Presentation, diagnosis, and management of popliteal artery entrapment syndrome: 11 years of experience with 61 legs

Popliteal Artery Entrapment Syndrome: Updates for Evaluation, Diagnosis, and Treatment

ABSTRACT

Popliteal artery entrapment syndrome remains difficult to diagnose. Meanwhile, our limited knowledge and understanding make treatment decisions complex. The list of differential diagnoses for exertional leg pain is broad. Oftentimes, patients exhibit confounding and coexisting diagnoses. However, accurate and rapid diagnosis of popliteal artery entrapment syndrome is essential to reduce potential lasting damage to the popliteal artery. A combination of clinical history, physical examination, ankle-brachial index, along with dynamic and static imaging such as duplex ultrasound, computed tomography angiogram, and magnetic resonance angiography, aids diagnosis. Surgical treatment may be definitive depending on the type of popliteal artery entrapment syndrome, but there have been recent advances in diagnostics with intravascular ultrasound and nonsurgical treatment with botulinum toxin type A. Further research is needed to standardize diagnostic criteria, uncover innovative diagnostic methods, and validate promising nonoperative treatment options.

Concurrent Chronic Exertional Compartment Syndrome and Popliteal Artery Entrapment Syndrome

Exertional leg pain occurs with notable frequency among athletes and poses diagnostic challenges to clinicians due to overlapping symptomatology. In this case report, we delineate the clinical presentation of a young collegiate soccer player who endured two years of progressive bilateral exertional calf pain and ankle weakness during athletic activity. The initial assessment yielded a diagnosis of chronic exertional compartment syndrome (CECS), predicated on the results of compartment testing. However, her clinical presentation was suspicious for concurrent type VI popliteal artery entrapment syndrome (PAES), prompting further radiographic testing of magnetic resonance angiography (MRA). MRA revealed severe arterial spasm with plantarflexion bilaterally, corroborating the additional diagnosis of PEAS. Given the worsening symptoms, the patient underwent open popliteal entrapment release of the right leg. Although CECS and PAES are both known phenomena that are observed in collegiate athletes, their co-occurrence is uncommon owing to their different pathophysiological underpinnings. This case underscores the importance for clinicians to be aware that the successful diagnosis of one condition does not exclude the possibility of a secondary, unrelated pathology. This case also highlights the importance of dynamic imaging modalities, including point-of-care ultrasound, dynamic MRA, and dynamic angiogram.

Long-Term Results of Surgical Treatment for Popliteal Artery Entrapment Syndrome

INTRODUCTION

Popliteal artery entrapment syndrome (PAES) is a rare disease of the lower limbs, mainly affecting young patients, due to extrinsic compression of the neurovascular bundle at the popliteal fossa. The aim of this study was to describe our experience during a median 15-year period.

METHODS

Patients treated for PAES in our institution from 1979 to 2024 were included. Preoperative, intraoperative, and postoperative data were analyzed.

RESULTS

A total of 47 patients with a total of 78 limbs were treated. Duplex ultrasound with active maneuvers was performed in all limbs (100%). Angiography was performed in almost all patients (97.4%), computed tomography angiography in 56 (71.8%), and magnetic resonance angiography in 22 (28.2%). Concerning surgical treatment, musculotendinous section was performed in 60 limbs (76.9%), and autologous venous bypass was achieved in 18 limbs (23.1%). The rates for freedom from target lesion revascularization-meaning that no significant stenosis or occlusion during follow-up required revascularization-and 15-year primary patency were 92.4% and 98%, respectively.

CONCLUSION

Long-term results of surgical treatment for PAES seem to be very satisfying. Myotomy with or without arterial reconstruction using venous bypass can lead to good patency at 15 years of follow-up.

Popliteal entrapment syndrome: diagnostic, surgical management and short-term results of a ten-year experience

INTRODUCTION

Popliteal artery entrapment syndrome (PAES) is a rare cause of lower limb claudication in young sportsperson without cardiovascular risk factor. We reported our diagnostic approach, surgical management and short term outcomes of this syndrome, over a 10-year period.

MATERIAL AND METHOD

Sportsperson with intermittent claudication systematically received color duplex ultrasonography with dynamic maneuvers in the sport medicine department. In case of PAES suspicion, diagnosis was confirmed by dynamic computed tomography or dynamic magnetic resonance angiography. Each patient was then evaluated by a vascular surgeon and surgery was performed. We retrospectively screened patients who underwent PAES surgery between 2010 and 2020 in the department of surgery in Angers university hospital.

