Popliteal Artery Entrapment Syndrome

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Popliteal Artery Entrapment

Masquerading as Asthma

David Wang, MD, MS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 8 - AUGUST 2002

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In Brief: Patients don't always report symptoms that seem unimportant to them. Symptoms that don't respond to routine medical management, or that can't be fully explained by the signs observed, warrant a closer look and further questioning. Although the condition is uncommon, young athletes can develop functional popliteal artery entrapment. Diagnostic studies include examination of dorsalis pedis and posterior tibial pulses, Doppler ultrasonography, and arteriography. Treatment of functional popliteal artery entrapment usually includes surgical exploration, release of the popliteal artery, and a myomectomy of the medial gastrocnemius head.

Family practice physicians often see athletic patients who report activity-related ailments. Although rare, functional popliteal artery entrapment should be part of the differential diagnosis for patients who have exercise-induced lower-leg pain. In the following case, the patient's initial symptom was respiratory, and she did not mention leg fatigue until the second visit. A somewhat rare condition with an atypical presentation could easily have been missed or misdiagnosed. This case underscores the need to ask enough questions, cast a wide net when making a differential diagnosis, and remain open to unusual possibilities if ordinary treatments fail.

Case Report

History. A 20-year-old female collegiate sprinter who had been diagnosed as having exercised-induced asthma came to our sports medicine clinic for treatment of fatigue and increasing shortness of breath with exercise. The patient described difficulty breathing and diminishing athletic performance that added 10 seconds to her 400-m times. She felt she was not responding to recent changes made in her asthma medication by her primary care physician, and she requested further evaluation. Her medications consisted of long- and short-acting beta-agonists, an inhaled corticosteroid, a leukotriene inhibitor, and a nonsedating antihistamine.

The patient reported that her breathing problems were inspiratory and not expiratory. Because this is atypical for asthma, a graded exercise test was performed. When the patient became symptomatic, pulmonary function tests demonstrated a mild expiratory-flow drop consistent with mild asthma. The severity of her symptoms could not be explained by the mild degree of obstruction observed.

When asked about her breathing at a follow-up visit, she stated that the shortness of breath actually began as "tired legs." The athletic training staff was asked to monitor posterior tibial pulses if she became symptomatic during practice; trainers documented the absence of posterior tibial pulses but strong femoral pulses.

Physical exam. Her ankle-to-brachial blood pressure index was normal at rest (1.02) but decreased after 5 minutes of running to 0.79. A duplex scan of her lower extremity was normal. Doppler ultrasonography measurements of the posterior tibial pulse revealed arterial obstruction with resisted ankle plantar flexion. The posterior tibial pulses returned when active plantar flexion was discontinued. A lower-extremity angiogram demonstrated 100% blockage of the popliteal arteries with passive dorsiflexion of the ankle (figure 1).

Diagnosis. The diagnosis was bilateral functional popliteal artery entrapment.

Treatment. The patient underwent surgical exploration of the popliteal space to release the artery so that it would be less likely to become obstructed (figure 2). Through a popliteal approach, the artery appeared normal but was compressed by the gastrocnemius head. Fibrous bands and medial genicular arteries that tethered the popliteal artery were released to increase the mobility of the artery when it is compressed by the medial head of the gastrocnemius muscle. The medial head of the gastrocnemius was not initially divided because the patient wanted to preserve as much athletic function as possible. Postoperative Doppler studies were normal.

Follow-up. After an uncomplicated 3-month postoperative course, the patient was able to resume full activities and return to competitive running. She discontinued all of her asthma medications except prophylactic use of the short-acting beta agonist. Over the next 2 months, she trained at full intensity, and her performance approached her previous premorbid best.

