Brief Answer:
Many thanks for your inquiry

Detailed Answer:
Please specify the question you would like me to answer.

I've read your statements and description of your problem as well as responses from colleagues. In one case a consultant gave his opinion on what he felt would be the diagnosis you may be suffering from, however, your response to that answer indicated that you were really looking for his opinion on the types of tests that could be performed in such a situation.

I'd like to be certain that I am addressing your concerns as directly as possible. I will ask you this, however, right off the bat which is whether or not you have results from lab tests, the results of the angiogram from 2014 before the angioplasty was performed (heart I assume), an echocardiogram, MRI of the back, or EMG/NCV studies of the back and/or lower extremities? My thought process is the following. Whatever the underlying problem may be....it seems to be something that would affect both legs and specifically, both CALVES at the same time.

This would suggest that it would have to be something that uniformly affects the ain and rigidity in the calves. The description of worsening of this pain upon walking or standing which DOES NOT RELIEVE with rest is a bit unusual as far as your situation is concerned since most folks might right think that you were suffering from what is called INTERMITTENT claudication having to do with the vascular system's inability to supply good blood flow to the legs. This could be due to a heart problem in terms of decreased pumping action but more commonly occurs from blockages in the vascular tree that supplies the legs. But interestingly in this case is the fact that upon rest things do resolve and the pain and stiffness of the calves seems to remain...as you say, "for hours." Stretching makes the muscles "catch" which I interpret as a CRAMP or LOCKING UP which then, has to work itself out.

The other possibility is that there is something metabolic going on and even though you state that you live "cleanly" with respect to not being diabetic, not having vices, and being in overall good health...another common problem that faces us as we age is the PREDISPOSITION...especially of leg and calf muscles to cramp. Sometimes this can be due to NEUROGENIC causes (why I asked if you had an MRI of the lower spine) as well as EMG/NCV electrical studies which would test the integrity of the nerves and conducting system to the muscles through the lumbar plexus of nerves. Any type of arthritic disease or compression of the nerve roots exiting the spinal cord which travel to the legs can cause this picture and this could be hypothesized by putting together imaging studies along with electrical studies to see if the muscles in fact are going into a phase of prolonged cramping.

Metabolic causes could include poor thyroid, calcium, thyroid, or even parathyroid hormonal levels. Looking at muscle enzymes such as ALDOLASE, CPK, and both serum as well as urinary MYOGLOBIN could give a sense of overall MUSCLE TISSUE health and address the idea of cramping.

There is one other thing I'm thinking may be possible...but maybe not based on your statement that you are NOT NOTICING any swelling in the leg. However, has anybody looked at with the thought of trying to explain what's going on using a diagnosis of COMPARTMENT SYNDROME. This is a condition where there is increase pressure that build up in the legs themselves. It is very painful and usually comes on after prolonged standing or exercise. There is a tightness to the skin and sometimes people will say that their calves and shins feel very hard to the touch....but not necessarily cramping and it's not the type of thing that relieves quickly as a cramp does once the muscle releases.

Is it possible you have this disorder? For this, the testing that would need to be done would include manometry testing of the anterior and posterior compartments of the legs before exercise and after exercise. Ideally, at the time you develop the pains and rigidity to see if pressures rise above normal levels. If that is the case then, the procedure that needs to take place would be some type of fasciotomy or release of whatever may be causing these increased pressures to develop.

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 56 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

---

Brief Answer:
Many thanks for your updates and information

Detailed Answer:
I will give you an opinion since you've asked for it regarding the 2D Doppler. Although I do not want to make a statement to prevent you from doing what other doctors have recommended....I will tell you that in my own opinion this is not a test I would've thought of at first intention based upon the symptoms that you relate which is that of pain in the legs and calves becoming painful and very hard (CALVES) which you state DOES NOT RELIEVE even upon repose until hours later. Later in your summary you state that upon stretching there is a muscle CATCH but I don't know whether this means a sudden CRAMP comes on or the legs CEASES to move without pain or obvious obstruction. You also state clearly there is no discoloration to the skin nor is there obvious swelling.

