Swollen Calf

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

  • Ruptured Achilles Tendon
  • Varicose Eczema
  • Phlebitis

Rare Diagnoses

  • Muscle Herniation Through Fascia (Especially Tibialis Anterior)
  • Muscular Neoplasm
  • Pseudohypertrophy (as in Muscular Dystrophy)

Ready Reckoner

Key distinguishing features of the most common diagnoses

CellulitisSwollen AnklesMuscularBaker’s CystDVT
FeverYesNoNoNoPossible
BilateralPossiblePossibleNoNoPossible
Sudden PainNoNoYesPossiblePossible
Previous Swelling Behind KneeNoNoNoYesNo
Skin RedYesPossibleNoNoPossible

Possible Investigations

Likely:None (unless sent to hospital).

Possible:FBC, ESR/CRP and other investigations for swollen ankles (see also 'swollen ankles' section); usually in hospital – D-dimer, ultrasound, venography.

Small Print:None.

  • FBC, ESR/CRP: Elevated white cell count and ESR/CRP in cellulitis.
  • D-dimer: Raised level suggests DVT but is not conclusive.
  • Ultrasound: May help diagnose DVT and useful in confirming ruptured Baker’s cyst as the cause. Venography necessary to confirm DVT in some cases.

Top Tips

  • The swelling resulting from a muscle rupture can be impressive – but a typical history with pain (described as ‘like being shot in the calf ’) preceding the swelling should clinch the correct diagnosis.
  • Varicose eczema is often misdiagnosed as cellulitis. Clues are that it is commonly bilateral, itches more than hurts and is not accompanied by fever. To complicate matters, varicose eczema can become infected, causing cellulitis.
  • Anxiety about possible DVT may cloud the presentation – careful questioning may reveal that swelling is, in fact, long-standing and/or bilateral, making DVT very unlikely.

Red Flags

  • Patients with unexplained DVT are three to four times more likely than controls to have an underlying malignancy – so, once the DVT has been dealt with, consider appropriate investigation.
  • In high-risk patients – such as those who have just returned from a long haul flight – your index of suspicion for DVT should be raised.
  • When the history suggests muscular rupture, ensure that the Achilles tendon is intact.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.