At 5 months postsurgery she developed a "deadness" in her legs and a shorter stride length with hard interval training. Clinically, she no longer had dorsalis pedis and posterior tibial pulses with resisted plantar flexion, indicating a return of the popliteal entrapment syndrome. Ankle-to-brachial index testing postexercise again demonstrated a decline, and Doppler studies again showed decreased flow in the popliteal artery. With the ankle in a neutral position, magnetic resonance imaging (MRI) of the popliteal space did not show any abnormalities except the medial gastrocnemius muscle touching, but not impinging on, the popliteal artery. The patient's symptoms rapidly worsened until she had pain in the calves with normal ambulation and could not walk to class without pain.

Additional treatment. The patient underwent a second procedure to free up any scarring from the first procedure and to release the medial head of the gastrocnemius muscle. The medial head of the gastrocnemius was found to be quite large and touching the artery, even with the ankle in a neutral position. Myomectomy of the medial gastrocnemius head almost immediately relieved the patient's ambulatory pain.

Further follow-up. Within 2 months she was active in martial arts and running 30 minutes without pain. She is still occasionally using the short-acting beta- blocker for very mild asthma before exercising.

Background on Artery Entrapment

Stuart1 first described popliteal artery entrapment in 1879, but it was not until 1959 that Hamming2 diagnosed and surgically treated the condition. Since then, there have been several descriptions3,4 of an aberrant popliteal artery through and around the medial head of the gastrocnemius muscle. In 1985, Rignault et al5 described a symptomatic patient who had normal popliteal spaces. They defined this as functional popliteal entrapment syndrome. A recent literature review6 revealed that functional popliteal entrapment was more common than structural popliteal entrapment caused by anatomic variants.

Reports of popliteal artery entrapment syndrome are more common in athletic men, probably because much of the literature describes military populations. With women becoming more active in competitive sports and reports derived from nonmilitary populations, we may see more women diagnosed with this condition.

Most reports of popliteal artery entrapment occur in younger athletes, possibly because younger people are more often involved in vigorous training that can lead to functional hypertrophy of the gastrocnemius.6 Hypertrophy of the gastrocnemius medial head may contribute to functional entrapment of the popliteal artery because of their proximity. The development of functional popliteal entrapment syndrome may also be multifactorial; a tight or immobile, hypersensitive, or spasmodic popliteal artery may be contribute to entrapment.

Clinical Features

Claudication with pain provoked by some level of work is the most common presenting symptom in 90% of patient reports. Repeated popliteal artery compression causes trauma to the arterial wall, leading to premature localized atherosclerosis. As the pathology progresses, acute ischemia can occur if there is an occlusion of the artery or thrombosis within an aneurysm.7 Symptoms of acute or chronic ischemia, such as paresthesias, discoloration, temperature change, pain at rest, or tissue necrosis, account for the remaining 10% of patient reports. Popliteal entrapment is bilateral in 25% to 43% of patients.7,8

In this patient, shortness of breath was a very unusual symptom of popliteal entrapment, and the symptom of "tired legs," discovered only at the second interview, was attributed to exercise-induced ischemia of the lower leg. While pain often accompanies ischemia, this patient was unable to recall any history of lower-leg pain; perhaps because the tiredness occurred before pain and created a perception that she was exercising at near-maximal capacity. The patient may have perceived the oxygen debt of the lower leg as shortness of breath and attributed it to her asthma. Pain may develop as the condition worsens, as in this case when the patient reported pain with ambulation after the first procedure.

Investigation

Diagnosing popliteal entrapment can be difficult. In a study by Deshpande and Denton,6 5 of 8 patients had been treated with posterior compartment decompression for presumed chronic compartment syndrome before the correct diagnosis was made.

Diagnostic studies are needed if the history or clinical exam suggests popliteal artery entrapment. Initially, blood pressures of the dorsalis pedis and posterior tibial arteries should be obtained with Doppler ultrasonography. Evaluation of ankle pulses with active plantar flexion and passive dorsiflexion can be helpful, because the pulses are significantly diminished or absent in patients who have entrapment. The knee should be at or near full extension to put more stress on the gastrocnemius muscle, which increases the sensitivity of these maneuvers. Pulse disappearance with provocative maneuvers of the ankle can also occur in unaffected, asymptomatic athletes.9

Duplex scanning can also be used and may be quite sensitive and specific for arterial occlusion in elderly patients. Arteriography can confirm positive Doppler or duplex studies.8 Arteriographs often appear normal when the ankle is in a neutral position; therefore, evaluations must be done with the ankle actively plantar flexed.

