What Are the Most Common Causes of Lower Leg Pain?

Calf fibular muscle pain and tenderness are characteristic manifestations of venous thrombosis. Venous thrombosis is an acute non-suppurative inflammation of the veins and is accompanied by secondary vascular lumen thrombosis.

Calf muscle pain and tenderness

Calf fibular muscle pain and tenderness are characteristic manifestations of venous thrombosis. Venous thrombosis is an acute non-suppurative inflammation of the veins and is accompanied by secondary vascular lumen thrombosis.

Affected area

Limbs

Related diseases

Pulmonary embolism, thrombosis, venous thrombosis, venous thrombosis in lower limbs, venous edema

Related symptoms

Trauma, low fever, varicose veins, venous thrombosis, calf muscle pain and tenderness, etc.

Affiliated Department

Other departments

Related inspections

EMG

In the mid-19th century, the three elements of deep venous thrombosis proposed by RLK Fillshaw-venous blood flow retardation, hypercoagulable state of the blood, and venous intimal injury-were still recognized by the vascular surgery community by 2019. Most venous thrombosis occurs in the pelvic cavity and the deep veins of the lower limbs. This is closely related to the anatomy and function of the lower limb veins. The lower limb veins have more venous valves. When the human body is standing or sitting, the venous pressure of the lower limbs is much higher than the body. Other parts. The lower extremity venous return is dependent on the pump generated when the muscles contract. Therefore, the lower extremity venous blood returns slowly when standing and sitting. Thrombosis often occurs in a venous valve bag when there is no significant venous intimal damage. The thrombus is not tightly adhered to the vessel wall, is easy to fall off and can cause pulmonary embolism.

70% of the lower extremity blood flows back to the heart through the deep veins, and 30% goes to the superficial veins (large saphenous and small saphenous veins). The superficial vein flows into the deep vein (femoral vein) at the base of the thigh. Therefore, thrombus formation in the popliteal vein and femoral vein will cause the superficial veins to dilate and the blood flow to increase after the deep vein blood flow is blocked to compensate the deep vein blood flow obstruction. As a result, great saphenous varicose veins and concave edema of the affected limb appeared. Thrombosis occurs in the veins. The tenderness of the calf muscles is obvious. When the forefoot is sharply dorsiflexed, deep calf muscle pain (Hormans' sign) is induced.

According to the location of the thrombus, it can be divided into two categories.

1. Superficial venous thrombosis often involves large saphenous veins or small saphenous veins or their branches, which mostly occur on the basis of varicose veins. The main feature is pain in the site of thrombosis, and there is a red, low-temperature cord in the superficial veins. There are tenderness, redness and swelling around, the emboli are not easy to fall off, and generally do not cause pulmonary embolism. In addition, migrating superficial venous thrombosis is often a suggestive symptom of cancer.

2. Deep vein thrombosis can be divided into the following two types according to its location and condition.

(1) Deep venous thrombosis of the lower leg: It often occurs in the deep veins of the lower leg, such as the posterior tibial vein and peroneal vein. It is more common in patients with less motion in the bed, and it usually occurs in the second week after surgery. The left lower limb is most common. It is characterized by pain and tenderness in the calf muscles of the calf, severe throbbing after exercise, and even worse in dorsiflexion of the foot, and the systemic symptoms are not significant. There may be Homan sign during examination, that is, straight leg, dorsiflexion of the foot, and gastrocnemius muscle Lesion of the diseased vein is painful, and the circumference of the gastrocnemius muscle may be thickened by more than 5 cm compared with the healthy side.

(2) , femoral venous thrombosis: secondary to calf venous thrombosis, but mostly primary from the iliac femoral vein, common in postpartum, sudden onset, severe diffuse edema of the affected limb, elevated skin temperature or slight The superficial veins are dilated, there is intolerable pain in the inner thighs and significant tenderness along the veins, especially the femoral triangle, and the systemic symptoms are not severe.

