When a Cramp Is Actually a Clot

Deep-vein thrombosis is often mistaken by both patients and doctors for something else. I was suspicious of what I thought was a runner's cramp, and got lucky.
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Eryn Vorn/flickr

A glutton for good running weather, I could not resist the Thanksgiving weekend weather. It was pitch-perfect: cloudless, warm, a cool breeze. The month before I had run my fastest marathon: just under four hours at the 2012 Marine Corps Marathon. So, I should have been recovering with light, slow, shallow runs.
 
But several hours on a cramped five-hour flight the night before had me buzzing with pent-up energy. So, I ran. Probably too far, probably too fast.
 
Sitting at a table in Starbucks on Saturday, Sunday, and Monday, plugging away all day on a project, time slipped by. It felt good to focus, all that energy cleared from my metabolic cache. When I stood to go home Monday night, my calves immediately tightened. The pain in the right calf eased, but the pain in the left calf did not.
 
I rested, iced, elevated the leg, and doubled up on liquids and bananas, but the pain did not subside. On Wednesday, I limped to work and trolled sports-medicine web pages. One web site after another said generally the same thing: A deep vein thrombosis (DVT), or blood clot, can closely resemble a leg cramp or a muscle tear. My stomach clenched.
 
Recent long travel; a prolonged period of remaining in the same position; and red, painful, swelling were among the causes and symptoms listed. I had all but the redness and swelling. I called my doctor. She said to go to the nearest emergency room. I meant to sound as matter-of-fact when I told my boss why I was leaving early, but it came out more as a warble. 
 
The emergency room’s ultrasound technician’s questions turned to silence as she tapped buttons on a keyboard and stared at the images on her screen, rarely looking up as she moved her wand over the clear jelly-like coating she’d smeared on my leg. When she stepped out of the room, I peeked at the images on her computer screen. I saw blue and grey shapes and a small red mound, like an ant hill.

It’s probably a muscle tear, the student doctor said. He came to prepare my history for the ER doctor. It would take a longer flight and longer period of immobility than a weekend at Starbucks to develop a DVT, he said. I was ready to believe him and would have, if it weren’t for that little red mound.
 
I was poking my leg to pinpoint the pain for the cheery nurse who’d come to check my vitals, when the ER doctor came in. He told me to take my hand off of my leg and not to do that again. 

An estimated one in 1,000 Americans are diagnosed each year with a DVT, according to the Centers for Disease Control and Prevention. The number of Americans with DVTs, including those undiagnosed, is estimated to be up to 600,000. As many as 100,000 deaths each year are directly or indirectly linked to a DVT.

Though I have flown farther and sat still in coffeehouses for longer in the past, the doctor told me the blockage most likely was the result of my weekend sojourn in Starbucks, exacerbated by the flight. I might also have been a bit dehydrated from the travel and the run.

Whatever my particular cocktail of factors, the effect was the same: Blocked, the blood built up along the walls of the vein, clotting. Similar to a crash on a highway, the clot slowed the blood that tried to snake around it. The blood piled onto the clot, making it bigger and the passageway narrower.

A DVT is not usually life-threatening, by itself. But if part of the clot breaks loose and is thrown back into the bloodstream to travel freely, eventually it may lodge in a passageway too small for it, such as those found in the lungs. The result, a pulmonary embolism (PE), can kill you.

More than one-third of DVT patients have PE’s, according to the Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolismissued in 2008. “Often, the first symptom of DVT is a fatal PE,” Dr. Elizabeth G. Nabel, director of the National Institutes of Health’s Heart, Lung, and Blood Institute wrote in the report.

DVT/PE is an underappreciated problem in our society, said Dr. Anthony Venbrux, professor of radiology and surgery and director of the vascular and interventional radiology division at the George Washington Medical Center, echoing the report’s findings.

“We tend to dismiss them, saying ‘I’ll take an ibuprofen or use a heating pad.’ ‘We,’ meaning everyone, including physicians,” Venbrux said. “A classic example is a physician who was an athlete and didn’t want to acknowledge that it was DVT in the upper extremity that he was experiencing.”

Early diagnosis is the key to a positive outcome, and diagnosis is not difficult or painful. Now, completely noninvasively, we can rule in or rule out a DVT with 98 percent accuracy using a Doppler ultrasound, Venbrux said. “In the old days, we would have to inject contrast dye.” Nonetheless, many DVTs are believed to slip through the cracks, dismissed or unrecognized.

“The tragedy of these diseases is that their diagnosis is easy to overlook because the signs and symptoms are often diffuse and difficult to recognize. In many cases, there are no clinically apparent signs at all,” Nabel said.

As I quickly learned, the default treatment is to let nature takes it course, assisted by an intense, steady regimen of blood thinners, which rob the blood of its ability to stick to the little red mound, which my body would slowly absorb. The flip side was that my blood also could not stick together well enough to scab should I sustain a bleeding injury.

Around that time, I also discovered ClotConnect.org, which held a wealth of understandable information on blood clots for patients and doctors. Beth Waldron, the program director of Clot Connect at the University of North Carolina Hemophilia and Thrombosis Center, herself had a DVT and two PEs in 2003.

By her own account, Waldron thought she pulled a muscle in the gym. She went to the doctor and was prescribed muscle relaxers. When the pain continued, she tried to work through it until, walking up the stairs to the shower one day, she couldn’t catch her breath. “The world went floaty,” she said.

Eventually, she was prescribed antibiotics for a respiratory infection, she said. But, after taking her antibiotics for five days, under the impression that this wasn’t serious, Beth had a pulmonary embolism that “was off-the-chart painful,” she said. At the hospital, they found a pulmonary embolism in each lung and a DVT from midcalf to her hip. She was in the hospital for nine days and because the doctors found that she has a genetic risk factor, she is now on blood thinners for life.

“About half of those who develop [deep vein thrombosis/pulmonary embolism] have two things in common. First, they have one or more identifiable risk factors for the disease. Second, they experience some sort of triggering event, such as hospitalization, trauma, surgery, or a prolonged period of immobilization,” the surgeon general’s report said. The other half of cases are mostly unprovoked, or “silent,” producing “few, if any, symptoms,” it said.

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Christine Pulfrey is a writer and editor based in Washington, D.C.

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