Calf muscle pain and tenderness
Introduction
Introduction Muscle pain and tenderness in the calf muscles are characteristic features of venous thrombosis, an acute non-suppurative inflammation of the vein with secondary intravascular thrombosis. The lesion mainly involves the superficial veins of the extremities or the deep veins of the lower extremities. Its clinical features are local swelling and pain of the affected limb, subcutaneous sputum and tender cord or accompanied by venous return obstruction such as superficial varicose veins. Even if the thrombus falls off, it can cause pulmonary embolism.
Cause
Cause
In the mid-19th century, RLK Filshaw proposed three elements of deep vein thrombosis - venous stasis, hypercoagulable state, and venous intimal damage, which are still recognized by the vascular surgery community. The vast majority of venous thrombosis occurs in the deep veins of the pelvis and lower limbs. This is closely related to the anatomy and function of the veins of the lower extremities: the veins of the lower extremities have more venous valves. When the human body is standing or sitting, the venous pressure of the lower extremities is much higher than the body. Other parts. The venous return of the lower extremities relies on the "pump" produced by the muscle contraction. Therefore, the venous return of the lower extremities is slower when standing and sitting. Thrombosis often occurs in venous valve pockets when there is no obvious venous membrane damage. The thrombus has no close adhesion to the vessel wall, is prone to detachment and can cause pulmonary embolism.
70% of the lower extremity blood flows back to the heart through the deep vein, and 30% through the superficial vein (large hidden, small saphenous vein) flows into the deep vein (femoral vein) at the root of the thigh. Therefore, the iliac vein, femoral vein thrombosis, deep vein blood flow obstruction, the superficial vein will expand, blood flow increased to compensate for deep vein blood flow obstruction. Then there is great saphenous vein varicose and concave edema of the affected limb. Thrombosis in the superficial veins, tenderness of the calf muscles, and acute dorsiflexion of the forefoot, induced deep pain in the calf muscles (Homans's sign).
Examine
an examination
Related inspection
EMG general radiography
According to the different sites of thrombosis, it can be divided into two categories.
1. Superficial venous thrombosis: often involving the great saphenous vein or small saphenous vein or its genus, mostly on the basis of varicose veins, the main feature is the pain in the thrombosis site, the surface of the superficial vein has a red, low-heat cord Things, tenderness, redness around, emboli are not easy to fall off, generally do not cause pulmonary embolism, in addition, migratory superficial vein thrombosis is often a suggestive symptom of cancer.
2. Deep vein thrombosis: According to its location and condition, it can be divided into the following two types.
(1) deep vein thrombosis of the calf: often occurs in the deep veins of the calf, such as the posterior tibial vein and the iliac vein, etc., more common in patients with less bed movement, often occurs in the second week after surgery, the left lower limb is the most common, It is characterized by pain and tenderness in the lower leg muscles, severe pain after exercise, and more dorsiflexion in the foot. The systemic symptoms are not significant. There may be Homan's sign when the test is performed, that is, the calf is straight, the foot is dorsiflexed, and the gastrocnemius is inside. The diseased vein is affected by traction and pain, and the circumference of the gastrocnemius muscle is thicker than the healthy side by more than 5 cm.
(2) , femoral vein thrombosis: can be secondary to the calf vein thrombosis, but more than the primary iliac vein, common in postpartum, rapid onset, severe diffuse edema of the affected limb, increased skin temperature or slightly convulsions Superficial vein dilatation, unbearable pain in the inner thigh and significant tenderness along the vein, especially in the trigone area, the systemic symptoms are not heavy.
Diagnostic examination
1. Ask if there is any history of trauma, time of injury and treatment, history of long-term bed rest, surgery, pregnancy, childbirth and oral contraceptives, history of repeated venipuncture or intravenous infusion catheter. Whether the symptoms and the disease period are consistent, the location and development of the onset, the nature of the pain, whether there is fever, swelling and pain of the affected limb.
2. During local examination, attention should be paid to the presence or absence of tenderness, tenderness, and swelling of the affected limb (the circumference should be accurately measured on the thickest plane with a tape measure and compared with the same plane on the healthy side). And temperature (measured by the skin temperature measurer compared to the contralateral side), whether there is a change in the distal pulse of the limb, whether there is a tender cord on the body surface, whether there is an infected lesion and the foot boots Nutritional changes in the area, such as desquamation, itching, pigmentation, eczema and ulcer formation.
3. When the diagnosis is difficult or to determine the extent of the lesion, feasible ultrasound, pulse Doppler spectrum examination, venography (can effectively determine the presence or absence of thrombosis, thrombus location, extent, morphology and collateral circulation.