Diagnostic check

1. Ask if you have a history of trauma, time of injury and treatment, history of long-term bed rest, surgery, pregnancy, childbirth and oral contraceptives, and history of repeated venipuncture or intravenous infusion catheters. Whether the symptoms and duration are consistent, the location and development of the onset, the nature of the pain, whether fever, swelling and pain in the affected limb, etc.

2. During the local examination, pay attention to the tenderness, tenderness, and swelling of the affected limb (you must accurately measure the perimeter with a tape measure on the thickest plane every day, and compare it with the same plane on the healthy side). Skin color And temperature (compared to the contralateral side, it is best to use a skin temperature measuring device), whether there is a change in the pulse of the distal limb, whether there is a tender cord on the body surface, whether there are infection lesions and foot boots Area nutritional changes, such as scaling, itching, pigmentation, eczema and ulcers.

3. When it is difficult to diagnose or to define the scope of the lesion, ultrasound examination, pulse Doppler spectrum examination, and venography can be used to effectively determine the presence or absence of thrombus, the location, scope, morphology, and collateral circulation of the thrombus.

4. Venous pressure measurement, dorsal venous puncture, needle pressure sensor or transparent plastic tube (filled with heparin-physiological saline solution) to measure venous pressure. Normal pressure is generally 12.7kPa (130cmH20), which is used for ankle extension. During flexion, the gastrocnemius muscle contracts, and the pressure drops significantly, generally it can be reduced to 5.9kPa (60cmH20). After stopping the activity, the pressure rises, and the recovery time exceeds 20s. For those who have thrombosis and blockage of the main vein, the pressure at rest or during activity is significantly increased, and the rise time is generally not more than 12 seconds.

Diagnosis of acute lower extremity venous thrombosis is often not difficult. Patients with postpartum, fractures, trauma, and postoperative surgery should consider the possibility of this disease if they experience limb pain, swelling, or superficial vein distension. When diagnosis is difficult, venous pressure measurement and venography can be performed. Radionuclide lower extremity venography is helpful for diagnosis and is safer. Doppler ultrasound blood flow detector can be used to check the thrombus formation outside the iliac crest and femoral vein. The venous thrombus deep in the muscle or in the pelvis is not accurate. The 125I-labeled human fibrinogen test is the most valuable for diagnosing deep muscle deep calf vein thrombosis. If it can be continuously checked for several days, the accuracy rate can reach more than 85%.

For those who have no significant pain and obvious swelling of their limbs, attention should be paid to distinguish them from lymphedema. The latter has a slow course, thickened skin, no superficial varicose veins, and swelling subsides after the limbs are raised in bed.

According to the location of the thrombus, it can be divided into two categories.

1. Superficial venous thrombosis: Large saphenous veins or small saphenous veins or their branches are often involved, which mostly occur on the basis of varicose veins. The main feature is pain in the site of thrombosis, and the outer surface of the superficial veins has a red, low-temperature cord. There are tenderness, redness and swelling in the surroundings, and the emboli are not easy to fall off, and generally do not cause pulmonary embolism. In addition, migrating superficial venous thrombosis is often a suggestive symptom of cancer.

2. Deep venous thrombosis: According to its location and condition, it can be divided into the following two types.

(1) Deep venous thrombosis of the lower leg: It often occurs in the deep veins of the lower leg, such as the posterior tibial vein and peroneal vein. It is more common in patients with less motion in the bed, and it usually occurs in the second week after surgery. The left lower limb is most common. It is characterized by pain and tenderness in the calf muscles of the calf, severe throbbing after exercise, and even worse in dorsiflexion of the foot, and the systemic symptoms are not significant. There may be Homan sign during examination, that is, straight leg, dorsiflexion of the foot, and gastrocnemius muscle Lesion of the diseased vein is painful, and the circumference of the gastrocnemius muscle may be thickened by more than 5 cm compared with the healthy side.

