WffiffiMffiI.
ffi ffil Mffiffi
Deep-veinThrombosisin Runners.Beware
the Limping Athlete Dr Gordon Ining
Deplrtment of Anacsthesi;r
Grootc Schr.rurHosl.rit;rl
ObserVirton'
L .l[rc I ')\\ l1
Curriculum vitae
Gorcion In'inq stucliecllt Ncrrclstle, Engllncl
nte re hc obt.rinet.lrr NIll llS. He camc to
Soutlr Afiic.r it l97l utere hc speci;rlizctlin
Alriresthesia.He then pursucclhis intcrcst in
Sports Mcclicinc, lccturing in Phr.sicllogvencl
Sports Sciencerrt UCT, anciobtaineclrr NISc in
S p o r t sN l e c l i c i n ei n 1 9 8 3 . U u t i l r e c e n t h h c l r s
i n p r i Y i r t cp r r c t i c e a s a C l P ,s e e i n gm a i n l V
sports r.nedicincproblems. Hc obtilineclirr.r
N I M c r i ( A n . r e s )i n 1 9 9 0 a n r l i s a t p r c s e n ti r
cor.tsult.rntiurircsthetistlt (lroote Schuur
Hospit;ll ri'ith ,r specielinte rcst in chronic prrin.
Dr GorclonInir-rg
ldeqr,rrrtc
lv irt errch rcf r-cshr.nenttrrblc,
hc fclt ven,tircci lftenvarcls. He srrt
dou.n after fir-rishingthe rrrccanrl, or-r
Tlr ltistoricsoJ'tbn:cntnnerc arc
attcmptillg t() gct up, firuncl he $'ls
d.ncnlterl.Thet,ptrvrtted with cal.fpains,
r.rnablcto do so. He w':rscrrrricclt<l
initially thou.ght to ltc tnu,rcletcars.
the n.rcclicaltent \\ficrc nvo litrcs of
-t,
Venograms demottstrateddecp cirt
itttravcuousflr-riclu.'crcgiven u'ith
tltrombosisn ith progrcssioTtt0 thc
rapicl rcsolution of his "t<ltrrlfirtiguc".
The
Jbruoralreins in nuo swbjects.
Four chvs after thc rnarrrthonhc
tucchanivn,recognitionand trcatwent
prepirrccito go firr his f-irstpostoJ'renousthrombosisis rn inycd nnd
n r r r a t h ( ) nn r n . H o n c v e r . o n r r i s i n g
rclaterl to tlr threcpntiettts.
thrrt rtrornirrg,hc ti'lt ::rscvcl'cPlirr irr
his right meclialthigh:rncl his calf fclt
S AJi lam Prnct l99I; 12: 183-5
"sorc". The cliscon-rtbrtu,rrssnch thirt
he clicln'tattemDt to r-Llrlbut n'cnt tcr
his phvsiothcrllrist fbr trcirtrnent.
Phr.siothcrapr,,i nch,rdinuhard, clecl-r
transvcrsccross-fi-ictions()\'cr thc
I(EYWORDS:
tenclcr spot ir1thc thigh cliclnot
SportsMedicine;Muscles;
improvc his sl'nt1'rton-rs.
Thc c1at,aftcr
Thrombosis;Venous; Running phr.siotl-rerapv
hc presclrtcclu.ith a
ssollen, paintul calf i.rnclpositive
Homau's sign (clorsif'lcxior.r
of thc
anldccirusingcalf pain). An
Three rur.rncrsu'ith calf plins u.crc
cmcrgcnc\'\'en()grainconfi rmccl the
secnin ir privirte sports meclicinc
diagnosisof a clcepveir.rthror.r-rbosis
prlcti.e . Tuo Irld lr,rdprcvi<lr.rs
cxtcncling Llp to the micl-thigh. Hc
treatmcnt bV pirr,siOtl.rerapists
u-asl'rospitalizcclanclanticorlgulation
and
\\'crc not improYing and onc \\'asseell treatmcut,ll'asinstitr.rtccl.