4. Intravenous pressure measurement, foot venous puncture, needle pressure sensor or scaled transparent plastic tube (filled with heparin-physiological saline solution) to measure venous pressure, normal pressure is generally 12.7kPa (130cmH20), for ankle joint extension When flexion is active, the gastrocnemius contraction, the pressure drops significantly, generally can be reduced to 5.9 kPa (60 cmH20), the pressure rises after stopping the activity, and the recovery time exceeds 20 s. There are thrombosis and occlusion in the main vein. The pressure at rest or activity is significantly increased, and the recovery time is generally no more than 12 s.
Diagnosis
Differential diagnosis
The diagnosis of acute venous thrombosis of the lower extremities is often not difficult. Postpartum, fracture and trauma, post-operative patients, if there is limb pain, swelling, superficial venous engorgement, should consider the possibility of this disease. When the diagnosis is difficult, venous pressure measurement and venography can be performed. Radionuclide venography of the lower extremity is helpful for diagnosis and safer. Doppler ultrasound blood flow detector can be used to check the thrombosis of the external and femoral veins, and the examination of venous thrombosis in deep muscle or pelvic cavity is not accurate. The 125I-labeled human fibrinogen test is most valuable for the diagnosis of deep muscle venous thrombosis in deep muscles. If it can be continuously examined for several days, the accuracy rate can reach more than 85%.
If the pain is not significant, and the swelling of the limb is obvious, attention should be paid to the identification of lymphedema. The latter has a slow course of disease, thickening of the skin, no superficial varicose veins, and the swelling subsides after the bed is raised.
According to the different sites of thrombosis, it can be divided into two categories.
1. Superficial venous thrombosis: often involving the great saphenous vein or small saphenous vein or its genus, mostly on the basis of varicose veins, the main feature is the pain in the thrombosis site, the surface of the superficial vein has a red, low-heat cord Things, tenderness, redness around, emboli are not easy to fall off, generally do not cause pulmonary embolism, in addition, migratory superficial vein thrombosis is often a suggestive symptom of cancer.
2. Deep vein thrombosis: According to its location and condition, it can be divided into the following two types.
(1) deep vein thrombosis of the calf: often occurs in the deep veins of the calf, such as the posterior tibial vein and the iliac vein, etc., more common in patients with less bed movement, often occurs in the second week after surgery, the left lower limb is the most common, It is characterized by pain and tenderness in the lower leg muscles, severe pain after exercise, and more dorsiflexion in the foot. The systemic symptoms are not significant. There may be Homan's sign when the test is performed, that is, the calf is straight, the foot is dorsiflexed, and the gastrocnemius is inside. The diseased vein is affected by traction and pain, and the circumference of the gastrocnemius muscle is thicker than the healthy side by more than 5 cm.
(2) , femoral vein thrombosis: can be secondary to the calf vein thrombosis, but more than the primary iliac vein, common in postpartum, rapid onset, severe diffuse edema of the affected limb, increased skin temperature or slightly convulsions Superficial vein dilatation, unbearable pain in the inner thigh and significant tenderness along the vein, especially in the trigone area, the systemic symptoms are not heavy.
diagnosis
1. Ask if there is any history of trauma, time of injury and treatment, history of long-term bed rest, surgery, pregnancy, childbirth and oral contraceptives, history of repeated venipuncture or intravenous infusion catheter. Whether the symptoms and the disease period are consistent, the location and development of the onset, the nature of the pain, whether there is fever, swelling and pain of the affected limb.
2. During local examination, attention should be paid to the presence or absence of tenderness, tenderness, and swelling of the affected limb (the circumference should be accurately measured on the thickest plane with a tape measure and compared with the same plane on the healthy side). And temperature (measured by the skin temperature measurer compared to the contralateral side), whether there is a change in the distal pulse of the limb, whether there is a tender cord on the body surface, whether there is an infected lesion and the foot boots Nutritional changes in the area, such as desquamation, itching, pigmentation, eczema and ulcer formation.
3. When the diagnosis is difficult or to determine the extent of the lesion, feasible ultrasound, pulse Doppler spectrum examination, venography (can effectively determine the presence or absence of thrombosis, thrombus location, extent, morphology and collateral circulation.
4. Intravenous pressure measurement, foot venous puncture, needle pressure sensor or scaled transparent plastic tube (filled with heparin-physiological saline solution) to measure venous pressure, normal pressure is generally 12.7kPa (130cmH20), for ankle joint extension When flexion is active, the gastrocnemius contraction, the pressure drops significantly, generally can be reduced to 5.9 kPa (60 cmH20), the pressure rises after stopping the activity, and the recovery time exceeds 20 s. There are thrombosis and occlusion in the main vein. The pressure at rest or activity is significantly increased, and the recovery time is generally no more than 12 s.
