Differentiating Post-Thrombotic Syndrome from Tendinitis Symptoms

Post-thrombotic syndrome (venous insufficiency) "and" tendinitis?

Dear Doctor, four months ago I developed deep vein thrombosis (DVT) in my calf due to tight bandaging from an injury.
After taking anticoagulants, a follow-up ultrasound two weeks later showed no thrombosis.
However, after exercising, I experienced muscle tendonitis (diagnosed via orthopedic ultrasound) in the same calf.
During my follow-up with the vascular specialist, I was diagnosed with post-thrombotic syndrome.
Currently, after walking about 5 minutes daily, my calf becomes increasingly stiff, and the stiffness extends to the front of my thigh in the afternoon.
However, when I lie down for half an hour, my leg softens, and there is about a 5% swelling.
I need to continue anticoagulation therapy.
For the past two months, I have been dealing with both "post-thrombotic syndrome (chronic venous insufficiency)" and "tendonitis," and despite taking both medications, I have not healed.
How can I clarify whether my current symptoms are due to post-thrombotic syndrome or tendonitis? Additionally, since small blood vessels cannot be assessed via ultrasound, could there still be thrombosis in the small vessels due to their size?

Da A, 40~49 year old female. Ask Date: 2015/10/31

Dr. He Dongjin reply Cardiology

Hello, based on your description, your calf becomes increasingly stiff after walking each day, but it softens after lying down for half an hour.
This is more reminiscent of post-thrombotic syndrome or tendonitis, and there are no swelling symptoms.
It is likely caused by venous insufficiency.
You should continue your medication.
Changhua Hospital cares about you.

Reply Date: 2015/10/31

More Info

Differentiating between Post-Thrombotic Syndrome (PTS) and tendinitis can be quite challenging, especially in the context of a recent history of deep vein thrombosis (DVT) and ongoing symptoms. Both conditions can present with similar symptoms, such as pain, swelling, and discomfort in the affected limb, but they have distinct underlying mechanisms and treatment approaches.

Post-Thrombotic Syndrome (PTS) is a complication that can occur after DVT. It is characterized by chronic pain, swelling, and changes in skin color or texture in the affected limb, often due to venous insufficiency caused by damage to the venous valves during the thrombotic event. Symptoms of PTS typically worsen with prolonged standing or walking and may improve with leg elevation or rest. In your case, the fact that your leg becomes hard after walking and softens when elevated suggests venous congestion, which is consistent with PTS. The swelling you describe (approximately 5%) and the hardness that extends into the thigh could also indicate venous stasis.

On the other hand, tendinitis usually presents as localized pain around a tendon, often exacerbated by movement or activity involving that tendon. In your case, if the pain is more generalized in the calf and not limited to a specific tendon area (like the Achilles tendon), it may lean more towards PTS. Tendinitis typically does not cause the same degree of swelling or changes in skin texture as PTS.

To differentiate between the two, consider the following:
1. Location of Pain: Tendinitis pain is usually localized to the tendon area, while PTS pain can be more diffuse and related to venous congestion.

2. Response to Activity: Tendinitis pain often worsens with specific movements and may improve with rest. PTS symptoms may worsen with prolonged standing or walking but improve with leg elevation.

3. Swelling Characteristics: PTS often presents with swelling that is more pronounced at the end of the day or after prolonged activity, while tendinitis swelling is usually localized.

4. Skin Changes: PTS can lead to skin changes such as discoloration, thickening, or ulceration, which are not typical in tendinitis.

Regarding your concern about small blood vessels and whether they could still harbor a thrombus, it is indeed possible that smaller vessels may not be adequately visualized on standard ultrasound imaging. However, if your follow-up ultrasound showed no evidence of thrombus, it is less likely that small vessel thrombosis is the primary issue. If there is a high suspicion of ongoing venous issues, further imaging techniques such as venography or advanced ultrasound techniques may be warranted.

In conclusion, it is essential to work closely with your healthcare providers to monitor your symptoms and possibly consider further diagnostic imaging if your symptoms persist or worsen. They may also recommend physical therapy or other interventions tailored to your specific diagnosis, whether it be PTS or tendinitis. Keeping a detailed symptom diary, noting when symptoms worsen or improve, can also be helpful in guiding your healthcare team in making a more accurate diagnosis and treatment plan.

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