The p;-rticnt
untreatecl.
maclcirrruneventfill rec()\'cn,.aDrlrt
tiom mikl hlcnrot.'trsis ,,n tlc iirrt
rlar'.A clrestr-rirr'-t.CG irntl n.lioRunner I
nuclcotidc h-rngscirnningtaileclto
Hc u'as a fbrtv-fir,evcar old male u.h<r conflrrn l significirr-rtpulnr<lnan.
had beena rcgular runncr fbr
cmbolus.
cighteen months. Hc had complcted
three marathons anclone ultranlarathol.l(56 krlomctres) ancl had
hrrd musclc tcars ;lreviouslv,
Runner 2
successfirIlv trerrteclbr. phvsiothcrapr'.
He lras nruning cighfl, to ()r1c
A tu.'entv-cigl'rt
,ve:rrold tcmale u'l.r<r
hr.rndrcdkilometrcs per \\'eck up to
htrd becn jogging firr onc l'nonth
the tin"rcof being scen.FIe \\'asa non- prior to bcing h<ls1-ritalizcd
fbr a
sr-nokcr,\\'lls not on ru1\rmcclication
small gx,u;recological
proccdr-rre.
This
and had no othcr signilicant history.
proccclurcll'as pcrfbrmecl in thc
lithotorur.position undcr gcncral
He ran rr standarclmarathon in a
ruraesthcsia.
Shc u'asa light smokcr
pcrsonalrecord tir-ucof 3 hrs 35 mins (claimcclB ciglrcttcs pcr clat')anci
fbur daysprior to bcing seen.Thc
\\.ason the or;rl contreceptivcpill. Shc
r.uarath()nn'as helcl in l'rot conditions
haclno other mcdicalhiston'of
irnd, although he strrtcdthat hc drank
signific:rnce.
Summary
1 8 3 S A F . r n r i l vP r r c t i c cM r r v l 9 9 l
SA Huis.rrtsprlktr'li,\L:i 199 I
... Dccp-veinThrombosisin Runners
Afte r rcsting in bccl ti>r tlr'o clar.saftcr
the opcrltion she u'cut fbr her first
grainin botlt
nrn and experiencccl
calr-cs.This \\rasso sc\,crethat shc u':.rs
r,rnirbleto continue thc rnn and urr.ts
limping l'rrrcllv
u,hen flrst scen.
An emcrgcrrc\'\'enorlranl conf-rrmcci
thr<lrrboses
bi lrrteralclccp-r.ein
cor.rf-rnccl
to the calf vcins. She r.r'rrs
hosl'litalizcil,
trertmcnt u'asinstitutcd
anc.lshe u'rrsstronglv rrcfised to stop
smoking irnd usc othcr fbrms <lf
c()ntrrccptlon.
Runner3
A fbrfi,-nr<rvear olci nraleu.ho h'.rci
been a rcgulrrr rlrflrlt^rfirr several
vcars.Hc had bccn:,rvcraging
30-50
i.il,r,''''ctrc.pcr u'cck until bu.siness
fbrcccl hirl to stol-r
commitn'rcr.rts
running rcgularlytor six u.eeksjust
prior to his prescntatiou.Tl.rcsc
comnritrrrcr.rts
i nvolvcclscvcral tri;ls tcr
Iohirnncsburs anclI)u rbar-r,oftet.r
rctuming thc sanrcclrrt',rrssociatec.l
n i t l r n t r r r r c l o r rbst r s i n c slsl l c e t i r " r g s .
fiictionccl" it, to r-roar"ail.Whcn tl-re
srrclIir.rgand discrlr.nfbrtpersistccland
u.astrf1bctinghis thigh, he sought
lurthcr irclvice.Arr cr.nergencl'
vellogram confirmccl a dccp-r,ein
thror.nbosis
extenclinginto the
fcnror:rl vein. Hc u'ls hospitalizcd
ancltrcatcd Llnevel-rtf
ulh'.
kn<lu'nas'crucificions'.Att averascof
tor.rr,tlrc ro tcn rrrinutcscssionsirc
r-rsr.raI
lY acieqr.r:rtc
to symptomatically
"cul'c" l chronic t'a[f tcar irt .r runncr.
