Martin Nash: A 21-Year-Old Sprinter With Medial Calf Pain and Bruising

Learning Objectives

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Learn the common causes of medial calf pain.
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Learn the common causes of tennis leg.
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Develop an understanding of the anatomy of the popliteal fossa.
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Develop an understanding of the differential diagnosis of tennis leg.
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Learn the clinical presentation of tennis leg.
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Learn how to examine the lower extremity.
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Learn how to use physical examination to identify tennis leg.
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Develop an understanding of the treatment options for tennis leg.

Martin Nash

Martin Nash is a 21-year-old sprinter with the chief complaint of, “I heard a pop and it felt like someone stuck a knife in my leg.” Martin reported, “Doc, I can’t believe this happened to me. I was in the starting block for the qualifying 100 and I hear the starting pistol; I push off and I hear a sound like another pistol going off. I feel a sharp pain in my calf, and down I go. It’s just not fair. This was supposed to be my year, and here I am limping around with a leg that looks like it got hit by a baseball bat. I’ve been trying to rehab my leg, and the hydrotherapy and ice rubs seem to help, but now that the swelling is going down, I noticed that I have a big divot in the back of my leg. What’s that all about?” I responded to Martin, “Just a few more questions. Any fever, chills, or other constitutional symptoms such as weight loss, night sweats, etc.?” Martin shook his head no. I asked Martin if he had ever had any previous leg injuries and he again shook his head no.

I asked Martin how he was sleeping and he said, “My sleep is getting a little better each day as the swelling and pain improve, but just look at my leg. What a mess I’ve gotten myself into! What am I going to do?” Martin looked like he was about to cry, so I again reassured him that I would do my best to sort out what was going on and get him better.

On physical examination, Martin was afebrile. His respirations were 18, his pulse was 78 and regular, and his blood pressure was 134/70. Martin’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of Martin’s left lower extremity revealed ecchymosis that ran from his medial calf to the ankle. I agreed his leg looked like it had been hit with a baseball bat. The calf was a little warm, but there was no obvious infection. Examination of his left medial calf revealed tenderness to palpation and an obvious defect in the medial calf. The Thompson squeeze test was negative for Achilles tendon rupture ( Fig. 15.1 ). There was no obvious abnormal mass or bursitis, specifically there was no suggestion of a Baker cyst. There was no obvious evidence of thrombophlebitis or pseudothrombophlebitis, but Homans sign was difficult to interpret, given the amount of residual calf pain from the traumatic event. A careful neurologic examination of the upper extremities was completely normal. Deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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A history of the sudden onset of left medial calf pain after a push-off injury
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An audible pop was associated with the injury
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A feeling like a knife was stuck into the medial calf
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Significant bruising
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A divot in the medial calf
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No numbness
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No weakness
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No history of previous significant lower extremity injuries
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No fever or chills
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Mild sleep disturbance
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Pain on weightbearing and squatting
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Pain relief with elevation and flexion of the affected medial calf

The Physical Examination

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The patient is afebrile
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Massive ecchymosis from the medial calf to the ankle
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Tenderness on palpation of the left medial calf
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Obvious defect at the distal end of the gastrocnemius muscle
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No evidence of ruptured Achilles tendon as evidenced by negative Thompson squeeze test
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No abnormal mass noted
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No thrombophlebitis or pseudothrombophlebitis
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No obvious infection

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper extremity neurologic examination, motor and sensory examination

What Tests Would You Like to Order?

The following tests were ordered:

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Ultrasound of the left medial calf
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Magnetic resonance imaging (MRI) of the left medial calf

Test Results

Ultrasound examination of the left medial calf reveals a large hematoma within the torn gastrocnemius muscle ( Fig. 15.2 ). MRI scan of the left medial calf reveals an acute medial gastrocnemius muscle tear with focal areas of hematoma and a partially retracted muscle belly ( Fig. 15.3 ).