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Probability diagnosis

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Simple muscular cramp

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Muscle soreness (post exercise)

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Muscle injury esp. gastrocnemius tear

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Claudication esp. vascular (intermittent)

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Serious disorders not to be missed

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Vascular:

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  • Deep venous thrombosis

  • Peripheral vascular disease

  • Superficial thrombophlebitis

  • Popliteal artery entrapment

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Infection:

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  • Cellulitis

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Other:

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  • Achilles tendon rupture

  • Neurogenic claudication

  • Deep posterior muscle compartment syndrome

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Pitfalls (often missed)

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Referred pain: knee, spine

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Ruptured Baker’s cyst

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Superficial posterior compartment syndrome

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Nerve entrapment e.g. tibial, sural

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Stress fracture of fibula

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Rarities:

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  • Hypocalcaemia→cramps

  • Motor neurone disease

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Masquerades checklist

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Diabetes

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Drugs e.g. beta blockers

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Thyroid/other endocrine: hypocalcaemia

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Spinal dysfunction: L5 referred

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Is the patient trying to tell me something?

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Possibly muscle tension

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Key history

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A history of the features of the pain-quality, onset (acute or slow), ‘tearing’ or ‘popping’ sound, relation to activity and associations esp. back or knee pain.

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Document any preceding sporting activity, travel, immobilisation, varicose veins or claudication—neurogenic or vascular pattern.

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Key examination

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  • Calf muscle examination incl. Achilles tendon, functional stress, swelling or bruising

  • Lumbosacral spine and knee of affected side

  • Veins and arteries of leg esp. peripheral pulses

  • Neurological—sensation, power, reflexes esp. ankle

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Investigations

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Nil for most cases.

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Consider:

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  • FBE

  • ESR/CRP

  • muscle enzymes

  • imaging e.g. ultrasound, D-dimer, venography, angiography

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Diagnostic tips

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Neurogenic claudication is muscular pain starting proximal and radiating distal on walking, and persists for a while after resting. Vascular claudication starts in the calf, radiates proximal and abates on rest.

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