MRI can distinguish a structural entrapment (caused by an aberrant course of the popliteal artery) from a functional entrapment, but in either case the treatment will be surgical.

Surgical Choices

Several surgical approaches can be used, but the least invasive surgery for functional entrapment is exploration and release of the fibrous bands and arterial branches tethering the artery. After the medial head of the gastrocnemius was surgically divided, 7 of 8 patients in the Deshpande and Denton study6 had complete relief. In this patient, the initial surgery was conservative compared with most procedures described in the literature (ie, divisions of the medial head of the gastrocnemius and release of the artery). Unfortunately, the less invasive procedure provided only short-term relief, and, ultimately, the patient needed a myomectomy of the medial gastrocnemius head.

Other approaches mentioned in literature include plantaris muscle resection and surgical release of the medial soleus from its tibial attachments.10 If arterial damage or occlusion is found, more invasive procedures, such as a saphenous vein bypass, may be needed.

Expecting the Unexpected

This case illustrates a very unusual presentation of a rare condition; however, sports medicine physicians often see patients who are young, very active, and at risk for popliteal entrapment. This condition should be suspected in patients who experience claudication or ischemic symptoms of the lower extremity. In this case, shortness of breath and fatigue were the initial complaints, perhaps representing an earlier phase of the condition. Early identification of popliteal entrapment is important to prevent more severe arterial disease.

References

Stuart TP: Note on a variation in the course of the popliteal artery. J Anat Physiol 1879;13:162-165

Hamming JJ: Intermittent claudication at an early age due to an anomalous course of the popliteal artery. Angiology 1959;10:369-371

Radonic V, Koplic S, Giunio L, et al: Popliteal artery entrapment syndrome: diagnosis and management, with report of three cases. Tex Heart Inst J 2000;27(1):3-13

Takase K, Imakita S, Kuribayashi S, et al: Popliteal artery entrapment syndrome: aberrant origin of gastrocnemius muscle shown by 3D CT. J Comput Assist Tomogr 1997;21(4):523-528

Rignault DP, Pailler JL, Lunel F: The 'functional' popliteal entrapment syndrome. Int Angiol 1985;4(3):341-343

Deshpande A, Denton M: Functional popliteal entrapment syndrome. Aust N Z J Surg 1998;68(9):660-663

Stager A, Clement D: Popliteal artery entrapment syndrome. Sports Med 1999;28(1):61-70

di Marzo L, Cavallaro A, Mingoli A, et al: Popliteal artery entrapment syndrome: the role of early diagnosis and treatment. Surgery 1997;122(1):26-31

Akkersdijk WL, de Ruyter JW, Lapham R, et al: Colour duplex ultrasonographic imaging and provocation of popliteal artery compression. Eur J Vasc Endovasc Surg 1995;10(3):342-345

Turnipseed WD, Pozniak M: Popliteal entrapment as a result of neurovascular compression by the soleus and plantaris muscles. J Vasc Surg 1992;15(2):285-293

Special acknowledgment and thanks to William Omlie, MD, for his expertise in the management of this case.

Dr Wang is an assistant professor in the Department of Family Practice, director of the sports medicine clinic at Boynton Health Service, and a team physician at the University of Minnesota in Minneapolis. Address correspondence to David Wang, MD, MS, Boynton Health Service, 410 Church St, Minneapolis, MN 55455.

Disclosure information: Dr Wang discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.

Any one out there have surgery for this syndrome?

Advice?

