








































DISABLEMENT MODEL CASE STUDY 

 

55 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

Deep Vein Thrombosis in Lower Extremity of a Female Collegiate 
Volleyball Athlete: A Case Study 
Lucas D. Dargo, DAT, LAT, ATC*; Kendra Borton, LAT, ATC; Rachel Roths, LAT, ATC; and Zachary Dougal, 
DAT, LAT, ATC† 
*Manchester University, North Manchester, IN †Ball State University, Muncie, IN  
 

 
ABSTRACT 

Deep vein thrombosis (DVT) occurs when a blood clot forms in 
deep veins in the body, usually in the lower extremity. DVT is 
commonly seen in older or hospitalized patients. This case is 
unique because the patient is a 20-year-old female division 
III collegiate volleyball athlete, which is not the typical age 
or population affected by DVT or clotting disorders. The 
patient presented with swelling, pain, and decreased knee 
flexion (3/5) and plantarflexion (4/5) strength in her left 
lower extremity. These impairments reduced her ability to 
walk or run. The patient’s athletic trainer (AT) initially 
diagnosed her with a left gastrocnemius muscle strain, 
resulting in contraindicated treatments. The AT referred the 
patient to the team physician, who referred her to the 
Emergency Department (ED) where she received a real-time 
grayscale and Doppler ultrasound of the left lower extremity 
deep venous structures, leading to the DVT diagnosis.  The 
patient received a dose of Lovenox, an intravenous 
anticoagulant, by the ED physician. The following day, she 
began 15 mg of Xarelto, twice per day for 21 days, to 
dissolve the blood clots. She could not participate in 
volleyball for approximately two weeks, which reduced her 
ability to socialize with teammates and coaches. The Wells’ 
scoring system is a clinical prediction tool to identify patients 
with low risk of being diagnosed with DVT. The AT had a low 
suspicion of DVT and therefore did not use the Wells’ scoring 
system, likely leading to a delay in the diagnosis and 
treatment. Although the patient reported that she had a 
positive outcome, ATs should be familiar with the Wells 
Clinical Prediction Rule. Blood clots in veins can dislodge and 
travel through the bloodstream. The loose clot can block 
blood flow in the lungs, forming a pulmonary embolism. Early 
diagnosis can prevent this life-threatening condition. 
Key Phrases 
Diagnostic testing, lower extremity, general medical 
conditions 
 
Correspondence 
Dr. Lucas Dargo, Manchester University, 604 E. College 
Avenue North Manchester, IN  46962. 
E-mail: lddargo@manchester.edu  
Twitter: @lucasdargo 
 
Full Citation 
Dargo L, Borton K, Roths R, Dougal Z. Deep vein thrombosis 
in lower extremity of a female collegiate volleyball athlete: 
A case study. Clin Pract Athl Train. 2020;3(2):55-62. 
https://doi.org/10.31622/2020/0002.8.   

Submitted: April 7, 2019 Accepted: March 15, 2020 
 

INTRODUCTION 

Venous thrombosis is a condition that includes 

deep vein thrombosis (DVT) and pulmonary 
embolism (PE). An annual incidence rate of about 
1 per 1000 adults,1 which rapidly increases after 
the age of 45.2 Incidence rates are slightly higher 
in men than women, and approximately two-thirds 
of episodes manifest as DVT, while one-third as a 
PE with or without DVT.3 DVT occurs when a blood 
clot forms in one or more of the deep veins in the 
body, usually forming in the lower extremity. 
However, it can also occur in the upper 
extremities.4 This disease typically occurs after 
surgical procedures and trauma in the presence of 
malignancy or inherited coagulation disorders, but 
can present without any apparent etiologic 
event.5 Approximately half of all DVT cases occur 
in hospitalized patients or nursing home residents.6 

Symptoms of DVT include tachycardia, pyrexia, 
leg pain and tenderness, swelling, and dilation of 
the superficial veins.  
 
