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Close concept: calves pains
Shin pains represent a complex clinical problem as are a frequent symptom not only such potentially dangerous state as venous thrombosis, but also many less dangerous diseases. In most cases shin pains are caused by one or several disturbances which will easily respond to treatment. Shin pains meet more than at 50% of patients with symptoms of the venous thrombosis confirmed with a flebografiya, however are not specific symptom, and their intensity and prevalence do not correlate with sizes (therefore, and with potential danger) venous blood clots. The doctor faces a dilemma: of what cases at shin pains it is necessary to suspect venous thrombosis and to resort to objective methods of research and in what — it with full confidence can be excluded.
In the present article various reasons of pains in shins are discussed, and also practical approach to their diagnosis by means of special and objective methods of research is planned.
Reasons of pains in shins
Pain receptors are located in the majority of tissues of shin, including in muscles, bones, ligaments, sinews, vessels and the fabrics surrounding them. Shin pains can be caused by inflammatory process in any of these structures as it happens, for example, at the deep vein thrombosis resulting from an inflammation of a vascular wall or the fabrics located around a vessel. Thereof shin pains can arise at a number of frustration (tab).
Reasons of pains in a shin
Stretching, spasms or injury of muscles
Direct muscle injury or lower extremity
Spontaneous hematoma in muscles
Arterial insufficiency (ischemia of muscles)
Rupture of a subnodal cyst (Baker's cyst)
Arthritis of knee or talocrural joints
Inflammation of soft tissues of the lower extremity
Damage of bones
Thrombosis of superficial veins
Pregnancy or reception of peroral contraceptives
Inflammation of a hypodermic fatty tissue
Injury of sinews
At most of patients venous thrombosis proceeds without clinical manifestations. Emergence of symptoms or signs is caused usually by the occlusion of a vein interfering a blood-groove, an inflammation of a vascular wall or the fabrics surrounding it, a combination of these factors or a thromboembolism of vessels of lungs. The most common clinical symptoms and symptoms of venous thrombosis are pain, morbidity at a palpation and puffiness. It is necessary to emphasize, however, that these symptoms are not specific and can be caused by any of the morbid conditions listed in the tab. Homan's symptom (emergence of pains in a certain time of day) is also not specific and it can be found at many frustration simulating venous thrombosis. Therefore, in spite of the fact that on the basis of the specified clinical symptoms it is possible to suspect venous thrombosis, they cannot be used for differential diagnosis and the choice of medical tactics. Less widespread displays of venous thrombosis are the phlebectasia, change of coloring of a shin, including pallor, cyanosis, reddening, and also identification at a palpation venous tyazhy.
Pain and morbidity at a palpation. The reason of pain and morbidity at a palpation most often are the inflammation of a wall of a vein and a perivascular zone, and in case of thrombosis of proximal veins — expansion of a vein. At a shin vein thrombosis pain and morbidity at a palpation are usually localized in sural area, and at fibrinferment of proximal veins — in a shin, in a hip or in ileal area. Patients with thrombosis of distal veins have shins of pain and morbidity at a palpation when they are caused by the expressed puffiness of fabrics, can have more diffuse character.
Pains at venous thrombosis have no characteristics. They can be aching or convulsive, acute or stupid, strong or moderate. Very often they amplify when walking, carrying weights and are combined with local morbidity at a palpation. Pains can decrease in a prone position with the raised legs and against treatment by heparin, however these symptoms are also not specific to venous thrombosis.
The accompanying symptoms. Increase in the sizes of an extremity owing to hypostasis often accompanies the pains and morbidity at a palpation arising at venous thrombosis. Usually after pressing on area of hypostasis there is a deepening, however sometimes hypostasis is expressed slightly and it can be determined by increase in turgor of muscles of a shin which is the best of all for estimating at the relaxed muscles. If swelling of a shin is caused by obstruction of a big proximal vein, it is usually localized distalny places of obstruction and can be moderately painful. The puffiness caused by an inflammation usually is localized in the place of thrombosis and is followed by pains and morbidity at a palpation. If to place a leg in the raised situation, puffiness usually decreases.
The phlebectasia is rather rare display of acute venous thrombosis. This symptom is a precursory symptom of disturbance of outflow of blood on veins and usually disappears if to place an extremity in the raised situation, and also at development of a collateral blood-groove. Change of coloring of integuments of a shin also is rather rare display of venous thrombosis. The shin can have pale, cyanochroic or reddish-blue coloring. The cyanosis caused by disturbance of venous return and a congestive hypoxia arises at patients with obstruction of proximal veins of a shin, In Rare Instances, at the expressed inflammation of perivascular fabrics, the shin can have diffusion-red coloring that complicates differential diagnosis with an inflammation of hypodermic cellulose. Pallor, though is not a characteristic symptom, it can be found at early stages of a vein thrombosis of iliofemoral area and is probably caused by a spasm of arteries.
