilateral leg swelling is a very common presentation to the vascular laboratory, emergency room, or the vascular specialist’s office. The incidence of leg swelling secondary to muscle rupture is not known, but the clinical syndrome of strain or rupture of the medial head of the gastrocnemius muscle commonly known as “tennis leg” is not an uncommon presentation to the sports medicine specialist or emergency room physician. Medial calf injuries occur more commonly in men than in women, and these injuries usually afflict athletes and others in the fourth to sixth decades of life. Medial calf injuries are most commonly seen acutely, but up to 20% of affected patients report a prodrome of calf tightness several days before the injury, thus suggesting a potential chronic predisposition.¹

Muscle Rupture

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  Most commonly involves the medial head of the gastrocnemius muscle and is provoked by dorsiflexion of the ankle while the knee is extended. This so-called “tennis leg” often occurs during racquet sports.

  
  
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  Tennis leg has also been reported in other sports-related activities such as running, basketball, football, skiing, and rugby.^2,3

  
  
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  Gastrocnemius ruptures occurring during daily activities such as stepping off a curb or climbing stairs have been reported.^3,4

  
  
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  Ruptures or strains occurring in middle-aged or older patients may be associated with loss of flexibility or physiologic changes of muscle with aging.^5,6

  
  

  Less commonly reported are injuries or ruptures to the soleus, plantaris, flexor hallucis longus muscles, and lateral head of the gastrocnemius muscle.²

Calf Swelling

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  Swelling is usually acute, and depending on the size, may be due to the hematoma itself with compression of adjacent structures.

  
  
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  May be secondary to dissection of blood between muscles or deep within the muscles (ie, gastrocnemius and soleus).

Calf Hematomas

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  Can occur with direct trauma, muscle rupture, or spontaneously.

  
  
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  Spontaneous intramuscular hematomas occur more commonly with anticoagulation.

History

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  Commonly, the patient will complain of acute onset of pain in the proximal posterior calf related to a physical activity.² Patients often report a pop in the calf or a sensation of being kicked or shot in the calf, followed by increasing pain and swelling within 24 hours. Some patients will report the injury associated with daily activities such as climbing stairs, stepping off a curb, or getting up from namaz praying.^2,7

  
  
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  Individuals who are anticoagulated that experience a spontaneous or unprovoked muscle rupture or hematoma may report either a more gradual onset of symptoms or the simultaneous onset of discomfort and swelling with the rupture.

Physical Examination