Working Diagnosis:
Acute compartment syndrome due to a hematoma from a gastrocnemius tear.

Treatment:
This patient underwent an emergent four-compartment fasciotomy without complication

Outcome:
Post-surgery, the patient recovered sensation and strength in the right leg.

4 days following discharge, he developed an acute DVT, was readmitted, and placed on anticoagulation therapy.

3 months following the initial presentation, the patient was able to return to full activity as tolerated with mild swelling as the only residual symptom.

Author's Comments:
Acute compartment syndrome is a surgical emergency requiring a high index of suspicion by the examiner to ensure rapid treatment and favorable outcomes.

Without timely recognition, increased pressures can lead to irreversible tissue ischemia, permanent sensory deficits, and paralysis. most commonly occurs with trauma such as fractures, crush injury, and contusions. It is less common to occur with muscle tears, as in this case.
This patient's case illustrates the classic progression of symptoms: Pain out of proportion to the clinical situation, which led to pain with passive stretch, and eventually signs of paresthesias and sensory deficits.

Editor's Comments:
This case underscores the importance of keeping a differential broad even in cases that may appear as simple straightforward cases. A calf strain or rupture of the head of the gastrocnemius is not uncommon in an older male athlete, particularly in sports that require sudden, quick, explosive moves. Ruptures often occur at the myotendinous junction. This patient’s course did not follow the usual trajectory of improvement with time and relative rest. It is important to recognize potential rare complications when the patient’s symptoms do not follow the expected course.

Cases of compartment syndrome can be missed and patients may not always present acutely or even sub-acutely, as in this scenario. The classic signs and symptoms of compartment syndrome (5Ps) only occur in the very late stages (pain, pallor (pale skin tone), paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness with movements). In real-world practice, they are unreliable indicators and the clinician must have a high suspicion for compartment syndrome.

References:
1. Compartment Syndrome. In: Brukner & Khan's Clinical Sports Medicine. North Ryde, New South Wales: McGraw-Hill Education (Australia); 2020:25-26.

2. Power RA, Greengross P. Acute lower leg compartment syndrome. Br J Sports Med. 1991;25(4):218-220. doi:10.1136/bjsm.25.4.218.

3. Gorczyca JT, Roberts CS, Pugh KJ, Ring D. Review of treatment and diagnosis of acute compartment syndrome of the calf: current evidence and best practices. Instr Course Lect. 2011;60:35-42.

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