At thrombosing of a vessel easily available to a palpation, to the touch is defined soft tyazh. If the vein is located superficially, local temperature increase of an extremity can be defined.
Stretching or traumatizing muscles
Muscle pains can, arise after fast walking, jogging, occupations by tennis, circulations in badly picked up footwear. The sensation of discomfort can arise right after an unusual muscular exercise or later 12 — 24 h. Usually there are shin pains, however they can take also a hip. The morbidity at a palpation which sometimes is rather expressed can be noted. Puffiness happens not always, but muscles of a shin can look intense, become heavy and blown up. At some patients of pain are followed by significant increase in the size of a shin as a result of hypostasis.
If in the anamnesis there are instructions on an unusual exercise stress, and pains and morbidity at a palpation are observed in both legs and cover group of the muscles relating to front bolypebertsovy area to make the correct diagnosis rather simply. If, however, pains and morbidity at a palpation are noted in one extremity and cover only shin muscles, it is almost impossible to distinguish a muscle strain from venous thrombosis without use of objective methods of research.
Rupture of muscles
As a result of sudden severe stretching or reduction of muscles of a shin during bending in an ankle joint there can be a gap sural less often — a bottom muscle. Usually there is a rupture of a small site of a muscle in the place of its connection with a sinew, but there can sometimes be big gaps and even separation of a muscle from a sinew or a sinew separation. As a rule, the myorrhexis arises at sudden bending of an extremity in the direction opposite to the operating force, for example, at the time of start or sharp osta-forging during run. It is followed by sudden severe pain in back part of a shin which can be felt as a direct stroke to shin muscles. This pain can abate for some time, and then be replaced by the constant amplifying in process of increase of a hematoma and emergence of a spasm of muscles of a shin.
At inspection local morbidity comes to light, sometimes it is possible to propalpirovat the limited swelling caused by a hematoma. At a complete separation or a separation of a muscle in the place of its attachment to a sinew (a full separation of a sinew) sometimes it is possible to propalpirovat an interval between a muscle and a sinew.
In several days in the field of a back surface of a medial anklebone or an anteromedial surface of a shin ecchymomas can appear, however it is not an obligatory symptom. Pains and morbidity at a palpation can remain within several days and even weeks, amplifying during movements, especially when bending in an ankle joint.
Direct muscle injury or shins
The muscle injury got during intensive sports activities or as a result of accident can lead to emergence of the delayed pain and increase in the sizes of a shin owing to formation of a hematoma and development of an inflammation. In similar cases often there are considerable diagnostic difficulties as venous thrombosis is frequent complication of an injury of a shin.
Spontaneous hematoma of a muscle
In rare instances at the patients receiving anticoagulants emergence of pain and increase in the sizes of a shin without the previous injury or as a result of insignificant damage can be noted. It is sometimes difficult to define whether these symptoms are result of bleeding or recurrent venous thrombosis, especially at the patients receiving anticoagulants concerning venous thrombosis. The differential diagnosis of two of these states which is carried out on the basis of objective methods of research is important very much as wrong statement of the diagnosis of venous thrombosis at the patient with bleeding and continuation of anticoagulating therapy can; to lead to catastrophic effects.
Insufficiency of arterial circulation
As clinical signs of insufficiency of an arterial blood-groove and venous thrombosis significantly differ, these states seldom confuse among themselves. Pain at acute occlusion of arteries arises suddenly and can be followed by some local morbidity at a palpation. At arterial insufficiency an extremity cold, pale, pulse is not probed and usually the shin is not increased. In rare instances at early stages of an acute vein thrombosis of iliofemoral area considerable pallor of an extremity as a result of the accompanying spasm of arteries can be noted, the clinical picture reminds that at arterial thrombosis, however the specified states can be differentiated without effort in several hours after emergence of the first symptoms.
It is easy to distinguish the shin pains resulting from a prelum of a sciatic nerve or a lateral cutaneous nerve of a hip from pains at venous thrombosis as they have characteristic localization. Neurogenic pains are not followed by increase in the size of a shin, arise suddenly and amplify at the movements leading to nerve stretching. Dysfunctions of a peripheral nervous system can be noted, however even at their absence the specified states can be distinguished from each other on the basis of data of the anamnesis and inspection of the patient.
Rupture of a subnodal cyst
At a rupture of a subnodal cyst (Baker's cyst) the liquid which is contained in it can go down on intermuscular spaces of a shin and cause the inflammatory reaction which is followed by pains, morbidity at a palpation, local fervescence, increase in the size which can remind acute venous thrombosis. In most cases in the anamnesis there are instructions on arthritis, an injury or an operative measure in the field of a knee joint. The rupture of a subnodal cyst can sometimes arise at the patients who do not have in the anamnesis of an injury or arthritis of a knee joint, or emergence of pains and increase in a shin can be preceded observed within several months or years of pain and swelling in the field of a popliteal space of this extremity. The diagnosis can be made on the basis of a X-ray analysis of a knee joint, but as the same patient can have at the same time both a venous thrombosis, and a rupture of a subnodal cyst, first of all it is necessary to exclude the diagnosis of venous thrombosis.
