52-Year-Old With Calf Pain After Travel

Published on December 1, 2025

Download the article PDF: Clinical Image Challenge December 2025

Differential Diagnosis

Deep vein thrombosis (DVT)
Baker cyst
Ruptured Baker cyst
Muscle strain
Superficial vein thrombosis

Diagnosis

POCUS reveals a non-compressible left popliteal vein (white circle) with hypoechoic intraluminal material, consistent with acute proximal DVT. The popliteal artery (red oval), located just beneath the vein, appears anechoic (black), as expected. Based on these findings, the patient was diagnosed with a DVT and started on rivaroxaban. Follow-up care was arranged.

Discussion

DVT diagnosis in the urgent care can be delayed by limited imaging access or slow turnaround times for D-dimer test, which can guide the need for imaging in low and moderate-risk patients.¹

Proximal leg compression POCUS has been shown to have high sensitivity and correlation with formal vascular studies. For example, a study of hospitalist-performed POCUS showed 100% sensitivity and 95.8% specificity when compared to formal vascular scans.²An emergency department (ED) meta-analysis found 96% sensitivity and specificity for proximal leg compression POCUS.³

POCUS DVT scan typically includes compression of the proximal deep vasculature in 2 regions: the inguinal area (assessing the common femoral vein at the saphenofemoral vein junction and at the confluence of deep femoral and superficial femoral veins) and the popliteal area (popliteal vein to the junction with calf veins), or 3 regions (adding an isolated femoral vein compression). It is referred to as a “2-point” or a “3-point” scan, depending on how many regions are included in the exam. A 3-point ultrasound may offer increased sensitivity for DVT in cases where an isolated femoral vein clot is present.⁴

POCUS not only improves diagnostic accuracy and efficiency but also impacts patient experience and cost of care. Patients report better quality of care when POCUS is used.⁵ The average cost of an ED visit for a primary care-level concern is approximately $2,000, while the 2025 Medicare global physician fee for a unilateral lower extremity vascular ultrasound is $114.^6-7 Using POCUS in the clinic can thus result in over $1,800 in savings per encounter by avoiding ED-based imaging and evaluation.

In this case, POCUS enabled rapid confirmation of a potentially life-threatening condition, facilitating same-day treatment initiation while avoiding ED transfer.

What To Look For

Noncompressible deep vein segment.
Echogenic intraluminal material (not always seen).
Anechoic cystic structure in the popliteal region (Baker cyst) as an alternate diagnosis.

Pearls for Urgent Care Management

For presentations concerning for a DVT, calculate the Wells score to risk-stratify.
To diagnose DVT, use high-sensitivity D-dimer in conjunction with POCUS and avoid ED referrals.

References

Kearon C, et al. Diagnosis of deep vein thrombosis with D-dimer adjusted to clinical probability: prospective diagnostic management study. BMJ. 2022 Feb 15;376:e067378. doi: 10.1136/bmj-2021-067378.
Fischer EA, et al. Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study. J Gen Intern Med. 2019 Oct;34(10):2062-2067. doi: 10.1007/s11606-019-05120-5.
Pomero F, Dentali F, Borretta V, Bonzini M, Melchio R, Douketis JD, Fenoglio LM. Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis. Thromb Haemost. 2013 Jan;109(1):137-45. doi: 10.1160/TH12-07-0473.
Zuker-Herman R, Ayalon Dangur I, Berant R, Sitt EC, Baskin L, Shaya Y, Shiber S. Comparison between two-point and three-point compression ultrasound for the diagnosis of deep vein thrombosis. J Thromb Thrombolysis. 2018 Jan;45(1):99-105. doi: 10.1007/s11239-017-1595-9.
Andersen CA, Brodersen J, Rudbæk TR, Jensen MB. Patients’ experiences of the use of point-of-care ultrasound in general practice – a cross-sectional study. BMC Fam Pract. 2021 Jun 18;22(1):116. doi: 10.1186/s12875-021-01459-z.
UnitedHealth Group. 2019. The high cost of avoidable hospital emergency department visits. UnitedHealth Group. Accessed: August 25, 2024. [Online] Available: https://www.unitedhealthgroup.com/content/dam/UHG/PDF/2019/UHG-Avoidable-ED-Visits.pdf
Centers for Medicare & Medicaid Services. Physician Fee Schedule Look-Up Tool. Accessed August 28, 2025. Available: https://www.cms.gov/medicare/physician-fee-schedule/search