Interactive Quiz: Calf Pain With Muscle-Limited Involvement

Welcome to Rheumatology Consultant’s latest interactive diagnostic quiz. Over the next few pages, we’ll present a case and ask you to make the diagnosis and treat the patient. Along the way, we’ll provide details about the case, and at the end, we’ll share the patient’s outcome.

Ready to get started? >>

First, let’s meet the patient …

A 37-year-old woman with no significant medical history had unexplained right calf pain and elevated inflammatory markers. She described the pain as sharp and stabbing, which worsened with activity. She also reported intermittent swelling of the lower part of the leg, which also was tender to the touch.

Findings of a review of systems were negative for any constitutional, cardiopulmonary, gastrointestinal, or neurological complaints. Vital signs were normal. Physical examination revealed a shiny and taut appearance to the right lower extremity with exquisite tenderness to palpation to the musculature of the calf.

Findings were negative for deep vein thrombosis on Doppler ultrasonography and negative for arterial insufficiency on ankle-brachial pressure index. Electromyography findings were negative for myopathic or neuropathic abnormalities.

Are you correct? >>

Answer: Magnetic resonance imaging

While the clinicians considered either computed tomography angiography of the abdomen or arteriography of the mesenteric or renal system, the lack of symptoms such as fever, weight loss, abdominal pain or angina, hypertension, renal insufficiency, hematuria, or proteinuria, made them feel as though there was no indication to do so.

Magnetic resonance imaging (MRI) scans of the lower extremity showed hyperintensity on fat-suppressed T1-weighted images of the musculature with associated subcutaneous nodularity (Figures 1 and 2).