The abovethrce runners orcscnted
r v i t l re a l fp l i n , i r r ( l i l l n \ o c e s e st h i g h
pain. The diagnosisof chronic musclc
l)iscussion
Deep-r'cinthromboscs have
pro'iotrslv becn rc1'rortecl
ir.r
n r n n er s ' t t [ r t r tn r r r s tb e r el l r i v c l l ' r ; r r c
occLlrrcnces.Hcxvcl'cr, as a misscci
diagnosisrnay prcsent r.r.itl-r
a
pulrlonan' emtrolisr.nand ser.crc
rcspirrrtonrproblcnrs,aa high inciex
Be arvareof thc possibilin' of
other pathologicsmimicking a
conlmon lnlury
IJrgencv is necessaryto
diminish the risk of pulmonary
embolism
t c ; r r\ \ e s i n i t i e l l vr r r r r l ci n t u ' o p . r t i c r r t s
rvith thc incorrect treatmcnt
institutcd. With subscoucntcareful
c r . r r r r i n a t i o rt rl r, c c a l f m r r s c l c u
scrc
firuncl to bc srvollen,\\.arnr,gcnerallr,
tencleranclu'ith 1-rromincntsuperficial
vcins,all the clinical critcria fbr a
n thrombosis.
clec;l-r'ci
of susl'ricionmllst tl'rcrefbrebc
r-naintaincd.
Virchou', in ltl56 dcscribccla triacl of
factors lvhich iutcract to promote
venoLrs
thrombosis.This triacl
Cirlf pains arc an cxtrcmeh'c<lr.r.rn-ron,cor.rsists
of vcssclu'all dam:rgc,ar-r
Deeo-r'cinthromboseshal'c
almost ubiqr-iitor.rs
injun n.itlr
activation of tl'rc intrinsic clottinq
endurirncerllnncrs. The maiorifl, of
n r c c h r u r i s nr rrr c lI s l o r r i n uo f t l r c . bcen reported to bc relatively
t l t es c p r r r i ul sr c d u c r o c h r o n i c ,o r
blood flor.v.Rnnncr No f uossiblr,
rarc in runncrs - lrut now we
Thcse
acllte
on
chronic
calf
tears.
lrrrtlsonresludglirrgo1'hlrxi.lflorr drrc
slrspcct r-nisseclcliagr-rosis
rcsplrllglucll to strctr'hirrgcrcrciscs,
to haemclcclnccntration
bccauseof
heel raiscs.shoe rcolaccmentrvherc
i nlclcquatehvclratiolrdrrring t hc
neccssirr,v,
trainir.rg^modifi
cation ucl
marathon fbur clavsbcfbre presenting
phvsiotirerapl.rloclalities, of lvhich,
u'ith pain. Runncr 2 u'as c>uthc oral
He u'as it tt<lnsmol<cr,\\'ils on no
deep transvcrscfl'ictions or cross
contraceptivcpill and sn.rokcd,both
161;5
nretlieationrrndlratl nr) |r11'1
fiiciions appearto bc thc rnost
of uhich at-tcctthc instrinsic
rnedicirl histon' clf relg'irncc.