RESULTS

Between January 2010 and December 2020, 38 patients with 67 symptomatic legs underwent surgery for PAES. Twenty three (60.5%) were men. The mean age at the time of surgery was 24.7 +/- 9 years. Clinical presentation was bilateral in 30 patients (81.1%). Duplex ultrasound demonstrated severe stenosis or occlusion in 45 legs (77%). When performed, CT-scan demonstrated popliteal artery compression in all cases (100%). According to Whelan and Rich classification, 36 patients (94.7%) had type 6 PAES. There was no mortality or severe complication after surgery. Morbidity included 4 post-operative hematoma (6%) and 8 prolonged healing (13%). The mean time of follow-up was 2.3 months +/- 1.2 months. After surgery, D-scan showed no signs of remaining popliteal artery compression in 92.5% of the case. Twelve patients (33.3%) were able to resume sport, 18 (50%) partially and 6 (16.6%) did not resume sport yet.

CONCLUSION

We report a cohort of 38 patients who underwent surgery for popliteal artery entrapment syndrome. Among them, 36 (94.7%) were functional PAES. Morbidity included 13% of prolonged healing. Two months follow-up demonstrated good results at dynamic D-scan without signs of remaining popliteal artery compression in 92.5% of the cases. These short-term results showed that one third of patients able to resume sport activity at initial level.

Popliteal Artery Entrapment Syndrome: A Diagnostic and Treatment Enigma for Orthopaedic Surgeons

Popliteal artery entrapment syndrome (PAES) is an uncommon condition that causes recurrent posterior leg pain and foot paresthesia in running athletes. This condition occurs most commonly due to an accessory or abnormal implant of the medial head of the gastrocnemius muscle. It may mimic or coincide with other chronic conditions of the lower extremity including chronic exertional compartment syndrome but is most consistent with vascular claudication. Clinical features that distinguish PAES from other causes of leg pain include a sensation of coolness of the posterior leg during exercise and associated paresthesia of the plantar aspect of the foot. Physical examination often reveals decreased intensity of the posterior tibial or dorsalis pedis pulses with passive dorsiflexion or active plantarflexion of the ankle. Diagnostic tests that confirm the presence of PAES include lower extremity angiography during active resisted plantarflexion or maximal passive dorsiflexion, and magnetic resonance angiography done after exercise provocation. Nonsurgical treatment with physical therapy and stretching of the gastrocnemius complex should be done as the first line of treatment. When conservative treatments are ineffective, referral to a vascular specialist for surgical intervention with a muscular band excision or transection, vascular bypass, or arterial reconstruction is necessary.

Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.

Popliteal Entrapment Syndrome as a Cause of Chronic Lower Extremity Pain in a 16-Year Old

Popliteal entrapment syndrome is an uncommon cause of intermittent claudication in young patients lacking atherosclerotic risk factors. ZS is a 16-year-old cisgender female with type 1 diabetes complicated by microalbuminuria, obesity (body mass index (BMI) = 45.86 kg/m²), and a history of perinatal stroke with residual right-sided hemiparesis, who presented with six months of worsening bilateral, exertional lower extremity pain. Common causes of chronic bilateral lower extremity pain include peripheral vascular disease and diabetic neuropathy. Less common etiologies include trauma, infection, or juvenile idiopathic arthritis. Given her risk factors, the patient's pain was initially managed as a diabetic neuropathy with pregabalin. Symptoms failed to improve, and she re-presented with positional coolness of the right lower extremity, diminished pulses of the bilateral lower extremities, and weakness in her toes. CT angiography demonstrated occlusion of the right distal superficial femoral and popliteal arteries and diffused tibial disease. Ultimately, the patient was discovered to have right-sided femoral-popliteal occlusion, and she required urgent femoral-tibial bypass. Despite an initial improvement in symptoms postoperatively, she continued to have lower extremity pain and recurrent arterial thrombi, even with antiplatelet and anticoagulation therapy. Eventually, the patient required a right-sided below the knee amputation. This case highlights the high index of suspicion that clinicians must have in young patients with lower extremity pain, both with and without atherosclerotic risk factors, as early intervention facilitates better outcomes. Introduction.

