Ask a doctor on the topic of Internal medicine

TVT? What to do?

May 16, 2016 | 20,00 EUR | answered by Dr. med. Ive Dr. Schaaf

Dear Dr. Schaaf,

Thank you for your quick response to my question regarding the diagnosis assessment.

Now I would like to describe my situation in more detail. Six months ago, I had a bicycle accident with a severe muscle strain on the back of my right thigh. When sitting, I often felt like there was a thick lump, like half a melon, under my thigh. When walking quickly, the muscles in the back of my leg would cramp for a long time, and surprisingly, the calf muscles were also affected. The condition in the calf lasted quite a while.

About 3-4 weeks ago, after increased cycling, I started experiencing diffuse pain in my right calf. These pains would occur briefly, sometimes at rest, sometimes during movement, sometimes pulling, sometimes cramping. Occasionally, there would be a sensation of cold in the calf, but when touched, it was always the same temperature as the other calf. Sometimes there was also a feeling of decreased sensitivity, although I could still feel everything when touched. There are also long pain-free periods in between, sometimes even for days. The calf is about 1 cm thicker than the other, which could be due to a previous knee injury on the left and increased strain on the right side. Consequently, the thigh is also stronger.

I also have a tender spot to the right of my lower back.

Yesterday, as I was planning to fly, a general practitioner determined that my D-dimer levels were three times higher than normal as a precaution. A Doppler ultrasound the next day showed no thrombosis. According to the doctor, the thrombosis or thrombus has dissolved and I am advised to take Heparin and Marcumar.

Now my questions:
Are there reliable diagnostic methods to determine if a thrombosis is present or was present? What is your assessment?

I would greatly appreciate a response.

Happy Pentecost and best regards,

C. Zühl

Now my questions:

Dr. med. Ive Dr. Schaaf

Good evening,

I'm sorry for the late reply. There are numerous possible causes for an increase in D-dimers, it doesn't have to be a thrombosis. It is conceivable that a thrombosis occurs and then resolves quickly, but that is not to be assumed. If you want to be absolutely sure that there is no thrombosis present and no remnants of a thrombosis can be seen, you would need to undergo a phlebography, which is a radiographic contrast imaging of the veins, or a contrast-enhanced MRI. However, these procedures are not typically done in your case due to the burden on the body and cost considerations.

Your symptoms are more in line with pain originating from the spine rather than a thrombosis. It would be more reasonable to treat you with physical therapy, NSAIDs, and possibly massage, rather than with Heparin or Warfarin.

Please keep in mind that my assessment is based on the information you provided and is only an estimation, not a (remote) diagnosis.

Since you seem to be very unsure, my suggestion would be to monitor D-dimers and have an ultrasound done. Massage of the muscles on either side of the spine is beneficial, as well as physical therapy. Taking Ibuprofen or similar medication seems justified given your symptoms. If everything resolves quickly, you can then infer the diagnosis.

Get well soon!

Dr. Schaaf

Any further questions?