Atraumatic Calf Swelling In Recreational Cyclist

Abstract

HISTORY: 51 year-old male presented with intermittent left calf pain and swelling for the past 2 months. The pain and swelling became constant the week preceding his presentation. He had no known injury but first noticed the pain after a spin class 2 months ago. The pain was worse with cycling, jogging, and swimming and at the end of the day. He had no knee pain, ankle pain, or hip pain. He denied lower extremity weakness or numbness. The pain did not radiate. PHYSICAL EXAMINATION: There was a soft tissue enlargement in posterior medial aspect of left calf that was mildly tender to palpation, soft, and non-mobile. Transillumination of the area was positive. No overlying erythema or skin changes were noted. Calf musculature and strength were normal. There was no tenderness along the rest of the gastrocnemius or Achilles tendon and no pretibial edema was present. Neurovascular examination was unremarkable. DIFFERENTIAL DIAGNOSIS: 1. Deep Vein Thrombosis 2. Synovial Cyst 3. Abscess 4. Morel-Lavallée lesion 5. Lipoma 6. Hematoma TESTS AND RESULTS: - Knee x-rays: Grossly normal; generally preserved joint space, with osteophyte formation and mild patellofemoral arthritis - Bedside ultrasound of calf: Large, hypoechoic, cystic appearance; connected with a small stalk to the posterior knee joint capsule (popliteal); no vascularity seen on Color Flow Doppler - Fluid analysis: Yellow, hazy; no crystals seen; minimal nucleated cells FINAL/WORKING DIAGNOSIS: Synovial cyst connected to the popliteal aspect of the knee joint TREATMENT AND OUTCOMES: 1. Bedside ultrasound evaluation 2. Aspiration of popliteal cyst, 85cc of straw-colored fluid, sent for analysis 3. ACE wrap recommended in attempt to prevent re-accumulation of fluid 4. Orthopedic evaluation due to re-accumulation of fluid, recommended continued monitoring given asymptomatic nature 5. Could consider surgical excision if becomes symptomatic