Arthritis of knee and talocrural joints, heelstring inflammation
Pains and swelling of an extremity at arthritis of knee and talocrural joints or at an inflammation of heelstring can be mistakenly taken for symptoms of venous thrombosis. During the collecting the anamnesis and inspection of the patient usually it is found out that pain, morbidity at a palpation and swelling are localized in the affected joint therefore in most cases these states can be distinguished from venous thrombosis without effort. The confusion sometimes arises at patients with a system lupus erythematosus at whom the acute arthralgia in the field of a knee or ankle joint is combined with pleurisy that mistakenly take for venous thrombosis with a thromboembolism of a pulmonary artery. However it is easy to distinguish these states, having carried out careful collecting the anamnesis and inspection of the patient.
Inflammation of other tissues of the lower extremity
At a palpation of the lower extremity the inflammation of hypodermic cellulose, a lymphangitis, a vasculitis, a miositis and a panniculitis can be followed by pains and morbidity. Usually at a bright clinical picture it is easy to distinguish these states from venous thrombosis on the basis of one clinical data, however at early stages and at an atypical current they can be confused with a shin vein thrombosis. At an atypical current the inflammation of hypodermic cellulose or a lymphangitis is difficult to be distinguished from phlebitis with the expressed perivascular inflammation: in each of three cases pains, morbidity at a palpation can be observed and increase in the sizes of a shin or pain and morbidity at a palpation in the field of a femoral triangle. At a miositis there are diffuse muscular pains occupying groups of muscles directly not adjacent to deep veins of a shin. Clinical symptoms of a vasculitis and a panniculitis are rather characteristic and diagnostic problems usually do not arise.
Damages of bones
Damages of bones of the lower extremity, including tumors, subperiostal hematomas and changes, can be followed by pains, morbidity at a palpation and increase in the size of an extremity which sometimes at first sight can remind clinic of venous thrombosis. Diagnostic problems can arise at elderly patients at the bruises which are followed by a femur neck fracture as bleeding at them is often resulted by increase in the lower extremity. At such patients, especially in the presence of a senile sclerosis, it is difficult to find out the anamnesis of an injury. The diagnosis of a fracture of femur usually becomes obvious after careful clinical inspection, however it must be kept in mind that very often changes are combined with venous thrombosis
Patients with varicose expanded veins after stay upright can have for some time pains and morbidity at a palpation in a shin. In certain cases at an inflammation and fibrinferment of visible expanded veins of pain superficial varicose can amplify. When the described clinical symptoms are combined with more diffuse pains in a shin or hypostasis of the lower extremity, there can be difficulties at an exception of the diagnosis of the combined deep vein thrombosis without use of objective methods of research.
Thrombosis of superficial veins of a shin
At most of patients with thrombosis of superficial; shin veins the diagnosis does not raise doubts. Pain and morbidity are localized in superficial veins, easily available to a palpation. Nevertheless in certain cases localization of pain and morbidity at a palpation can go out of the area of the affected superficial veins and be followed by increase in the size of a shin; in similar cases the deep vein thrombosis of a shin is excluded on the basis of objective methods of research.
Pregnancy and reception of oral contraceptives
Pains and morbidity at a palpation in a shin can arise during pregnancy or as a result of reception of the peroral contraceptives containing estrogen. At pregnant women these symptoms are sometimes combined with the expressed puffiness of a shin and hip, sometimes unilateral. In many cases these symptoms are not a consequence of venous thrombosis. The reasons of pain and morbidity at a palpation at this category of patients are up to the end not clear, however the specified symptoms can be caused by a phlebectasia, as a result of reception of estrogen or a vein wall inflammation without the accompanying thrombosis, and in pregnant women — muscular spasms. During pregnancy emergence of unilateral puffiness can be promoted by a prelum of an ileal vein the increased uterus.
Usually patients with a posttromboflebitichesky syndrome note puffiness and the shin pains developing after long stay standing or after an exercise stress for a long time. At some patients pristupoobrazny strengthening of the specified signs which are combined with morbidity of a shin at a palpation is noted. In most cases sharply arising attacks are not a consequence of repeated venous thrombosis and need for carrying out anticoagulating therapy to such patients is absent, however the exception of acute venous thrombosis requires use of objective methods of research. Similar aggravations are caused most likely by the progressing dilatation of veins resulting in insolvency of function of venous valves and sudden increase in pressure in shin veins.