(2) , femoral venous thrombosis: secondary to calf venous thrombosis, but mostly primary from the iliac femoral vein, common in postpartum, sudden onset, severe diffuse edema of the affected limb, elevated skin temperature or slight The superficial veins are dilated, there is intolerable pain in the inner thighs and significant tenderness along the veins, especially the femoral triangle, and the systemic symptoms are not severe.

Diagnostic check

1. Ask if you have a history of trauma, time of injury and treatment, history of long-term bed rest, surgery, pregnancy, childbirth and oral contraceptives, and history of repeated venipuncture or intravenous infusion catheters. Whether the symptoms and duration are consistent, the location and development of the onset, the nature of the pain, whether fever, swelling and pain in the affected limb, etc.

2. During the local examination, pay attention to the tenderness, tenderness, and swelling of the affected limb (you must accurately measure the perimeter with a tape measure on the thickest plane every day, and compare it with the same plane on the healthy side). Skin color And temperature (compared to the contralateral side, it is best to use a skin temperature measuring device), whether there is a change in the pulse of the distal limb, whether there is a tender cord on the body surface, whether there are infection lesions and foot boots Area nutritional changes, such as scaling, itching, pigmentation, eczema and ulcers.

3. When it is difficult to diagnose or to define the scope of the lesion, ultrasound examination, pulse Doppler spectrum examination, and venography can be used to effectively determine the presence or absence of thrombus, the location, scope, morphology, and collateral circulation of the thrombus.

4. Venous pressure measurement, dorsal venous puncture, needle pressure sensor or transparent plastic tube (filled with heparin-physiological saline solution) to measure venous pressure. Normal pressure is generally 12.7kPa (130cmH20), which is used for ankle extension. During flexion, the gastrocnemius muscle contracts, and the pressure drops significantly, generally it can be reduced to 5.9kPa (60cmH20). After stopping the activity, the pressure rises, and the recovery time exceeds 20s. For those who have thrombosis and blockage of the main vein, the pressure at rest or during activity is significantly increased, and the rise time is generally not more than 12 seconds.

After venous thrombosis, if it is confined to the calf vein, the thrombus can gradually be mechanized, and the blood flow can be re-opened. Most of them do not leave symptoms. It develops into chronic lower extremity venous insufficiency, and limb swelling is not easy to subside. Because deep vein valves are damaged during thrombosis and inflammation, even if the blood flow is reopened, the hydrostatic pressure generated by gravity will cause the accumulation of cellulose in the tissue, the hardening of fatty connective tissue, the change of the skin with stasis dermatitis, and even the occurrence of veins. Stasis ulcers cause a degree of illness in the limbs.

Early stage of deep vein thrombosis of the lower extremities, easy to fall off. If the emboli is large, embolism in the left and right main pulmonary arteries can cause large pulmonary embolism, which is often one of the causes of sudden death. Therefore, it is important to prevent venous thrombosis of the lower limbs.

It is particularly important to strengthen prevention for elderly, obese and patients with previous thrombophlebitis. Patients with fractures, trauma, and postoperative movements are encouraged to actively move their limbs and perform deep breathing exercises to promote venous return. Get out of bed as early as possible. During pelvic and lower limb surgery, the operation should be gentle to avoid damaging the blood vessels. Wear elastic socks after surgery to promote venous return of the lower limbs. For patients undergoing surgery, heparin or dextran can be used to reduce platelet activity in order to combat the hypercoagulable state of blood that may occur after surgery. Deep venous thrombosis is mainly treated non-surgically. In the acute phase, bed rest is needed to raise the affected limb, which can reduce pain and promote local inflammation to subside. To prevent the spread of blood clots, heparin and coumarin drugs are used for anticoagulation therapy. In order to prevent venous function caused by thrombus, thrombolytic therapy should be started early in the onset of the disease. The commonly used drugs are streptokinase and urokinase.

To prevent pulmonary embolism, venous thrombectomy can be performed within 48 hours after iliac vein thrombosis. For those who have a slightly longer course of disease, thrombus is not easy to remove and there is a risk of pulmonary embolism, a filter plug device can be placed in or outside the inferior vena cava to prevent pulmonary embolism.