The Well’s Clinical Prediction Rule, commonly 
known as the Well’s scoring system, is a valid, 
nine-item, clinical prediction rule for DVT. This 
clinical prediction rule previously demonstrated 
excellent interobserver reliability (Kappa = 
0.85),8 developed as a safe and feasible pretest 
with probability for DVT.9 It is critical for ATs to 
be familiar with these 9 questions so they may 
consider using this tool if a patient presents with 
signs and symptoms consistent with DVT, 
particularly when the patient presents with three 
or more signs and symptoms. The number and 
location of the clots, patient's age, and absence 
of trauma created a unique case of DVT. In this 

https://doi.org/10.31622/2020/0002.8


Deep Vein Thrombosis in Lower Extremity of a Female Collegiate Volleyball Athlete: A Case Study 
 

 

56 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

case study, the patient first received a 
misdiagnosis due to the lack of suspicion. 

Patient Information 

This case follows a 20-year-old female Division III 
collegiate volleyball player. A timeline of this 
case is provided (Figure 1). On August 14, 2017, 
the patient reported to the athletic training facility 
(ATF) with a swollen lower left leg and discomfort 
with walking. The team’s AT performed the initial 
evaluation. During this evaluation, the patient 
reported to the athletic trainer (AT) that she had 
no previous history of DVT. The patient revealed 
to the clinician that she took Propafenone-Ethinyl 
Estradiol (YAZ) 3-0.02 mg, a daily oral 
contraceptive medication. The patient reported 
that she had previously diagnosed with pes planus 
a few months earlier in the summer preceding 
camp, and received a walking boot for two 
weeks. Furthermore, she stated that a week 
before reporting to the ATF, her uninvolved leg 
had swelled, but reduced within a couple of days.  

Differential Diagnosis and Evaluation 

After four days of treatment, the patient did not 
progress as the AT had expected for a 
gastrocnemius muscle strain. During this time, the 
patient returned-to-play without restrictions. The 
team physician later referred her for additional 
diagnostic testing due to her calf swelling and 
difficulty with walking. During his evaluation, the 
team physician referred her to the hospital for a 
Doppler ultrasound to rule out DVT. The patient 
drove to the ED via her mother’s personal vehicle.  
After being admitted to the ED, the patient’s 
mother reported to the ED physician that the 
patient had a factor V Leiden deficiency, an 
inherited blood-clotting disorder due to a 
mutation of the blood’s factor V protein. 
Furthermore, the patient received a Doppler 
ultrasound, positive for DVT. 

The patient had three blood clots, one in each of 
her left femoral vein, popliteal vein, and the 
profundal vein. The Wells’ scoring system (Table 
1) would have revealed a score of 3 at the initial 
evaluation; one point given due to her recent 
immobilization of the walking boot, one point 
given for her entire left leg swelling, and localized 
tenderness along the distribution of the deep 
venous system of her left lower extremity. Due to 
the low suspicion for DVT, there were no 
measurements of calf girth or the use of the 
Homan’s sign to rule in or rule out DVT. Due to the 
location of pain, obvious swelling, use of 
contraceptive, suspicion for DVT should have been 
raised and the use of the Wells’ score would have 
suggested a high probability for a DVT diagnosis.

 

Initial visit to AT: 
August 18, 2017 

Referred to team 
physician: August 

23, 2017

Seen by team 
physician & sent 

to ED: August 
24, 2017

• Removed 
from sport

Patiet underwent 
Doppler 

Ultrasound

• Diagnosed with 
DVT

• Given a dose of 
Lovenox 

Patient started 
21 day 15 mg -

Xarelto (2X 
daily)

Cleared by team 
physician to RTP: 
September 15, 

2017

Figure 1. Timeline of Care;  
AT, athletic trainer; ED, emergency department; RTP, return-to-play 



Deep Vein Thrombosis in Lower Extremity of a Female Collegiate Volleyball Athlete: A Case Study 
 

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

Body Structure and Function  

Manual muscle testing determined the severity 
within the left lower extremity: 3/5 knee flexion, 
5/5 knee extension, 5/5 dorsiflexion, and 4/5 
plantarflexion. The patient reported with knee 
flexion and plantarflexion limitations. Once the 
patient received the correct diagnosis of DVT, the 
focus of her treatment changed from the 
musculoskeletal system to the circulatory system.  
The ED physician referred the patient to a 
hematologist for additional care. The patient 
reported that she still had pain throughout the 
range of motion of the left knee. 

