This patient had chronic venous disease of the lower limbs, and the soft tissue calcification probably represents phleboliths within varicose veins.

The causes of bilaterally symmetrical smooth periosteal reaction include:

• hypertrophic osteoarthropathy
• pachydermoperiostitis
• vascular insufficiency
• thyroid acropachy
• fluorosis

Periosteal reaction due to venous stasis is typically solid and undulating and initially separated from the cortex, as in this case.

Image contributed by Dr Laughlin Dawes.