Popliteal Artery Entrapment Syndrome

Lisa,

Have you had your workup already? I noticed your post was back in April. I hope you have found someone to evaluate and treat you. If yes, would you share your experience? Thanks.

I've been a runner for almost 30 years and never took an extended break until I got injured (tendinopathy). When I tried to return to running, I had similar symptoms (calf tightness during running or walking uphill that leads to numbness of feet) and couldn't run more than 2 minutes without my legs shutting down. I couldn't even do more than 15 calf raises, so my PT told me to practice those but I didn't get better after 1 month.

Anyway, I ignored his gloom and doom prediction about fasciotomies and surgery and found on this message board that some people had success with Botox from Dr. Joseph McGinley in Casper, WY. I was pretty confident that I had PAES even though I had no testing done by other doctors, so I booked an appointment and traveled there for the testing/treatment. Within 3 hours, I had 2 MRIs, 2 Angiograms, ultrasound, and the injections (because the results of the testing concluded I had 100% occlusion in my R leg and moderate occlusion in the L, as well as compartment syndrome in the posterior compartment). My legs already felt better during my 4 hour drive back to the Denver airport. Two weeks later I started to run, and it was very hard at first - I could only run 2 minutes at a time, really slowly, because my calves were so tight/weak, but I just kept doing 1 mile a day, then 1.5, 2, 2.5, etc. By week 9 I could run 3 miles with a few short breaks, and then week 12-13 I could run 5 miles at a time, 20 miles per week. I still have a hard time running up hills because the Botox is still active and the secondary muscles are still getting stronger, but it will continue to get easier as I gain strength, and when the Botox wears off, then the primary muscles will not need to return to their previous size.

I had to wait a month to get a call back from them, and then 6 weeks to get on the schedule, but it was all worth the $8800. Some people require 2-3 treatments, but they are cheaper than the initial treatment. I thought it was well worth it to avoid having 2 separate surgeries that were not guaranteed to work (take too much or too little muscle, you will be impacted negatively).

Just to add my experience to this.

I had compartment surgery release.

Before that i felt sometimes my calves would explode.

I believe the surgery worked, i never felt the same pain in my calves again. BUT

However lately, the same pain has appeared in the lower end of my feet. I mean the paw of my feet. Its the same cramping, slowly building up pain (claudication) as in compartment syndrome. It builds up, reaches a peak after 15m or so, and stays there. If i can grind through the pain, after 30-40 minutes it slowly goes away.

If i need to stop sooner, it needs like 30-40secs to relax again.

All these point out to something being blocked, so i believe something (a vein or an artery) is being pressed there.

As i read before, dorsiflexion (uphills, or flat shoes with no drop ratio) make the pain worse, but im not sure.

Sometimes its bad, to the point i cant run, some (most) times its manageable with some discomfort, rarely is like i was never in pain.

Running faster (perhaps the foot, doing less dorsiflexion), is actually more relaxing than running very slow pace. Its strange and very miserable.

I'll arrange a visit to a vein-doctor soon

Adding here too. I have PAES in both legs, with 100% occlusion in one and close to that in the other. I was a high level athlete in college and after, but quit running for a while when I went to grad school. In my late 20s, I tried running again and wasn’t able to do much of anything due to calf pain. Went to PT, had loads of tests and no definitive diagnosis because none of the mds did a dynamic ultrasound.

I basically just tried to tough it out for years, but was pretty convinced it was PAES after reading this forum and lots of medical journals. Then, 4 years ago I moved to Australia and took the opportunity to be evaluated for botox injections. I saw a sports medicine physician and he performed MRI, in office tests and dynamic ultrasound, confirming PAES. I did 2 rounds of Botox in both legs about 6 months apart. I only got temporary relief and was never able to return to full running. Basically a month after the injections, I would start to have calf pain again when trying to run (or even walking).

