Calf pain

EBM Guidelines
9.12.2009

Essentials

  • Diagnose acute arterial occlusion, deep venous thrombosis and erysipelas immediately.
  • Recognize critical ischaemia and refer the patient urgently.
  • Recognize compartment syndrome and stress fracture (which are particularly common in military conscripts and athletes).

Symptoms, signs and diagnostic clues

Table 1. Symptoms, signs, and diagnostic clues in calf pain
Symptom or signDiagnostic clue
Calf or ankle oedema «Leg oedema»1
  1. Deep venous thrombosis «Deep vein thrombosis»2
  2. Insufficient valves in deep veins (stasis eczema; «Venous insufficiency of the lower limbs»3)
  3. Ruptured Baker's cyst (history of a mass in the popliteal fossa; «Baker's cyst»4)
Erythema of the skinErysipelas «Erysipelas and cellulitis»5
Local pain in the skinSuperficial thrombophlebitis «Superficial venous thrombophlebitis»6
Intermittent claudication
  1. Lower limb ischaemia «Lower limb ischaemia»7 (weak or absent pulses; lowered ankle-brachial index on Doppler ultrasonography)
  2. Spinal stenosis «Lumbar spinal stenosis (LSS)»8
Back pain exacerbated by bending forwardsSciatica «Low back pain»9; pain often felt also elsewhere than in the calf
Pain felt near the heelAchilles tendon injury «Achilles tendinopathy and tendon rupture»10
Military conscripts or athletes
  1. Stress fracture (local tenderness on the tibia; «Stress fractures»11)
  2. Compartment syndrome «Muscle compartment syndromes»12
Sudden onset
  1. Muscle injury «Muscle injuries»13
  2. Ruptured Baker's cyst
  3. Arterial embolism (coldness, pulselessness, paleness; «Lower limb ischaemia»7)

Clinical examination

  • Localize the pain by history, palpation, and straight leg raising test.
  • Recognize pitting oedema of the ankle by pressing with a finger for long enough.
  • Palpate the peripheral pulses (only a strong pulse is definitely normal)
  • Examine the arteries (and veins) with a doppler stethoscope if available «Doppler stethoscopy in diagnostics»14.
  • Deep vein thrombosis can be excluded in low-risk patients with d-dimer test in primary health care «Deep vein thrombosis»2.