Calf Pain - A Football Player With Sudden Tension-Like Pain

HISTORY: A 17-year-old senior high school football player complained of right calf pain. He reports feeling slight tension-like pain of the anterior and lateral right lower leg after an opposing player fell directly on his calf during a tackle. He was adamant that he was okay as so to continue playing and the pain improved during the game. Following the game, the player reports pain worsening over the right anterior lower leg and lateral calf with self-reported swelling. He denied any numbness, tingling or skin changes on the day of the injury. He reported to the athletic trainer who encouraged him to follow up in the office. The patient was seen four days following his injury. His pain had improved but still remained in the lateral and anterior compartments of the lower right leg. ROS negative. PMHX: GI malabsorption, multiple stress fractures. PSHx: none. FHx: unremarkable. Meds: Vit D. PHYSICAL EXAMINATION: Examination of the right lower extremity in office revealed no gross deformity, ecchymosis, swelling or atrophy. Tenderness to palpation over his anterior and lateral compartments of the right lower extremity with a tense quality. The range of motion and strength testing was full. Talar tilt testing and Thompson testing were negative. Capillary refill was intact with bounding pulses easily palpated in the right lower extremity over the dorsalis pedis. DIFFERENTIAL DIAGNOSIS: DVT, Muscular hematoma, Compartment Syndrome (Acute/Chronic), Tibia fracture, Fibula fracture, Radicular syndrome, trigger point with referred pain TEST AND RESULTS: XR Right Tibia and Fibula - negative RLE Venous Doppler - negative MRI w/o RLE - thrombosis of intermuscular vein between the peroneal longus muscle and EHL in the mid-distal calf extending at least 10 cm MRI w/wo RLE - evidence of a lobulated heterogeneous mass in the right extensor digitorum longus muscle with signal intensity consistent with a spontaneous intramuscular hematoma FINAL WORKING DIAGNOSIS: Spontaneous Hematoma d/t trauma TREATMENT AND OUTCOMES: 1. Evaluated by orthopedic oncology, cleared to return to activity as tolerated 2. Hematologic and Gastrointestinal workup negative3. Repeat MRI in 2 months to evaluate for resolution 4. Was unable to return to sport prior to end of season