For all these reasons a Doppler of the legs and/or calves does not seem to have a high likely of finding anything...especially in the veins since the most obvious thing being sought would be that of a BLOOD CLOT in the venous system referred to as a DVT (deep venous thrombosis). If you look this entity up on the Internet I am sure you will find many references to this entity. However, none have any constellation of symptoms quite like yours. First of all, for both calves and both legs to be affected in the exact regions and for a time period of YEARS to me is highly unlikely. DVT's typically manifest themselves WITH SWELLING, WITH SKIN DISCOLORATION, HEAT, REDNESS, and pain tends not to go away AT ALL. If anything, untreated DVT's in some locations can actually get worse by extending themselves farther and farther downward...(since you've had this problem for years) and I would expect that after this period of time (1 year)...some other manifestation more commensurate with a typical DVT would've become manifest.

So again, please do not take this as an endorsement not to do tests or studies recommended by other professionals, however, I've stated my opinions as you've requested. I would be very grateful if you would followup with me in some way by writing me a short note when you have results from any of the tests you have decided to go forward with getting...either diagnostic or labs so that I may also learn from your presentation.

MRI utility. Perhaps, there's a point to be made for NO BACK PAIN but I may reconsider an MRI of the lumbosacral spine if the other diagnostic studies are negative only because a compromise to the sensory roots in the lumbar spine..or even the dorsal areas of the spinal cord may not cause very much pain but it can explain cramps in BOTH legs and PAIN in both legs that can last hours despite rest. The best way to gauge the utility of this suggestion, however, is by being EXAMINED PHYSICALLY by a neurologist since other bedside testing is necessary as a prelude to ordering this test such as sensory, motor, and reflex evaluation.

I do believe that the laboratory tests are important to get taken care of as well as reviewing test results of the angiogram and echocardiogram....though once again, I think this would be low yield to explain what's going on in the calves in terms of their becoming that hard and rigid in the absence of other cardiac symptoms of deficiency such as exertional shortness of breath, anginal pains upon walking, etc.

Also, my gratitude for your positive evaluation of my first set of responses and the offer to highly rate the encounter. I hope this explanation equally shows value to you and you may consider closing the query but staying in contact with me in the future when all tests are complete.

Cheers and all the best on your way to some answers.

---

Brief Answer:
Required Clarification on submission of this question

Detailed Answer:
Many thanks for your question now accompanied by testing and lab results.

I had required some clarification from those who distribute questions to the consultants since this series of questions had been submitted 2 weeks ago and closed 12 days ago after answering all concerns.

At this time I see that labs and other material accompany your query and will be very happy to go through them in detail in order to either modify or underscore prior thoughts and recommendations. Your patience in allowing the time necessary to give this data full consideration is greatly appreciated.

Please respond in the affirmative to this message and in this way I will be able to give you the balance of my thoughts in the next 24 hrs.

Once again, many thanks.

---

Brief Answer:
Neurogenic claudication seems most likely

Detailed Answer:
Good morning. Thank you for providing the labs and tests that were requested. As I had suspected your color doppler studies that were looking for blood clots and obstruction to arterial or venous blood flow did not turn up anything significant. Both reports are stating that circulation appears to be satisfactory. You will recall that I predicted this in my previous notes to you since your complaints in the calves was one that got WORSE with walking and standing BUT DID NOT resolve with rest for many hours. This is the hallmark of anything EXCEPT vascular claudication or blood flow obstruction.

