Working Diagnosis:
Partial-thickness tear of medial head of gastrocnemius with large intramuscular hematoma and partially occluded DVT of the peroneal vein at mid-calf.

Treatment:
Serial duplex ultrasounds were performed to monitor the peroneal vein DVT. No anticoagulation was started due to the large hematoma and the distal location of the clot. The patient was enrolled in physical therapy and performed progressive strengthening exercises. The patient was able to perform pain-free single leg exercises without loss of balance three months after the injury.

Outcome:
The patient was able to return to running and exercise four months after the injury.

Author's Comments:
Ruptured medial head of the gastrocnemius muscle (Tennis Leg) is a relatively common condition that presents with acute calf pain. The signs and symptoms can mimic that of DVT. Gastrocnemius muscle tears may result in hematoma formation and treatment consists of compression to decrease hemorrhage and early ambulation to facilitate hematoma resolution Return to sports is typically expected at around four weeks. These treatments are contraindicated for DVT and anticoagulation for DVT is contraindicated in the setting of a large hematoma. Therefore, it is important to determine the correct etiology of sudden onset calf pain in order to determine the correct treatment.

Editor's Comments:
Calf pain is common in athletes and can be due to musculoskeletal, neurological, and vascular causes. It is important to have a wide differential diagnosis when evaluating athletes with calf pain. Clinicians must maintain a high clinical suspicion for potentially life threatening conditions, such as DVT. D-dimer can be used as a screening and venous duplex ultrasonography is both sensitive and specific for the diagnosis of DVT. Tear of the medial head of the gastrocnemius (tennis leg), most commonly occurs in middle-aged athletes. Athletes typically feel a pop or feeling of being shot in the leg after attempting to forcefully plantarflex the ankle while the knee is extended. Treatment of medial gastrocnemius tears typically consists of rest, ice, compression sleeves, heel lifts, and crutches or immobilization in a walking boot for a short time, if needed. This is followed by progressive strengthening exercises. Time to return to play varies from a few weeks to 3-4 months, depending on the severity of the injury.

References:
2016 Sep-Oct;15(5):320-4. doi: 10.1249/JSR.0000000000000292. PMID: 27618240.
Flecca D, Tomei A, Ravazzolo N, Martinelli M, Giovagnorio F. US evaluation and diagnosis of rupture of the medial head of the gastrocnemius (tennis leg). J Ultrasound. 2007 Dec;10(4):194-8. doi: 10.1016/j.jus.2007.09.007. Epub 2007 Oct 25. PMID: 23396898; PMCID: PMC3553076.
Leow KS, Chew KM, Chawla A, Lim TC. Sonographic assessment of musculoskeletal causes of calf pain and swelling. Emerg Radiol. 2019 Jun;26(3):349-359. doi: 10.1007/s10140-019-01680-5. Epub 2019 Feb 13. PMID: 30761444.
Liu SH, Chen WS. Medial gastrocnemius hematoma mimicking deep vein thrombosis: report of a case. Taiwan Yi Xue Hui Za Zhi. 1989 Jun;88(6):624-7. PMID: 2794964.
McClure JG. Gastrocnemius musculotendinous rupture: a condition confused with thrombophlebitis. South Med J. 1984 Sep;77(9):1143-5. Doi: n10.1097/00007611-198409000-00023. PMID: 6484684.
Pacheco RA, Stock H. Tennis leg: mechanism of injury and radiographic presentation. Conn Med. 2013 Aug;77(7):427-30. PMID: 24195182.
Slawski DP. Deep venous thrombosis complicating rupture of the medial head of the gastrocnemius muscle. J Orthop Trauma. 1994;8(3):263-4. Doi: 10.1097/00005131-199406000-00016. PMID: 8027900.

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