Imaging Quiz: Calf Pain in a Recreational Basketball Player
Bryan D. Caldwell, DPM, MSTHE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 1 - JANUARY 1997
A healthy 43-year-old man presented with significant pain in his right calf 1 day after he was injured during a basketball game. While simultaneously pivoting and accelerating after a rebound, he reported, he had felt a blow to his right calf and heard a snapping sound. He was unable to finish the game and had been limping since the injury.
Physical examination revealed that the neurovascular status of his lower extremities was intact. No ecchymosis was seen on his right calf or foot. The Thompson test elicited adequate plantar flexion of the right foot in comparison with his uninjured foot. Dorsiflexion of the right foot with the knee extended elicited moderate pain, but dorsiflexion of the foot with the knee flexed was not painful. No palpable defect was found in the gastrocnemius muscle belly. Pain on palpation was noted at the lateral-to-medial upper third of his right calf, seemingly along the course of the plantaris muscle. In addition, palpation revealed fullness of the upper right calf, although no signs of compartment syndrome were appreciated.
The patient was placed in a Jones compression dressing and a posterior splint. He was instructed to use crutches and to avoid bearing weight on the affected limb during the acute phase of injury.
The patient returned after 7 days with throbbing pain. The physical examination again revealed an intact neurovascular status; however, moderate ecchymosis was now apparent from the insertion of the medial head of the gastrocnemius to the insertion of the Achilles tendon. Ecchymosis was also noted inferior to the medial malleolus. Although magnetic resonance imaging (MRI) is not frequently ordered for such a seemingly clear diagnosis, one was ordered in this academic setting. An axial short-T1 inversion recovery (STIR) MRI of the right leg is shown in figure 1.
Dr Caldwell is an assistant professor in the department of medicine at the Ohio College of Podiatric Medicine, a podiatric physician in the department of orthopaedic surgery at The Cleveland Clinic Foundation, and director of podiatric primary care residency training at Richmond Heights General Hospital, all in Cleveland. Address correspondence to Bryan D. Caldwell, DPM, MS, Dept of Medicine, Ohio College of Podiatric Medicine, 10515 Carnegie Ave, Cleveland, OH 44106.
The author thanks James Lichniak, DPM, and Bernice Krumhansl, PT, for their expert participation in the care of this patient.