Your labs show an insufficient level of Vitamin D which should certainly be replenished according to what your doctor considers satisfactory. In my patient population I shoot for serum levels of 60-80 and would replace someone with your numbers by prescribing 50,000IU D3 to be taking weekly for 4 weeks. I would then, ask the patient to take oral supplements of 2000IU DAILY for at least 8 weeks before retesting and depending upon levels to repeat or adjust the daily dosing. Having said all that about Vitamin D I will say that in the "big picture" and as far as your muscle cramping/pain is concerned it is unlikely to have any significant impact since your MRI's of the back especially show a nontrivial amount of arthritic and degenerative disc disease which more than adequately explain the symptoms. Simply put the nerve roots exiting from your spinal cord that travel down to control muscles in your legs such as your calves (where you are noticing most pain) are being irritated by compression from skeletal abnormaliteis in the way of arthritis. This is most likely OSTEOARTHRITIS which is commonly seen as we age beyond age 40-50 and of course, can accelerate once we surpass the 70 year mark in age. Also, degenerative disease of the spine is common in those who have worked throughout their lives doing laborious types of work involving bending, lifting, pushing, pulling, etc. Of course, arthritic disease also affects people who do desk jobs and often is related to genetic considerations. If the parents or siblings suffer from arthritic disease then, the chances are greater than one would feel the same symptoms given the time involved.

Unfortunately, treatment for your condition of arthritis in order to avoid the cramps and pains in the legs is a very difficult proposition because the disease process as seen in the MRI film is rather diffuse. In other words, there are multiple levels where you have problems. It is impossible by way of the films to tell exactly where the major source of problem is coming from and more likely than not the compilation of all the arthritic disease in the back is what is causing the major symptoms of cramping and pain.

Exercises, soothing baths of heat or warm compresses over the small of the back...not so much the calves....but the back where the source of the problem is may help but relief is often temporary. EXERCISE is the mainstay of treatment in this type of case. I would not consider surgery because of the widespread nature of the problem. There is far too much risk to get in to do a multilevel decompression procedure and run into complications...either from anesthesia, from surgical manipulation, or from the healing process.

Exercise, specifically AQUATHERAPY is what I recommend to all my patients for this type of condition. Please consult with a PHYSICAL MEDICINE AND REHABILITATION specialist to get specific orders as to what should be carried out during your therapy sessions....again, my recommendation is that you get aquatherapy but you could also easily do the more conventional and more easily accessible land types of exercises.

The cervical spine films also show some degree of arthritic degeneration and while I can't discount the possibility of there being some contribution to the legs acting up my guess it is very little. If anything, I'd expect to hear about problems or pains, numbness, or tingling going on in the arms, hands, or fingers...perhaps, pains in the neck with a radiating component. But I could just as easily believe you if you were to say that no symptoms of significance were present in the arms or neck....the disease process appears rather mild overall.

I have no opinion on the elevated amylase as it does not really fit into the picture you are describing especially since the MRI of the lumbar spine failed to reveal the presence of any mass lesion that was compressing upon the spinal cord such as might occur if there were a pancreatic tumor with metastatic lesions to the spine. While the levels of 100+ seem significant compared to normal I'm afraid I would have to recommend you consult with another type of specialist to get answers to what that might mean such as a GI or INTERNAL MEDICINE specialist.

There is one test I had recommended but was not obtained and that is the EMG/NCV test. This is an invasive test and now with the results of the MRI I might counsel you not to get that test done at this time. I don't believe it will add much to the diagnosis especially since I do not think you are a good surgical candidate fort any procedure at this time. The electrical may be able to localize pathology of the nerves more precisely to say which roots are clearly being COMPRESSED or PINCHED vs. which ones are probably clear and free at this time. But again, I don't see where that information would be of much value unless you planned on consulting a NEUROSURGEON or ORTHOPEDIST to consider operating (I would not go that route if it were myself or anyone in my family.....at least not immediately). I would first go for a good solid program of physical therapy for a minimum 4-6 months, I would do as much aquatherapy as I could possibly do myself and eat healthily. Then, after this has been done diligently I would go for a re-evaluation with the doctor or neurologist and see how the calves were doing.

Aghain, if I've provided useful and helpful information to your questions could you do me the favor by CLOSING THE QUERY and including some further positive words of feedback along with a 5 STAR rating if you are understand both what I believe is the most likely problem as well as my ideas for a good approach to intervene?

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 122 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

---