Activity and Participation  

During the initial evaluation, the patient could not 
walk without pain and had an observable limp. 
Functional tests were determined to be 
unnecessary to perform during this time. The AT 
withheld the patient from practice following the 
initial evaluation and established the goal to help 
control the patient’s pain and swelling. Two days 
later, the patient returned to the AT without the 
need for crutches. Although the patient’s calf still 
had some swelling, she returned to full practice 
participation for two days before she had to 
discontinue activity due to pain. During this time, 
the patient received treatment: 20-minutes of 
compression cryotherapy, seven minutes of a milk 
massage, instrument-assisted soft tissue 
mobilization, bike or treadmill warm up, and 
abdominal core workouts. 

Following the DVT diagnosis, the patient received 
a single dose of Lovenox to dissolve her blood 
clots. The ED physician discharged her the same 
day as arrival. She returned to her dorm room, 
where she elevated the affected area above the 
level of her heart when sitting. She wore a 
compression stocking and applied a warm 
compress or heating pad to the affected area as 
directed by the ED physician. The physician 
encouraged the patient to avoid prolonged 
standing or bed rest, avoid smoking, to discontinue 
taking Meloxicam, and her oral contraception. 

After this time, the ED physician allowed her to 
return to activities of daily (ADL). The physician 
did not provide a specific progression for ADLs. 
Once the patient discontinued the 15 mg of 
Xarelto, taken twice a day for 21 days the 
physician determined the patient no longer had a 
risk for developing a PE. After that time, the 
patient returned to volleyball without restriction.   

Table 1. Wells criteria for the prediction of deep 
vein thrombosis (DVT)10,11 

Clinical Characteristic Score 

Active cancer (patient either receiving 
treatment for cancer within the previous 
6 months or currently receiving palliative 
treatment) 

1 

Paralysis, paresis, or recent cast 
immobilization of the lower extremities 

1 

Recently bedridden for ≥ 3 days, or major 
surgery within the previous 12 weeks 
requiring general or regional anesthesia 

1 

Localized tenderness along the distribution 
of the deep venous system 

1 

Entire leg swelling 1 

Calf swelling at least 3 cm larger than that 
on the asymptomatic side (measured 10 
cm below tibial tuberosity) 

1 

Pitting edema confined to the symptomatic 
leg 

1 

Collateral superficial veins (non-varicose) 1 

Previously documented DVT 1 

Alternative diagnosis at least as likely as 
DVT 

-2 

Wells scoring system for DVT: -2 to 0: low probability, 1 to 
2 points: Moderate probability, 3 to 8 points: High 
probability 



Deep Vein Thrombosis in Lower Extremity of a Female Collegiate Volleyball Athlete: A Case Study 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

Currently, there is not an established return-to-
play protocol for individuals recovering from a 
venous thromboembolism. However, it is critical 
that providers develop a structured program of 
gradually increased activity as tolerated by the 
patient.12 Roberts and Christie report a case of a 
female triathlete with acute lower extremity DVT 
that suggested a structured, gradual return-to-
training protocol (Table 2).13 In the first three 
weeks, the gradual introduction of ADLs is 
suggested, while patients complete their 
anticoagulation medication.13 Once 
endothelialization and adhesion are achieved, the 
potential for clot migration and embolism is 
reduced.12 Between the fourth to sixth weeks of 
this protocol, Roberts and Christie suggest a 
gradual return-to-training regimen that starts with 
non-weight-bearing exercises, next cycling, and 
finally,  running.13 If the patient reports any 
previous signs or symptoms returning, the protocol 
should be discontinued. Moreover, it is important 
the AT and patient note any bruising.12 In this case, 
the patient completed the first three weeks of this 
protocol prior to fully return to play (RTP). 
Additional sport-specific activities should have 
been gradually integrated prior to full RTP.  

Table 2. Post-anticoagulation return-to-
training recommendations. 
Weeks 1-3 Gradual return to ADLs 
Week 4 Begin non-weight-bearing 

exercises (e.g., swimming) 
Week 5 Begin nonimpact-loading 

exercises (e.g., cycling) 
Weeks 6 + Begin impact-loading 

exercises (e.g., begin running 
progression) 

 

Environmental and Personal Factors 

The patient hesitated to schedule the initial 
evaluation because she worried about losing her 
spot on the team. Also, she reported that the right 
calf presented similarly, earlier in the summer but 
resolved within a couple of days. After several 
days of pain and inflammation in her left calf 
causing difficulties with walking, she decided to 

seek help. The patient’s pain affected her ability 
to perform ADLs such as walking, running, and 
going upstairs. The patient discontinued her oral 
contraception due to the increased increase risk of 
DVT.         

