541 - Pain out of Proportion Following Physical Therapy: Superficial Posterior Lower Leg Compartment Syndrome Following Spontaneous Intramuscular Hematoma of the Gastrocnemius: A Case Report

Case Diagnosis: Superficial Posterior Lower Leg Compartment Syndrome Secondary to Spontaneous Intramuscular Hematoma in the Medial Head of the Gastrocnemius

Case Description: A 51-year-old female, with recent history of small bowel obstruction status post exlap and adhesiolysis, experienced a pop in her right lower leg during physical therapy, followed by escalating pain. A subsequent CT revealed a sizable hematoma in the superficial posterior compartment of the leg. Overnight, the pain worsened, impeding movement of the lower extremity and causing decreased sensation of the foot. Two days later, the patient underwent surgery for a right lower leg compartment release, evacuating approximately 300 ml of clotted hematoma from the medial head of the gastrocnemius. Subsequently, she underwent follow-up excisional debridement and irrigation of the skin, muscle, and tendon on post-op day 5. Despite these measures, the patient's pain persisted, necessitating additional debridements on post-op days 14 and 16.

Discussions: This case highlights the rare occurrence of superficial posterior lower leg compartment syndrome secondary to spontaneous intramuscular hematoma of the gastrocnemius. The patient's initial presentation during physical therapy, coupled with the use of heparin for DVT prophylaxis, underscores the need for heightened awareness. Physicians working in IRFs should take complaints of pain during therapy seriously and be quick to assess such complaints. The challenges in managing this case, necessitating multiple debridements despite initial surgical intervention, emphasize the complexities of treatment and potential impact on functional recovery. Further research into pathophysiology and optimal treatment strategies is crucial for enhancing functional outcomes in similar cases.

Conclusions: In summary, in patients who experience sudden extremity pain, compartment syndrome should be high on the differential, especially when on anticoagulation. As demonstrated in this case, prompt identification is crucial to minimize tissue loss and aid functional recovery, highlighting the vital principles of "time is tissue” and “tissue is function”.