Herniated Lumbar Disc Presenting as Isolated Calf Tetany

Case Report

Austin Sports Med. 2016; 1(1): 1001.

Herniated Lumbar Disc Presenting as Isolated Calf Tetany

Langfitt T and Bushnell B*

Department of Orthopaedics, Medical College of Georgia at Augusta University, USA

*Corresponding author: Bushnell B, Department of Orthopaedics, Medical College of Georgia at Augusta University, 330-Turner McCall Boulevard, Suite 2000 Rome, Ga 30161, USA

Received: January 06, 2016; Accepted: February 02, 2016; Published: February 05, 2016


A 46 year-old female presented to a sports medicine clinic with an isolated complaint of gradually worsening calf pain and cramping. This eventually progressed to a state of near constant calf tetany. After several reasonable but ultimately incorrect diagnoses, the patient was successfully treated with surgery for a herniated lumbar disc. This case highlights the importance of including lumbar radiculopathy in the differential for lower-extremity complaints, especially in cases with atypical presentations. We also review the relevant literature on this topic, including other abnormal presentations and the current recommendations for diagnosis and treatment of lumbar disc herniation.

Keywords: Herniated lumbar disc; Calf tetany; Achilles tendinitis; Abnormal presentation


MRI: Magnetic Resonance Imaging


Acute herniated lumbar disc typically presents with a history of acute onset of pain in the lower back. Classic lumbar radiculopathy symptoms of pain, numbness, and tingling radiating throughout the distribution of the involved nerve root may also be present. A thorough physical exam will usually reveal diminished or altered sensation in the involved dermatome, hyperreflexia, and/or abnormal reflexes, such as a Babinski sign. There may also be weakness and atrophy of the involved muscles, especially in more chronic cases. Diagnosis is most commonly confirmed by a magnetic resonance imaging study of the lumbar spine.

However, atypical presentations can occur. Outside of the case presented in this study, recent literature contains several additional examples to illustrate the importance of maintaining a high index of suspicion for disc pathology when dealing with patients with lowerextremity complaints. We present the case of a herniated lumbar disc in which the patient had an isolated complaint of gradually worsening calf pain that progressed to outright tetany before the diagnosis was made. We also review the current recommendations for the treatment and evaluation of suspected lumbar disc herniations.

Case Presentation

A 46 year-old female who worked as a medical office assistant presented to a primary care sports medicine clinic complaining of several weeks of pain and cramping in her left calf. Her past medical history included obesity, diabetes, and dyslipidemia. She had no prior history of trauma, neurologic disease, or spinal pathology. She was diagnosed with Achilles bursitis or tendinitis with an associated calcaneal spur and treated for several weeks with oral anti-inflammatory medications, activity modification, and physical therapy. During this time, she was seen and treated by multiple physical therapists who continued to approach her care with the presumptive diagnosis of calf strain or Achilles tendinitis. The patient then visited a chiropractor that treated the patient with electronic stimulation, ultrasound, and laser therapy on her calf, as well as deep tissue massage and stretching. After this treatment regimen was unsuccessful, the chiropractor then arranged for a referral to the orthopedic surgery clinic out of concern for possible exerciseinduced compartment syndrome.

As the patient’s condition worsened, her primary employer, an urologist, became increasingly concerned about the status of her leg. After a brief physical exam that revealed extreme calf tightness, the urologist was worried that the patient might have a Deep Venous Thrombosis (DVT), which he ruled out via ultrasound. Sharing the chiropractor’s concern for possible compartment syndrome, he expedited the orthopedic referral.

At the time the patient was seen by the orthopedic surgeon, her symptoms had been present for over three months. Her physical examination revealed normal light touch sensation and pulses in the left leg, but tetanic contraction of the left gastrocnemius muscle. She had passive dorsiflexion only to 10 degrees beyond than neutral. The patient was then admitted to the hospital for further workup of her complaints, with a presumptive diagnosis of an upper-motorneuron lesion or possible multiple sclerosis. MRI scans of the brain, the cervical spine, and the thoracic spine were all normal, as well as a lower-extremity nerve conduction study.

A neurologist was consulted to help with making a diagnosis and a lumbar spine MRI was ordered. Ultimately, this lumbar spine MRI revealed the diagnosis - an L5-S1 neural foramina protrusion of a sub acutely herniated disc with abutment and deviation of the left S1 nerve root (Figure 1). A neurosurgeon was consulted for surgical management, and the patient was taken expeditiously to the operating room for a minimally invasive left L5-S1 discectomy and decompression. The patient reported immediate relief of her symptoms after surgery. While she still had some soreness in her calf (likely from the sustained contractions), she reported in the surgical recovery room that her “tightness” was completely relieved. She was able to walk with minimal problems on postoperative day one. On postoperative day two, she denied any calf pain and was discharged. She returned to work two weeks after her surgery. At a two-year follow-up, the patient had maintained complete relief of her left-sided symptoms and had no complaints at all regarding the left calf.