I recently read an article in the Journal of Orthopedic and Sports Physical Therapy that discusses an interesting situation we should all be aware of – deep-vein thrombosis (DVT) presenting as a calf strain.1 The case involved a 21-year-old runner who presented with a calf that felt tight and achy. The patient related that he remembered straining his calf four days previously when he lifted 40 pounds over his head while straightening his knees out of a squat position. There was mild edema over the left calf, pain on toe walking, unilateral heel raises and double-leg squatting, and decreased dorsiflexion of 10° on the painful side. Lower extremity pulses were normal.
Ice, triceps surae stretches, a compression stocking and ibuprofen were prescribed. Three days later, he was 80 percent better and had no visible edema or ecchymosis; in fact, except for pain on palpation over the gastrocnemius and soleus, all previous positive tests were negative. I think most of us would agree with the diagnosis of a calf strain.
But four weeks later, the patient still felt a "low-intensity, nagging pain" in his left calf. An important finding regarding a possible deep-vein thrombosis was that the patient had experienced increased pain following a six-hour plane ride, causing him to seek help at a local emergency unit. He was told to use ice and stretching, which again relieved his symptoms. The main findings four weeks later, besides the pain after the plane ride, was that lower-leg edema was visible along with a 2+ pitting edema. All other previous tests were still normal.
cardiovascular mortality in North America.2 Unfortunately, a clinical diagnosis of DVT in the office can be difficult. For years, Homans' test was an acceptable test for DVT; the supine patient's knee is partially flexed and the practitioner forcibly dorsiflexes the ankle, exerting traction on the posterior tibial vein, causing pain.
Most studies give poor marks for Homans' sign, based on it being present in 33 percent of patients with true thrombosis and positive in greater than 50 percent of symptomatic patients without DVT.3 Venography is the reference standard for diagnosing DVT, but it is an invasive test that can be painful and is associated with allergic and other side effects. It should be reserved for patients having a high probability of the condition; other noninvasive tests, such as venous ultrasonography, impedance plethysmography4 and the D-dimer test, can often be used first for what are considered low-probability patients.
The D-dimer blood test, when negative, means it is most likely that the person tested does not have an acute condition or disease causing abnormal clot formation and breakdown. Most doctors agree that a negative D-dimer is most valid and useful when the test is done on people who are considered to be at low to intermediate risk for thrombosis. The test is used to help rule out clotting as the cause of symptoms.
In the case history described above, the lengthy plane ride was an important clue regarding potential DVT. We should tell our patients that regardless of the risk of DVT, they should avoid dehydration and frequently exercise their leg muscles. There is evidence that travelers on flights longer than six hours and with one or more risk factors for DVT should also consider knee-high graduated compression stockings, 15-30 mmHg at the ankle.
References
Theiss JL, Fink ML, Gerber JP. Deep vein thrombosis in a young marathon athlete. JOSPT, 2011;41(12):942-947.
Wells PA Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patient's probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost, 2000;83:416-420.
Cranley JJ, Canos AJ, Sull WJ. The diagnosis of deep venous thrombosis. Fallibility of clinical symptoms and signs. Arch Surg, 1976;111:34-6.
Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA, Jan. 11, 2006;295(2):199-207.
Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ, Oct. 24, 2006;175(9):1087-92. (Erratum in CMAJ, Nov. 20, 2007;177(11):1392.)
While cervical disc pathology can unquestionably produce radiculopathy, many patients presenting with arm pain, paresthesia or perceived weakness do not exhibit the clinical behavior of true nerve-root compromise. In these cases, failure to differentiate the primary pain generator may lead to unnecessary spinal injections, nerve ablation procedures or surgical consultation despite limited likelihood of benefit.
The New Jersey Board of Chiropractic Examiners has made a precedential decision, concurring with the Association of New Jersey Chiropractors' (ANJC) position paper on chiropractic X-ray guidelines. In plain terms, the board ruled, consistent with the ANJC position, that insurance companies cannot use medical X-ray rules or recommendations, like those written by the American College of Radiology (ACR), to decide whether a chiropractor's X-ray was necessary.
For decades, chiropractors have been told the answer to more professional referrals is simple: educate medical doctors about chiropractic. There is some truth in that advice; but it is also incomplete. The modern challenge is not simply getting another healthcare professional to know that chiropractors exist. It is becoming the kind of clinician (and building the kind of professional relationship) that makes collaboration easy and sustainable.
