Philadelphia Eagles quarterback Jalen Hurts is expected to miss the rest of the National Football League season due to blood clots in a situation that has turned from bad to worse. After initially being diagnosed with a left calf superficial vein thrombosis or SVT (a blood clot just beneath the skin), Hurts is now facing deep vein thrombosis (DVT) as well as bilateral pulmonary emboli, or blood clots in both lungs, according to a joint statement released on Monday from the Eagles and Hurts’s agent.
“A blood clot happens when the liquid blood forms into a gelatinous, more solid state,” said Caron Rockman, chair of the Department of Vascular Surgery at Hackensack University Medical Center. A common cause is external trauma, such as a musculoskeletal injury, she said.
Hurts was “cleated” in his calf, or struck with the spiked shoe of another player, in the Eagles’ Oct. 4 game. An ultrasound led to the superficial clot diagnosis, though he was cleared to play the following week. It wasn’t until a follow-up ultrasound revealed “movement” in the clot that the team pulled Hurts before the Eagles’ Oct. 18 game.
A superficial clot can “build and spill into” the deep vein system, said Thomas Maldonado, vascular surgeon at NYU Langone Health. (Superficial clots can also arise alongside deep ones at the same time, he noted.)
We asked vascular experts about the distinctions between superficial and deep blood clots and why it’s so important to seek medical care if you notice symptoms.
The difference between superficial and deep vein blood clots
It’s an “anatomic distinction,” Maldonado said. SVTs occur in veins just under the skin or in the fatty tissue right below it, while DVTs strike the veins buried lower, within the muscle.
A few triggers can prompt each kind. Besides a leg injury, trauma to the inside of a vein — for instance, while having an IV placed or blood drawn — can play a role in superficial clots, Rockman said, as can varicose veins, or bulging vessels just under the skin. Whereas, “stasis or stagnation of blood flow” is a more common cause for DVT, for example among people immobilized for a while due to illness or surgery, she said.
Being cooped up on a long-distance flight without getting up to walk around and stretch your legs can also contribute to DVT risk, Maldonado said. However, the chances of getting a clot from a flight alone without any other risk factors at play is very small.
And then there are a handful of factors that make people “hypercoagulable,” or prone to clots of any sort, such as a genetic predisposition, pregnancy or postpartum and certain kinds of cancer, she pointed out.
Whether you’re facing a superficial or deep clot matters because of the difference in risk: The deep ones usually pose a bigger threat, said William P. Shutze, a vascular surgeon at Texas Vascular Associates and vice president of the Society for Vascular Surgery.
One reason is that deep veins are larger, so a clot within one can really hinder blood flow, Shutze said. But even more concerning is the greater chance that a deep clot “dislodges like a pebble in a stream and travels to the lungs where it can cause a pulmonary embolism,” Maldonado said, or a blockage of a lung artery that can be life-threatening. Superficial clots, by contrast, are less likely to break free and head upstream, he explained.
SVTs often produce visible, palpable signs, like a tender, red cord or lumpy area of the skin, while DVTs generally cause more diffuse pain and swelling, Maldonado said. But the only way to definitively tell if you’re dealing with a blood clot and the type is with an ultrasound, he emphasized. Even if all signs point to a superficial issue, that doesn’t rule out a DVT lurking beneath the surface as well.
When a superficial clot progresses to a deep one
What complicates the matter of superficial versus deep is how the former can morph into the latter. Research suggests anywhere from 6 to 40 percent of people with an SVT also have or develop a DVT.
A few aspects of a superficial clot raise the risk that it spreads into the deep system, namely if it’s longer than five centimeters (making it extensive), or it’s located within three centimeters of where a superficial vein joins a deep one, Shutze said. (Intersections of the superficial and deep systems occur by the groin and in the crease behind the knee.) The only way to pinpoint these specific features of a clot is via ultrasound.
A superficial clot is also more likely to progress into a DVT if you have a history of DVT, have cancer or are male. That risk goes up, too, if you’re at elevated risk for clotting more broadly, for instance due to other factors such as being immobile for long periods of time, being dehydrated, smoking, taking hormonal contraceptives or having a genetic tendency to clot, Maldonado said.
Treatment for blood clots
DVT is generally treated with blood-thinning medication, Rockman said — the statement on Hurts’s health suggests it will constitute the bulk of his care. (It also noted that he’s “clinically stable and has no significant functional limitations” at this time.) A small subset of DVTs need greater intervention such as a clot-dissolving or removing operation, Rockman added.
Blood thinners help to keep a clot from growing or moving while granting the body time to naturally disintegrate it. The length of treatment can vary greatly depending on the severity of the clot, its location, what may have caused it and the person’s clot-related risk factors, Rockman said, but the baseline is three months.
By contrast, plenty of “garden variety superficial clots” can be treated with warm compresses and an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen, Rockman said, with regular monitoring to be sure the clot does not worsen or progress.
That said, certain high-risk SVTs — for example, lengthy clots or ones near a deep vein or occurring in people with other risk factors — can be treated with blood-thinning medication, too, typically at a low dose and for six weeks, Shutze said.
In most people, blood-thinning medication is very safe, with a couple rare exceptions — for example, people with a history of bleeding in the head or bleeding stomach ulcers, Maldonado said. But because blood-thinning medications can worsen bleeding in the setting of an injury, they can’t be used while playing contact sports, he noted. It’s likely the main reason Hurts is sidelined for the season: A hit to the head while on blood thinners, for instance, could cause a devastating brain bleed.
When to seek medical care for leg pain
Not every twinge or cramp in the leg is a blood clot. Injuries to the muscles, ligaments and tendons also commonly cause leg pain, as can soreness from working out or a transient charley horse (a.k.a. muscle spasm). But if you can feel a tender or puffy vessel or experience one-sided leg pain and swelling without an obvious cause, it’s important to get evaluated, Rockman said, whether by your primary care provider or at an urgent care facility. The same goes if you hurt your leg and have pain that seems out of proportion to the injury, she added.
Keep your risk profile in mind, too, Maldonado said. For example, if you have a history of blood clots or have recently had surgery or been immobilized for a lengthy stretch (on a long-haul flight, for instance), then the sudden arrival of leg pain or swelling is a bigger red flag. And especially if it’s associated with chest pain or shortness of breath, which are signs of a pulmonary embolism. In this case, it’s critical to head to the ER. Early intervention with blood-thinning medication can be life-saving and also reduce the risk of complications such as lingering fatigue and exercise intolerance.
Ultimately, Shutze encouraged people to err on the side of caution given the continued threat posed by blood clots in this country: As many as 100,000 Americans die from one every year. “As physicians, we would much rather see somebody who thinks that they have a blood clot and tell them they don’t than have them stay at home for two to three days and end up in the emergency room with a catastrophic or even fatal illness from this,” he said.
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