ctlectivc. l)eeo transr.crsefiictions is
coagulation mechanismmaking clots
la.v-ofI,hc l t c c h r r i c l t rf e
i r s t d c s c r i l rde b y ( - r r i . r x ' more co[rmotr. She also rvould have
Aftcr his br.rsincss-enfirrcccl
rcsumcclhis mnnir-rgbut almost
ll'hcrcl'rl,the tenclcr part of tl'rc muscle expcriencedstilsisin vcnous reo.rrnof
ir.nmecliirtclv
bcgan to cxpreriencc
l s p a l p . l t c du n t l l t l r c P a t l e n t s
tl'rccalf veins during her gcncral
discon'rfirrtin lris right calf associatccl svmptoms are recrcatcd.The area is
aniresthcticand possibl,tprcssureor-l
u.ith slight su'elling aficr rcaching thc then massagedharcl acrossthe muscle hcr calf veins c'h.rring
thc time her legs
top of his first hill. Thinking it to ['rc
fibrcs. Thc treatmcnt is extremch'
werc in lithotomv oclsition.Rr.rnner3
possiblv sufTcrcd'rcnous stasisancl
l calf tclr he urnt to rr
p a i n f i r ll b r r h c p a t i c n t ,r o t h c c x i c n r
phvsiothcrrrpistu'ho "cnrss
that thc cross fiictions are oficrr
tr.crr,.,.. behincithc kncesfkrrn
1 8 4 S A F a n r i l vP r r c t i c cM a r . l 9 9 l
SA Huisartsprakn,k Mei l99l
. . Deep-veinThrombosis in Runners
excessivesitting in planes and during
l o n g b u s i n e s sm c c t ir r g s .
As doctors dealing with the athlete
we should be aware of the possibility
of other pathologies mimicking a
common injury. Athletes who have a
previoushistory of deep-vein
thrombosis. smokers,those on the
oral contraceptivepill, those who
have recently been dehydrated during
a race. or nave sDentexcesslvetrme
sitting still, musi be consideredas
being at risk ofdeveloping a deep
vein thrombosis. An athlete who
pre sents with a calf pain and has
generalisedtendernesswhich may be
associatedwith a swoilen and hot
calf, togetherwith prominent
superficialveins. should be
investigatedpromptly with a
venogram. Urgency is necessaryto
institute the correct therapv in order
r o d i m i n i s hr h e r i s k o f a p u l m o r r a r y
embolism. Pulmonary embolism may
presentu.ith acute onset of pleuritic
type chest pain, shortnessof breath
and haemotvsis.In massiveembolism
death may rapidly ensue.Treatment
of deeo-veinthromboses consistsof
anti-coagulatiorrto prevent further
clot formation and to allow the body
to scal offor recannalisethe affected
vessels.The person is initially
hospitalized and intravenor-lsheparin
is started together with oral warf-arin.
Oral u'arfhrin is continued to
maintain adequateanti-coagulation
for threc to six months. After this
time warfarin is discontinued unless
other factors such as recurrent
pulmonary emboli are present.
Recurrent pulmonary emboli may be
treated surgically by clipping off the
inferior vena cavato trap emboii
befbre they reach the lungs.
to remind those dealing with athletcs
to be aware of more seriousproblems
which may be missedwhen seemingiv
common problems present
themselves.
References
I. Ati MS, I(ully MS, Corca ]R. Dccp vein
tl-rrombosisin a jogger. Am I Sports Med
1981.12 (2):169
2. Han'ey lS Jr. Effort thrombosis in the lou'er
extrernity of a mnner. Am I Sports Me d
l97B;6:400 2.
3. Mackie lW, Webster lA. Deep veir-r
thrombosis in marathon runners. Phys
S p o r t sM e d l 9 8 l r 9 : 9 1 6 .
4. Sidler G], BugaieshiSM, Sundcrlin ],
Wcltman A. Difficulty in diagnosing and
t r e . r t i n gd e c pr e i n t l r r o m h o s i si n a
e o m p c t i t i r c h l s h e r h . r lpl l l v e r . P l r v sS p o n :
M e d 1 9 8 5 ; 1 3 ( 7 ) :r 1 3 - r B .
5. C.vriaxJ. Rl-reumatismand Soft Tissue
Injuries. London: Balliire Tindall & Cassell
Ltd.1947.
All three patients reported here
returned to running and had no
further problems. They are presented
f 85
SA Family Practicc Ma,v 1991
SA Huisartsprako'k Mei 1991