Calf Pain

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Motor Neurone Disease
  • Multiple Sclerosis
  • Muscle Enzyme Deficiency
  • Psychological: Muscle Tension
  • Lead and Strychnine Poisoning
  • Ruptured Achilles Tendon

Ready Reckoner

Key distinguishing features of the most common diagnoses

CrampStiffnessCellulitisMuscle InjuryPVD
Worse at NightYesNoNoNoNo
Systemically UnwellNoNoPossibleNoNo
Worse with ExercisePossibleYesPossibleYesYes
Calf SwellingNoNoYesPossibleNo
Cool PeripheriesNoNoNoNoYes

Possible Investigations


Possible:Urinalysis, WCC, ESR/CRP, U&E, calcium, LFT, blood glucose or HbA1c, D-dimer.

Small Print:Ultrasound, venogram, angiography.

  • Urinalysis: Check specific gravity, glucose and protein (over and under-hydration, diabetes, renal failure as occasional causes of ‘simple’ cramp).
  • WCC and ESR/CRP: Both raised in infection. ESR/CRP raised in arthropathy.
  • U&E and calcium: Check renal function and electrolyte imbalance (e.g. from diuretics; hypocalcaemia).
  • LFT and blood glucose or HbA1c: If suspect alcoholism or diabetes resulting in a neuropathy.
  • D-dimer (usually in hospital): A raised level suggests a DVT, but is not conclusive.
  • Ultrasound/venogram: Further tests to diagnose DVT, performed in secondary care.
  • Angiography will be arranged by the specialist if peripheral vascular disease is suspected.

Top Tips

  • Bear in mind that many patients will be anxious about the possibility of DVT – reassure them about this if the diagnosis clearly lies elsewhere
  • Save the patient unnecessary investigation and possible anticoagulation by taking a careful history. A muscle tear and a DVT can both produce calf swelling and warmth. The former, though, is preceded by a dramatic and sudden pain in the calf, sometimes described as being like a kick or a gunshot.
  • It can be difficult to distinguish a simple muscle strain from claudication. Muscular pains tend to produce discomfort as soon as the patient stands; claudication usually starts after the patient has walked a predictable distance.
  • Patients with superficial phlebitis will fear the more serious DVT. Explain the difference to them.

Red Flags

  • Consider investigating the adult patient with recent onset of apparently simple cramps if associated with general malaise (these will be in the minority).
  • Claudication accompanied by nocturnal pain in the ball of the foot suggests critical ischaemia – refer urgently.
  • If the clinical picture suggests a DVT then refer urgently either to A&E or according to your local DVT pathway.
  • Do not overlook Achilles rupture. The presentation may sometimes be less dramatic than you would expect. Use the calf squeeze test to ensure that the tendon is intact.
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