Fast forward to this year, I’m back in the States and referred myself to Dr. Nitin Singh at UW Harborview Medical Center in Seattle. He’s a vascular surgeon who treats lots of people with PAES. Prior to the first visit, they had me do a lot of dynamic ultrasound imaging. At the first visit, they said the U/S was consistent with PAES, did a physical exam, then scheduled me for a more invasive arterial U/S before I would be eligible for surgery. That U/S confirmed PAES in both legs.

I was scheduled for my first surgery shortly after. They only do 1 leg at a time and that’s a good thing because you’re definitely sore after and walking tenderly. Surgery wasn’t long, but I stayed overnight in the hospital. I was sore and tired, but only taking Tylenol for pain and fine. I walked within the first 8 hours after surgery and it wasn’t pleasant, but was manageable. I saw a PT before discharge and she watched me walk around and said I didn’t need crutches. After going home, I took ibuprofen for soreness for another night or two. I’m 7 days post-op and walking and doing normal things. I will have sutures removed in a week (2 weeks after surgery).

I can already tell a huge difference. Before surgery, I couldn’t do 10 ankle raises without having fatigue and cramping. It’s still like that in my right leg, but not my left. I’m not far out from surgery, but already looking forward to having my right leg done in about 6 weeks. I avoided surgery for years because I thought I could manage it non-surgically or modify what I was doing. But the range of activity I could engage in kept shrinking until I wasn’t able to even ride a bike without issues.

Any updates?

Similar symptoms. Long time runner. Used to be able to run 70 miles per week. Relegated to a few miles a day. 30 mins in feet hurt like running on nails towards top. Calves become immediately fatigued running uphill or with some cadence.

MRI of feet showed calcification in arteries as if a full time smoker. RA indicators for connective tissue disease.

Every year progressively worsens from someone who ran 2 or 3 marathons a year to hobby jogger.

My (31M) story is very similar, I was a semi-competitive athlete in college, but quit running seriously around the age of 22-23. Throughout the rest of my 20's I ran periodically but not at a high level anymore. I did a few half marathons in those years, but I typically would really struggle the last few miles with calf cramps and fatigue in my lower legs. I typically just chalked it up to being a little heavier with poor conditioning, but in hindsight I believe it may have been the first signs of PAES.

At the age of 29 I was starting to get a bit more consistent with running again (still not competitive) and decided I wanted to see if I could get under 5 in the mile again so I started training for that. Doing 400's one day I had this cramping like pain in my left calf. This kicked off a 2 year cycle where I'd rest it for different periods of time, work on strengthening exercises, and stretch it all the time. Whenever I'd start building mileage back up I'd get the same pain after 10-20 minutes of running. During this time I tried PT a couple times, massage, a ton of stretching, strengthening, dry needling, etc.

I finally decided that maybe the issue wasn't just muscular or a conditioning issue so I went and saw a sports medicine doctor. After some x-rays and MRI's he referred me to a vascular surgeon with the hunch that it could be PAES, but possibly compartment syndrome. I had an ABI Ultrasound that showed my ABI was normal at rest, dropped significantly immediately after exercise, and returned to baseline within 5 minutes post-exercise. We did a couple of other ultrasounds where they looked at the popliteal artery to ensure there was no damage or cysts causing the occlusion. The doctor had all but confirmed it was PAES at this point, but ordered a peripheral angiogram to be certain. The angiogram confirmed that I had complete occlusion of the artery when I'd point my toes in the left leg and nearly complete occlusion of the artery in my right leg when I pointed those toes.

I just had surgery on the left leg last week. The surgeon said she removed about "half a fistful" of muscle between my gastrocnemius and the plantaris muscles. One week post-op I'm able to walk around alright with a limp, but it's getting better each day. Because I didn't have symptoms until 10-20 minutes into running, I have no idea if it's worked or not. Even though the right leg has not been symptomatic I'll be having surgery on it sometime in the next 1-3 months as well.

That's all, just wanted to share my experience since there isn't a whole lot of discussion out there on this disorder.

thank you so much for posting about your experience! I'm scheduled for popliteal artery release with Dr. Singh next week, and it's very reassuring to hear that your recovery was so quick and easy. If you see this: how did your second surgery go, and how are you doing now?