I had this surgery at the end of July. I was in the hospital for a few days but it wasn't bad. 30 staples and some problems walking due to the tendons shrinking, but they have since stretched out and all is fine. I feel a lot better and would definately recommend getting this done.

I had surgery on my left leg last April. I also will have to have surgery on my right leg in the next couple of months. As far as should you go for it, that is entirely up to you and how severe your condition is. Eventually, you will have to do something about it or you could possibly lose your leg...hence, surgery or inactivity. It's your call. If you have any other questions, feel free to ask. You can also check out another message board that I started a while back.

http://forums.wrongdiagnosis.com/showthread.php?t=29978

It may answer some of your questions.

Hope this helps,

Brenda

For those of you who replied that you did have surgery how soon were you back to running? My doc thinks I either have peroneal nerve entrapment or functional popliteal artery entrapment (lunmbar disc issues and compartment syndrome have already been ruled out be testing). I see a neurologist and a vascular surgeon who does a lot of work with athletes next week to confirm or rule out one or both of these issues. I\'d like to know in advance if I\'m facing surgery how long a road to recovery I may be facing. Thanks!

Get the surgery NOW! A day's delay could be fatal.

There is now a support group on facebook for those suffering from PAES. If you have a facebook account, please sign up for it. We need success stories too!

http://www.facebook.com/home.php#/group.php?gid=60576063296

Sorry to bump a 5 year old thread, but I'm wondering if anyone here has had experience with popliteal artery entrapment syndrome (PAES).

I was diagnosed with "medial tibial stress syndrome" a few years back and despite several interventions, I've had a hard time training without calf and shin pain. I also had an unexplained pulmonary embolism a couple of years ago... I'm not sure if the two are linked, but I'd appreciate hearing your experience if you've dealt with PAES of if anyone has any doctor recommendations for testing/treatment here in the US.

Thanks.

Sorry to bump this thread again, but...Hi NTHXC! I'm not sure if you got any answers yet, but I'm in the midst of treatment for functional PAES and maybe my experience so far will help. As far as testing, I saw a sports physician for my lower leg/calf pain andI was originally diagnosed with chronic exertional compartment syndrome so compartment pressure testing was done; that showed overall elevated pressures but not the post-exercise jump in pressure that is indicative of CECS. Next my sports physician referred me to a vascular surgeon with PAES in mind. He did MRI's with and without contrast while monitoring my heart, in several different ankle positions, and these showed a reduction in pulses during resisted plantar flexion. Finally, to confirm, he did a Doppler sonogram with different ankle positions before and after exercise to determine more precisely where the artery was being entrapped. Based on what he saw, I had bilateral surgery to take out the plantaris muscle in each leg and pull the soleus partly off of its attachments to my tibia, to release the artery. It was a relatively quick recovery and I was back to light running within six weeks! Now, at three months post-op and back into running regularly, my symptoms are returning. This is a possibility with scar tissue developing in a way that entraps the artery again, or even another part of a muscle, so I am going back to see my surgeon soon. Good luck and I hope your legs are feeling better!

I am having a hard time finding real information from patients about this condition. Most forum posts are very old and I am just looking for recovery information.

I've been diagnosed with CECS, and have exterior fasciatomies (sp.) and the interior on my right leg. I got a little relief, but when i started back at Roller Derby and running, i quickly realized that something is still very wrong. The ortho that did the leg surgeries was pretty much done. I live in a very rural area where the CECS was almost completely unknown, and have to travel 2 hours just to find a doc that is knowledgable about PAES. I am going for my appointment tomorrow and i'm freaking out a little about diagnosis. In the process of making sure it's not all in my head, I've seen another vein doc and she's the one that mentioned PAES and sent me to another specialist. I've always been athletic and have had to deal with the pain since i was 12 because everyone always blew it off as shin splints. Once i finally got a doc to say is CECS we went right into surgery and i ended having complications because i found out i'm allergic to Monocryl (wound glue). spent 6 months to get the wound to close and then on the second surgery i developed a huge blood clot around the wound which almost got my leg amputated. It's been a few years and i've lost a lot weight on purpose to see if that would help and it has not. So i guess the point is surgery and recovery questions.