INTERVENTION 

The patient’s AT initially provided treatment for a 
soft tissue injury, a left gastrocnemius muscle 
strain. The primary goals of the interventions were 
to reduce the patient’s pain and swelling. 
Treatments included 20-minutes of compression 
cryotherapy, seven minutes of a milk massage, 
instrument-assisted soft tissue mobilization, bike or 
treadmill warm up, and abdominal core workouts. 
The AT performed these treatments for three 
consecutive days. Once the patient received the 
DVT diagnosis, this course of treatment was 
discontinued. The massage and soft tissue 
treatments are contraindicated for a DVT 
diagnosis because of the potential risk factors for 
developing a PE by dislodging a blood clot.11 
After the ED physician diagnosed the patient with 
DVT they did not suspect an active PE. The ED 
physician discharged the patient the same day as 
arrival and instructed her to begin ambulation 
within 24 hours, elevating her left calf above her 
heart when seated. The day following discharge, 
the patient began a 21-day series of twice-daily 
15 mg of Xarelto. After the 21-day series, the 
patient could perform all ADLs. The team 
physician cleared the patient for full RTP. To 
reduce the potential of bleeding, the hematologist 
ordered the patient to reduce her dosage of 
Xarelto to one daily dose of 20mg.  
 
The patient was instructed by the team physician 
to discontinue taking Propafenone-Ethinyl 
Estradiol (YAZ) 3-0.02 mg because of its known 
side-effect of increasing the risk for clot 
formation.14 Additionally, the team physician told 
her to discontinue taking Meloxicam, an acne 
medication, due to its possible interactions with the 
Xarelto. The ED physician prescribed the patient 
15mg of Xarelto, administered orally twice daily, 



Deep Vein Thrombosis in Lower Extremity of a Female Collegiate Volleyball Athlete: A Case Study 
 

 

59 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

to treat the pre-existing blood clots and prevent 
new clots from forming. Following her visit to the 
hematologist, further testing confirmed that the 
patient was positive for factor V Leiden mutation. 
This is an inherited blood-clotting disorder due to 
a mutation of the blood’s factor V protein.15 As of 
January 2019, the patient continued to see both 
her hematologist and primary care physician 
several times throughout the year for a physical 
exam and a comprehensive metabolic panel to 
monitor the status of the blood clots.  
 

OUTCOMES 

Body Structure and Function  

The Xarelto is expected to continue to shrink the 
blood clots. This allows the body to naturally 
dissolve them. The left leg continues to remain 
swollen. The hematologist deemed this as normal; 
this condition is referred to as post-thrombotic 
syndrome.15 After 22 months following her 
diagnosis, the patient is now able to complete full 
range of motion without pain. Muscle strength 
returned to pre-injury performance. Strength was 
accessed by the patient’s ability to perform both 
ADLs and sport participation without any 
restrictions.  

Activity and Participation 

The team’s AT monitored the patient for signs and 
symptoms as she RTP. The team physician followed 
Roberts and Christie’s suggested RTP protocol for 
the first three weeks,13 keeping the patient out of 
sport participation. Neither the team physician nor 
the AT initiated a gradual RTP progression after 
this time. The patient successfully competed in the 
rest of the volleyball season without her symptoms 
returning or sustaining any additional injuries.     

Environmental and Personal Factors 

The patient reported that she was pleased with 
how she performed following her RTP. Since her 
left leg was more swollen than the right, people 
often asked her if it was safe for her to RTP. This 

caused her to be irritated. The oral contraception 
medication the patient was taking may have 
predisposed her the blood clots.  

DISCUSSION 

Deep vein thrombosis is a rare and emergent 
medical condition, especially in young active 
individuals.14 It is critical that ATs are educated 
properly on the appropriate recognition and 
management for DVT. The Wells’ scoring system is 
a helpful 9-item clinical diagnostic prediction tool 
for DVT;6 based on yes or no questions. Each 
question is given a numeric value (Table 1). A 
score of zero or lower suggests DVT is unlikely 
(5%), 1-2 moderate risk (17%), 3 and above DVT 
is likely (17-53%).9,10 An AT should consider using 
the Wells’ scoring criteria if they suspect a patient 
presents with any combination of signs or 
symptoms of DVT, such as sudden shortness of 
breath, chest pain or discomfort that worsens when 
they take a deep breath or cough, feeling 
lightheaded or dizzy, have a pulse > 100 beats 
per minute, coughing up blood, or having 
posterior leg pain.  

