Swollen calf - red flag symptoms

Refresh your knowledge of red flag symptoms to look out for in presentations of swollen calf.

The most acutely sinister cause is DVT (Photo: Dr P. Marazzi/Science Photo Library)
The most acutely sinister cause is DVT (Photo: Dr P. Marazzi/Science Photo Library)

Red flag symptoms

  • Recent immobility or surgery
  • 3cm discrepancy compared to the other calf
  • Unilateral swelling
  • Calf pain/tightness/redness

Calf swelling can be unilateral or bilateral. The most acutely sinister cause for this symptom is a deep vein thrombosis (DVT) and it is important to identify or exclude this potentially dangerous condition.

History

There are many causes for calf swelling. In exploring this condition, it is important to establish if the calf swelling is unilateral or bilateral. Also, one should find out whether the symptom is acute or chronic.

There may be a history of trauma, and this may guide you towards a possible fracture, ruptured muscle or potential compartment syndrome. A history of a chronic medical condition, such as diabetes or congestive heart failure, may predispose to conditions such as cellulitis.

Risk factors for a DVT include smoking, taking the oral contraceptive pill, obesity, and thrombophilic states such as factor V Leiden, as well as pregnancy and increasing age.

Examination

The patient may not be able to bear weight or may be walking with a limp. The patient may be tachycardic and possibly febrile.

Examination of the calf may show features of inflammation including redness, warmth, tenderness and enlargement compared with the contralateral calf at a fixed point. Homan's test demonstrates pain on dorsiflexion of the foot, but this should be done with caution as it may trigger fragmentation of a clot.

Peripheral pulses should be assessed, as the dorsalis pedis pulse may be absent in a deep vein thrombosis, but this sign may also be suggestive of compartment syndrome. Bilateral calf swelling and peripheral oedema can suggest conditions such as congestive heart failure.

Investigations

Investigations will be directly guided by the clinician's assessment of the calf swelling. Well’s score can further stratify the risk of a deep vein thrombosis and a score greater than one should warrant further investigations within secondary care.

These include blood tests such as a d-dimer, full blood count, clotting screen, renal and liver function tests. Doppler ultrasound should also be considered. If other conditions are suspected, consider tests such as a limb x-ray, knee ultrasound and even magnetic resonance imaging. If a deep vein thrombosis is suspected, urgent referral to the nearest secondary care centre is vital.

Possible causes

  • Calf trauma
  • DVT
  • Thrombophlebitis
  • Cellulitis
  • Ruptured gastrocnemius muscle
  • Bone tumour
  • Ruptured Baker's cyst
  • Fracture
  • Compartment syndrome
  • Lymphoedema

Dr Anish Kotecha is a GP in Gwent, Wales. This article, originally by Dr Mehul Mathukia, first appeared on 9 July 2010 and was updated in November 2019.

Visit MIMS Learning for an interactive version of this article and a CPD certificate

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

NHS England to redesign GP appraisal in light of COVID-19 pandemic

NHS England to redesign GP appraisal in light of COVID-19 pandemic

GP appraisals are being redesigned to have a greater focus on wellbeing and reduced...

Primary care to lose millions in funding unless PCNs hit recruitment targets in pandemic

Primary care to lose millions in funding unless PCNs hit recruitment targets in pandemic

Hundreds of millions of pounds could be lost to primary care if primary care networks...

Practices told to prepare for 'major expansion' of flu vaccination as QOF pared back for 2020/21

Practices told to prepare for 'major expansion' of flu vaccination as QOF pared back for 2020/21

GP practices have been told to 'gear up for a major expansion of the winter flu programme'...

NHS England unveils GP contract plans for second phase of COVID-19 response

NHS England unveils GP contract plans for second phase of COVID-19 response

GPs have been told to re-start health checks and other suspended services as NHS...

More than 80% of patients report 'good' overall experience of general practice

More than 80% of patients report 'good' overall experience of general practice

Public satisfaction with GP services remains high, with 82% of patients reporting...

GPs condemn 'deafening silence' from chancellor on COVID support funding

GPs condemn 'deafening silence' from chancellor on COVID support funding

GP leaders have condemned a 'deafening silence' on COVID-19 relief funding for general...