Lower Leg Swelling - Noncontact Injury

HISTORY: 48-year-old male presented to clinic after ED visit for acute left thigh swelling. Reports pain and swelling to the left thigh after waking up 1 week ago. Denies any preceding trauma, falls, travel or injury. Has pain with ambulation, standing and when bending/flexing knee. He does have a history of diabetes, high blood pressure and is a former smoker. PHYSICAL EXAMINATION: Left medial thigh with approximately 10 cm area of hardened tissue at mid femur level. . No overlying skin changes. Able to perform straight leg raise test. Left hip with 90 degrees of flexion, knee with flexion from 0-140 degrees reproducing pain in thigh. DIFFERENTIAL DIAGNOSIS: 1.Deep Venous Thrombosis2.Muscle Strain3.Muscle Infarct4.Sarcoma TESTS AND RESULTS:Left knee and femur radiographs with no acute osseous findings.Labs: A1c (15.6%), POC Glucose (521), ESR (61), CRP (0.81)Left knee MRI with contrast significant for enhancement and edema of the vastus medialis and short head of biceps femoris muscle likely due to muscle infarct with areas of myonecrosis as well as superimposed grade 2 or 3 vastus medialis muscle strain.Due to pain in posterior left knee presented to ED 6 weeks after initial diagnosis, repeat left knee MRI was done: showed enhancement and edema within the distal gracilis, distal vastus medialis, satorius, semitendinosus and short head of biceps femoris muscle suggesting nonspecific myositis secondary to early diabetic muscle ischemia without actual necrosis. Extent is increased to previous MRI, but myonecrosis of vastus medialis resolved. FINAL WORKING DIAGNOSIS: Vascular infarct secondary to diabetes resulting in myonecrosis of left vastus medialis, sartorius, semitendinosus and short head of biceps femoris with resulting myonecrosis. TREATMENTS AND OUTCOMES: 1.Recommended tight glucose control.2.Baby aspirin 81 mg started3.Pain management with Tylenol 1000 mg q6hr and Ibuprofen 800 mg q8hr4.Due to progression repeat MRI, lost ability to fully extend knee5.Atorvastatin, gabapentin ordered 6.Ultrasound ABIs ordered 7. Patient able to overall ambulate, pain has improved, has continued his job and currently working with PCP for diabetic management