Exertional Leg Pain in a Runner

Abstract

1699 HISTORY: A 35 year old African American male presents with progressive 2 year history of exertional posterior calf pain. Patient describes no pain at rest, but the pain becomes severe after ¼ to ½ mile of running. The pain is a crampy, sharp pain in the posterior calf without radiation, relieved with discontinuation of exercise. Past medical history was significant for hypertension well controlled on ramipril. Remote history, four years previous, of left leg deep venous thrombosis (DVT) following a prolonged airplane flight. No tobacco, alcohol, cocaine, or other drug use, and family history was negative for clotting disorders. The patient had been started on conservative therapy for 2 months without improvement. PHYSICAL EXAMINATION: African American male with normal neutral walking gait without limp. Lower extremity alignment was neutral without any asymmetry or obvious deformities. Tenderness to deep palpation in the posterior calves bilaterally, but no compartment tenderness at rest or with exertion. The patient had no bony tenderness or tenderness to percussion over the tibia or fibula. Ankle, knee, and hip had full passive and active range of motion. Strength was normal and symmetric throughout the lower extremity. Sensation to light touch and pin prick were intact with normal deep tendon reflexes. Distal pulses were diminished (1+) bilaterally but were symmetric with no change while in plantarflexion. The skin over the dorsum of his foot was slightly cool to the touch without pallor. DIFFERENTIAL DIAGNOSIS: Medial Tibial Stress Syndrome Chronic Exertional Compartment Syndrome Sural Nerve Entrapment Popliteal Artery Entrapment Arterial Occlusive Disease TEST AND RESULTS: Radiographs bilateral tibia/fibula −negative for fracture. Bilater duplex ultrasounds −negative for DVT Nerve Conducton Studies −negative Ankle Brachial Index −0.83 right side, 0.78 left side Arteriogram −severe femoral artery occlusive disease bilaterally from the groin to the tibial vessels Hypercoagulable work-up – + Lupus anticoagulant, + Anti-cardiolipin antibody (+ Antiphospholipid antibody syndrome) Rheumatologic panel −negative Echocardiogram (with bubble study) – negative for intracardiac thrombus or patent foramen ovale FINAL WORKING DIAGNOSIS: Extensive arterial occlusive disease in femoral arteries bilaterally. TREATMENT AND OUTCOMES: Unsuccessful attempt at thrombolysis Reduction of activity from running to walking as tolerated. Chronic anticoagulation with warfarin. Cilastazol for symptomatic treatment of intermittent claudication. Modification of cardiac risk factors. Unable to return to activity at previous level.