Extensive Venous Thrombosis in a Runner
Progression of Symptoms Key to Diagnosis
Alfred Fleming, MD; Donald Frey, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 1 - JANUARY 2022
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In Brief: Although usually considered a disease of sedentary people, deep venous thrombosis can occur in active patients. Physical findings may be difficult to differentiate from those of muscle trauma, a Baker's cyst, or hematoma. A high index of suspicion must be maintained, because delay in making the diagnosis and initiating anticoagulation may have fatal consequences. Doppler flow studies are required in all cases of limb pain or swelling in runners when deep venous thrombosis is even remotely suspected, as in this case of a 40-year-old man who developed ankle and lower-leg pain 1 month after a 10-km run. If promptly treated, patients can make a safe return to training without adverse consequences.
Family physicians are frequently consulted to evaluate running-related injuries. Leg pain and swelling are the most frequently reported symptoms of runners who seek treatment. Most commonly, history and physical examination reveal minor muscle trauma as the source of the pain. Less commonly, a Baker's cyst or exertional compartment syndrome may be diagnosed. Rarely, deep venous thrombosis (DVT) resulting from competitive running may be the cause.
Because the accepted risk factors for DVT include a sedentary lifestyle, smoking, obesity, and prolonged periods of inactivity, DVT may not be considered in runners who have pain and swelling in a lower leg. Failure to diagnose DVT promptly can obviously lead to significant morbidity from postphlebitic syndrome or death from pulmonary embolism. Consequently, it is imperative that family physicians consider DVT in the differential diagnosis of any runner who has lower-leg pain and swelling immediately or soon after competition. We believe this to be only the second reported case of DVT occurring in a runner after a race.
A 40-year-old man came to our office with progressive left lower-leg swelling and pain 1 month after completing a 10-km run. The patient had run regularly for the past 20 years. He developed ankle and heel pain and lower-leg discomfort after completing the run, which he attributed to finishing the race on an uphill slope. The patient continued to run over the next 2 weeks; however, the discomfort and ankle swelling continued. After a week off from training, he noted some improvement. The following week, after a 3-mile run, pain and swelling returned. Over the course of the next week, calf pain and swelling developed, associated with pain in the medial aspect of the anterior thigh, which made walking increasingly painful. The progression of symptoms prompted the patient to seek evaluation.
On physical examination, the left calf was tender to palpation, and left calf circumference exceeded that of the right by 3 cm. No warmth or erythema of the calf was noted. Dorsalis pedis and posterior tibial pulses were normal, as was tissue perfusion of the foot.
Because of the nature and duration of the symptoms and physical findings, the initial impression of the examining physician was extensive soft-tissue swelling from muscle trauma, with possible impending compartment syndrome. DVT was considered a possible, but unlikely, diagnosis. Ultrasound and Doppler flow studies revealed thrombosis of the left posterior tibial, popliteal, and superficial femoral veins. The patient was admitted to the hospital and started on intravenous heparin as well as oral warfarin sodium.
The patient did not harbor antiphospholipid antibodies or the factor V Leiden mutation. Protein C, protein S, and antithrombin III levels were normal. The patient was evaluated for the prothrombin 2010A mutation and was found to be negative. A ventilation perfusion scan was not considered or performed, because the patient was asymptomatic subsequent to this report. Prostate-specific antigen was normal. After achieving full anticoagulation with intravenous heparin and warfarin (partial thromboplastin time 1.5 to 2.0 times normal and international normalized ratio 2-3), the patient was discharged. The patient returned to work 2 weeks later and continued oral warfarin therapy.
While the pain decreased, postphlebitic swelling of the left lower leg continued over the next month. A follow-up ultrasound was performed 1 month later, which revealed resolution of the clot in the posterior tibial and popliteal veins with reestablished flow, but slow resolution of the clot in the superficial femoral vein. Two months after the thrombosis, our patient was allowed to begin walking and bicycling.
Attempts at running resumed during the third month after the thrombosis, while full anticoagulation was continued with oral warfarin. No bleeding problems occurred during initiation of training. Three months after the thrombosis, while anticoagulation was maintained with oral warfarin, the patient successfully completed a 10-km run, with discomfort noted 48 hours after the race. Two weeks later, he completed another 10-km run with decreasing postphlebitic swelling, less discomfort, and improved race times. He began running 3 miles two to three times per week as maintenance after the races. Anticoagulation with an international normalized ratio of 2-3 was continued for a total of 6 months, along with the use of elastic stockings. A regular training program of 9 to 12 miles per week is ongoing.
After the patient's mother died from a pulmonary embolus, the patient was rescreened and found to be homozygous for the thermolabile type of methylenetetrahydrofolate reductase deficiency (MTHFR C677T). This gene mutation was not evaluated at the time of the original presentation.
DVT is considered a condition that develops in sedentary patients.1 Intuitively, this condition is not considered when a runner presents with leg discomfort and swelling. Running is associated with a decrease in hemoglobin and hematocrit, a lower fibrinogen level, and an increase in fibrinolytic activity—factors that should, in theory, lower the risk of developing DVT.1
Family physicians are frequently called upon to evaluate runners who have unilateral lower-leg pain and swelling. The differential diagnosis of such patients includes compartment syndrome, hematoma, and Baker's cyst, as well as DVT.
Compartment syndrome, caused by direct or indirect trauma to muscle tissue contained within a fixed fascial space, results in progressive swelling and pain in the affected extremity. Unlike DVT, compartment syndrome usually results in diminished pulses distal to the compartment, cool extremities, and ischemic pain.
Although hematoma is usually the result of a direct trauma to the muscle, severe overuse may cause hematoma formation, as well. A hematoma is generally localized to only a portion of the affected muscle; however, the clinical picture of hematoma can often be confused with DVT.
Although a Baker's cyst usually manifests as a gradually expanding fluid-filled mass in the popliteal space, exercise may precipitate a more rapid expansion of the cyst, and pain may be more pronounced postexercise. This, too, may present a picture easily confused with DVT.
Because DVT is seen infrequently in runners, and is easily confused with the conditions noted above, it is imperative that ultrasound and Doppler flow studies be considered in any runner who has sudden, unexplained pain and swelling in the lower leg after exercise.2 As in this case, ultrasound studies can quickly assist in diagnosing a DVT and allow for rapid initiation of appropriate therapy.
As in other reported cases,1,3-5 a delay in diagnosis occurred with this patient. Only with progression of symptoms and a high index of suspicion was the correct diagnosis made.
Return to training was accomplished safely in this case by following the recommendations of Roberts and Christie,1 who advocate a gradual return to training. If done slowly and conservatively, return to training after DVT can be safely accomplished in active patients, as long as appropriate anticoagulation is maintained. At least 1 full month of anticoagulation and follow-up diagnostic studies, as well as an improved clinical status, are recommended before running is resumed.
This case report emphasizes the need for consideration of DVT in the differential diagnosis of leg pain in runners. Delay or failure to diagnosis DVT can have fatal consequences.
Dr Fleming is the chair and program director in the department of obstetrics and gynecology and Dr Frey is chair of the department of family medicine at Creighton University School of Medicine in Omaha, Nebraska. Address correspondence to: Alfred Fleming, MD, Creighton University School of Medicine, Dept of Obstetrics and Gynecology, 601 North 30th St, Omaha, NE 68131; e-mail to [email protected].
Disclosure information: Drs Fleming and Frey disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.