The Role of Magnetic Resonance in the Diagnosis of Chronic Exertional Compartment Syndrome

Chronic compartment syndrome is a common and often underdiagnosed exercise-induced condition, accounting on average for a quarter of cases of chronic exertional pain in the leg, second only to the fracture/tibial stress syndrome spectrum. It traditionally occurs in young runner athletes, although more recent studies have demonstrated a considerable prevalence in low-performance practitioners of physical activity, even in middle-aged or elderly patients. The list of differential diagnoses is extensive, and sometimes it is difficult to distinguish them only by the clinical data, and subsidiary examinations are required. The diagnosis is classically made by the clinical picture, by exclusion of the differential diagnoses, and through the measurement of the intracompartmental pressure. Although needle manometry is considered the gold standard in the diagnosis, its use is not universally accepted, since there are some important limitations, apart from the restricted availability of the needle equipment in Brazil. New protocols of manometry have recently been proposed to overcome the deficiency of the traditional ones, and some of them recommend the systematic use of magnetic resonance imaging (MRI) in the exclusion of differential diagnoses. The use of post-effort liquid-sensitive MRI sequences is a good noninvasive option instead of needle manometry in the diagnosis of chronic compartment syndrome, since the increase in post-exercise signal intensity is statistically significant when compared with manometry pressure values in asymptomatic patients and in those with the syndrome; hence, the test can be used in the diagnostic criteria. The definitive treatment is fasciotomy, although there are less effective alternatives.

Popliteal Artery Entrapment Syndrome (PAES) in a 17-Year-Old Adolescent

Introduction

Popliteal artery entrapment syndrome (PAES) is caused by compression of the popliteal artery (PA) due to deranged myotendinous structures. It can be asymptomatic or may present with exercise intolerance, claudication, or even limb-threatening ischemia. The clinical picture depends on the anatomy and degree of vascular compromise.

Case Description

We report a case of a 17-year-old Caucasian male with PAES Type II presenting with intermittent claudication and progression towards acute limb ischemia.

Diagnostics

MRI and MRA helped identifying the aberrant anatomy and thrombotic occlusion. Doppler ultrasound and conventional angiography have also been employed in a stepwise approach.

Intervention

The thrombus at the site of occlusion was removed by the use of catheter-directed lysis. Subsequently, popliteal artery release was achieved by myotomy of the aberrant medial head of gastrocnemius muscle (MHGM) and muscle transfer to the medial femoral condyle. A three-month regimen of 60mg edoxaban was recommended after surgery.

Outcome

Surgical correction of the anomalous anatomy and postoperative anticoagulation led to freedom of symptoms.

Lesson

Clinical presentation of PAES mimicking peripheral artery occlusive disease is very rare but potentially limb-threatening. PAES should be considered in young and otherwise healthy individuals.

A Case of Overlooked Popliteal Artery Entrapment Syndrome

Popliteal artery entrapment syndrome (PAES) is an uncommon cause of lower extremity claudication that is often overlooked. It most commonly occurs in young athletes without risk factors for peripheral vascular disease. We present a case of a 47-year-old man who went undiagnosed for over 10 years despite multiple orthopedic, chiropractic, and neurosurgery consults. A definitive diagnosis of PAES was confirmed in the catheterization lab by angiography. The patient underwent popliteal artery bypass surgery and his symptoms completely resolved. PAES must be considered in the differential diagnosis of lower extremity pain, especially in younger patients.

Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.

Don't Just Blame it on the Veins: An Update on Vascular Exertional Limb Pain

Exertional limb pain is a common problem encountered in recreational and competitive athletes. Affecting both the upper and lower extremities, this broad entity can be musculoskeletal, vascular, neurologic, oncologic, or infectious in origin. This article focuses on the vascular causes of exercise-related extremity pain, which encompass a cadre of elusive diagnoses. Specifically, we examine arterial endofibrosis, popliteal artery entrapment syndrome, and chronic exertional compartment syndrome of both the upper and lower extremities. For each of these conditions, we offer updates regarding the respective epidemiology, common signs and symptoms, worthwhile diagnostic modalities, and pertinent treatment options, all based on evidence and reports published over the past year.

Popliteal Artery Entrapment or Chronic Exertional Compartment Syndrome?

Diagnosis of lower limb pain in an athlete can be a challenging task due to the variety of potential etiologies and ambiguity of presenting symptoms. Five of the most commonly encountered causes of limb pain in athletes are chronic exertional compartment syndrome (CECS), medial tibial stress syndrome (MTSS), tibial stress fractures, soleal sling syndrome, and popliteal artery entrapment syndrome (PAES). Of these, the least frequent but potentially most serious of the pathologies is PAES. With an incidence of less than 1% seen in living subject studies, the condition is rare. However, a missed diagnosis will likely lead to progression of the disease and potential for unnecessary invasive procedures (McAree et al. 2008). In this paper, we present a young athlete misdiagnosed and treated for chronic exertional compartment syndrome. In both descriptive and a quick-reference table format, we review current literature and discuss how best to distinguish functional PAES from other causes of activity-related leg pain.