It is critical to ask patients about their current and 
past use of oral contraceptive medications 
because some brands and dosages can cause 
patients to be prone to blood clotting. Moreover, 
it is critical to determine if patients have a known 
medical history that includes genetic disorders. 
Vandenbroucke et al. found that there is an 
increased risk of DVT in oral contraceptive users 
who are carriers of factor V Leiden mutation.16 

Additionally, the AT in this case likely overlooked 
DVT as a differential diagnosis, due to lack of 
suspicion because of the patient’s young age and 
active status.  

The use of a patient-rated outcome measure, such 
as the SF-36, should be used throughout a 
patient’s treatment to measure their health-
related quality of life. The SF-36 would have 
complemented the use the Wells’ scoring system, 
as it can be used to track the overall quality of 
life of patients with DVT.17 The SF-36 can be used 



Deep Vein Thrombosis in Lower Extremity of a Female Collegiate Volleyball Athlete: A Case Study 
 

 

60 
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All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

to determine when a patient is ready to progress 
to the next step in the return-to-play DVT 
progression.13 Additionally, patients who develop 
post-thrombotic syndrome PTS after DVT report 
poorer health related quality of life using both 
generic and disease-specific questionnaires.18 For 
example, if the SF-36 was used in this case by the 
AT, they may have identified that the patient was 
having difficulty with ADLs as well as their 
emotional health. Although the patient’s care was 
delayed, this patient was able to return to full 
participation and ALDs.  Although the patient was 
able to fully return-to-play, as of 22 months post 
diagnosis the patient continued her treatment of 
20 mg of Xarelto, taken once daily. We 
recommend that ATs consider implementing the 
Wells’ scoring system when patient’s present with 
signs and symptoms consistent with DVT. Although 
evidence supports anticoagulation and early 
mobilization, guidelines for return-to-play require 
additional research.12 We propose ATs use 
Roberts and Christie’s suggested return-to-play 
protocol (Table 2) and patient-rated outcome 
measures to determine when DVT patients’ activity 
levels should progress.   

CLINICAL BOTTOM LINE 

When evaluating a patient who presents with calf 
pain, ATs should determine if other signs, 
symptoms, and risk factors associated with venous 
thrombosis are present (Figure 2). If warranted, 
ATs should consider implementing the Wells’ 
scoring criteria. This will aid the clinician in 
determining if the patient is a low, moderate, or 
high probability of DVT. If further consultation is 
needed, ATs should consult with their supervising 
physician or activate their emergency action plan. 
Early diagnosis can help prevent the progression 
of a DVT to a PE. Compression ultrasonography is 
considered the gold standard to diagnose DVT.19 

Additional research is needed to determine 
specific clinical practice guidelines. If the patient 
is diagnosed with DVT, patient-rated outcome 
measures should be used in combination with 
clinician-rated outcome measures to confirm the 

patient’s progress. Patients should be instructed to 
discontinue sport participation if signs or 
symptoms return. Particular attention should be 
given to bruising or loss of blood.  

 

Figure 2. Evaluation process for patient with potential DVT 

PATIENT PERSPECTIVE 

The patient agreed to do an interview about her 
experience. The interview was conducted 
approximately a year after she returned-to-play. 
The patient thought the care she received was 
adequate. She reported that the athletic training 
staff provided care to the best of their abilities 
and used the knowledge that was best at the time. 
The patient was asked what the athletic training 
staff could do differently about her treatment. 
She answered, “No milk massage or scraping  
because it made my leg hurt more.” When asked 
how she felt about her return-to-play, the patient 
answered, “I wasn’t worried. They warned me that 
my leg would remain swollen. I was more worried 
about getting other injuries.” When asked how the 
injury affected this year’s season, the patient 
replied, “It didn’t really affect this year. My leg 
still swells. I still have the blood clots, but they are 
shrinking. I am still on the medication. It’ll take time 
for the clots to go away. The only thing that is 
different is that I take the medication at night 
now.” 

Patient presents 
with calf pain

Determine if other 
signs, symptoms or 
risk factors for DVT 

are present

Implement the 
Wells' scoring 

system9,10

If the patient has a 
score ≥2, refer the 

patient for 
additional medical 

consulation



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All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

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