Subcutaneous hematoma in distal part of left leg

A 10 months old toddler was brought by his mother yesterday with a painful lump in the distal part of her left leg. She apparently fell 4 days earlier but his mother noticed the swelling only after 2 days when she was attending to her.

She was still able to hobble from one end of the table to the other end while hanging on to the sides. She only grimaced slightly when we examined the swelling. We did an Ultrasound scan for her showing a cystic swelling adjacent (but separate) to the Achilles tendon. He plain X-ray of the andkle and leg was normal.

The swelling subsided significantly with RICE treatment and topical Reparil gel. Her mother was advised to continue the same treatment for another few days. She was not given any NSAIDS.

Calf Cramps (with Medial Gastrocnemius strain)

A young lady in her 20s came this morning complaining of right calf residual pain after having a cramp while waking up this morning. Her mother gave her a hot traditional oil which she massaged on her calf but the pain persisted. She walked into my room with a limp and supported her weight on her forefoot.

She had several localised areas of tenderness along the medial gastrocnemius muscle but no apparent swelling. She also had an almost full ankle dorsiflexion and plantarflexion. She is likely to have suffered from a Right medial gastrocnemius Grade II strain. She was advised to undergo rice treatment and her calf was support with a crepe bandage to partially restrict movement and reduce pain. She would require an ultrasound scan to determine extent of the muscle injury if she wants to participate in sports.


Isometric exercises and hydrotherapy could be instituted to start her rehabilitation process along with electrotherapy. The duration of the rehabilitation will depend on the severity of the strain and her response to treatment (evaluate weekly).

Tibial Bone Bruise and Dependent Hematoma

Ms Lee is a lively lady in her forties who visited 'A' Famosa with her family members during the Hari Raya festive season. Little did she know that there were several youths who ran down the stairs pushing their way through. A teenage girl knocked into her causing her to loose balance and fall down the stairs. She hit her shin (anterior border of Tibial bone) causing it to swell in pain. She had to be carried to a Chinese traditional practitioner who applied medication and massaged the leg. The next day she noticed that there was a lot of bruising from her leg downward to her foot.

She was lucky that she did not have any crack (greenstick fracture) of the tibial bone but it would take her another 1 - 2 weeks to get rid of the bruising and swelling with medication. She should have done the RICE treatment.

Medial gastrocnemius (calf) myofascial pain

Mohamed is a 24 yrs old talented ex-junior hockey player who has tight painful calf muscles towards the 2nd half of every match but he noted that seemed to be symptom free during training session. He would request to be replaced to get time to ice and try to return to play after 10 minutes. As he plays in more matches, the pain becomes more unbearable and may even take a few days rest to be relieved. I evaluated his injury 5 days ago and found that he had localised muscle spasm in both his medial gastrocnemius heads (see photo)in both calf muscles.

He had an aversion for massage and has difficulty stretching his calf muscles. After trying myofascial release he seemed to be quite sore and requested injection to relieve the muscle spasm in the right medial gastrocnemius. After a short discussion about the pros and cons, we both decided to do myofascial injection* (Lignocaine 1% plus water**) to relieve his symptoms. (This was done as we were sure that he did not have a muscle tear. An ultrasound scan is required if a tear is suspected). The procedure went on smoothly (with 'some' pain as he told me he did not like needles) and he was told not to do any running or jogging. He was told to go into water to undergo aqua-jogging to assist in his recovery and undergo a rehabilitation program. I assured him that he would feel better after 2 days.

I reviewed him before player selection on match day 2 days ago and he was running without pain. The following day we had another training session whereby he said he felt better in the injected leg and wanted an injection in the untreated leg.

*see Injection of Lignocaine vs Dry Needling.
** see Advantage of Lignocaine Plus water vs Lignocaine 1% Neat.

Congenital Venous Malformation

Mr Tan saw me and thought he'd show me his left leg. "Doc, I've had this since I was 10 yrs old. I was hit by a book and the whole thing swelled up in pain! Since, then it seemed to grow slowly but doesnt give me any trouble". His left leg and foot was swollen. I thought it was not that obvious and possibly that's why his parents didn't notice it until then. He was seen by several doctors in Singapore and had his MRI's taken. Now, 12 years later it didn't give him any problems but just a little unsightly deformity.

After palpating the swelling, I found the swelling on the leg (9cm by 4cm) and dorsum of the foot (10cm by 5cm) to be non-pulsating, painless, boggy, with some induration (a depressed area probably where the vein perforates through). "Good! It's not an artery, not coming from the bone (I hope) and pain-free!", I said. You need to see a vascular surgeon who will work out whether you need further treatment (I was thankful to Mr Yusha from Hospital Kuala Lumpur who shared his experience with me when I was attached to the Vascular Surgical Unit).

Treatment depends on the depth, location, and extent of the venous malformation.

a) Routine observation of smaller lesions that cause minimal cosmetic or functional disturbance

b) Compressive stockings (e.g. tubigrip) to control swelling and pain in lower limbs

c) Injection of irritant solution into the lesion to shrink the abnormal veins. Unfortunately, multiple treatments are often required over time. (Sclerotherapy)

d) Laser treatment. The skin component of a venous malformation, consisting of small vessels, is sometimes treated with a Nd:YAG laser. Generally, several treatments six to eight weeks apart are necessary.

e) Surgery to localized and remove accessible lesions

d) Injection into the blood vessels to stop arterial blood flow in some selected cases in which there are abnormal connections to veins. (Embolization)

* Summary of treatment was adapated from this site.

Leg Contusion after kick!

A futsal player came in walking this morning. He showed me his swollen right leg and I thought it was just a contusion (soft tissue injury). He was able to do heel-raises and even hop on the injured leg!

After careful examination, I found a defect in his right tibial bone (as he received the kick from the midline outward). I took a marker to delineate the defect (see picture). I gave him some NSAIDS, Arnica Comp gel and told him to apply RICE treatment. He was also sent for an X-ray but it came back normal. He was told to return for a review in 1 week's duration.

He should have been wearing his shin guard!

To play or not to play!

It was 7.15pm and I was late for a pharmaceutical talk. John called as I was just approaching the venue. "Shucks!", I said. I needed the CME points but the player needed an urgent decision. To play or not to play!

I quickly returned to my apartment and he was already waiting there. He was walking and that was good news but he had a slight limp. I know some players who walked 'funny' after training due to a back problem and leg-length discrepancy.

A quick examination revealed a localised area of tenderness (pain upon application of pressure), muscle spasm adjacent to the junction between the medial gastrocnemius and soleus muscle. Tried a few light skills and he could not 'push-off' as required to play badminton.

He knew the consequences of injecting steroids and so he didn't ask me to do that. He had seen talented players who had muscle tears and tendon ruptures after indiscriminate injections done for the sake of competing.

"No-play!", I said. "I could give you a muscle relaxant to help relieve the spasm and you can continue with another 3 days of NSAIDS (anti-inflammatory and pain medication), but no play!". He was keen to improve his performance and insisted that he would decide the next day.

He played against a lesser known player and lost the next day. The press gave him such a bashing that I felt sorry for him. I know the player and he made the right choice to hold back and not push to win. He told me later that he just couldn't move and the pain worsened as he played. He had to play as he was required to by the coach to try. After a week he played much better in another major competition after undergoing rehabilitation and taking precautionary measures

rate me on

authorati