1. Do docs often to both legs at a time and if they do, how mobile are you?

2. Whats the recovery time after surgery, like how soon do you start walking?

3. do you wear braces, how much knee mobility is there?

4. And do you think it's worth it?

Hi,

I just came across this thread - i've been diagnosed with PAES, i'm a 36 year old woman - used to run marathons, but currently limited to around 1 mile due to claudication.

I have PAES in both legs - around 50% reduction in blood flow on the right leg and 75% in the left when running or hill walking.

I'm having surgery 2 weeks today on the right leg (it has better blood flow, but more symptomatic).

Vanessa to answer a couple of your questions:

1. They won't do both legs at the same time. My consultant is doing them separately. He says a 1 or 2 night stay in hospital, 2 weeks recovery and then about 6 weeks normal function before he does the other leg.

2. as above.

3. Apparently the worst part is the healing of the scar behind the knee, but I will have mobility exercises to do during the 2 week recovery for mobility. I'm guessing there'll be crutches in the beginning.

4. I think it's worth it. At the age of 36, i'm not willing to never run a long distance again. Ask me again in 2 weeks though and we'll see!

How did your surgery go? I am 54 and had 3 rounds of fasiectomies 17,18, and 19 years ago for bilateral 4 compartment syndrome in my lower legs.

4 months ago - I got compartment syndrome for the 4th time! My very smart ortho doc asked if I had every been evaluated for FPAES - well no and yes, I have it.

Had to get the CS dealt with first with high resting pressures and now am going to schedule the surgeries for the FPAES.

I tried to find a botox doctor around where I live - alas - Wyoming and Australia were the two options I found.

I get 100% reduction of blood flow in both legs with dorsiflexion - now I know what the pain is when I am hiking uphill and it occurs!

All I know is I don't want to deal with another round of CS at this point in my life and I am still hiking so need to deal with it.

I am seven months post op from bilateral type 3 PAES surgery. My upper thighs hurt, my skin is numb, behind my knees are very painful and I can no longer run at all. I used to run 3-5 miles a day and I need to get back to running. All of my pressures have been tested, my blood flow is normal and the doctors told me there was nothing else they can do. Has anyone experienced anything like this?

The skin being numb around and below the surgical site is common. I has surgery on both legs 7 years ago. I still have numbness sometimes. The pain behind the knee is most likely from immobilization. You should work with a GOOD physical therapist and work on mobilizing your scar tissue and stretching out the tissue around it. You should be back to running soon. I ran the Army ten miler 9 months after my second surgery.

My question to the group is about reoccurance of PAES. As state above, I had surgery 7 years ago. Over the last year I have been having the same symptoms as before. Does anyone know if it is common for this to return and what the treatment is for returning PAES. Thanks everyone.

I had this Popeil syndrome as a kid, just couldn't get rid of it, popped up every night while watching TV. http://tinyurl.com/ybvqmwwp.

Hi, Susan. I don’t know if you’re still on this board or forum as this is kind of an old thread, but I hope so. Finding information on PAES from people who’ve experienced it is not easy! Thanks for sharing your experience!

So I’m wondering...

How did your surgery go?

Who did it - a vascular surgeon, ortho, both??

How’s your recovery been?

Was the healing of the scar behind your knee as bad as you expected?

Are you running again?

I’m a 44 -year old female and so from everything I’ve read, I’m an unusual case. (And I worry recovery will be harder because of it.) I’ve just been diagnosed with PAES a few days ago and was just referred from my ortho to a vascular surgeon today, so I’m still waiting to find out what the plan is. Not knowing is driving me absolutely crazy! I have 100% reduction of blood flow in BOTH legs, and will definitely need surgery, but there doesn’t seem to be any permanent vascular damage yet. That’s as much as I know, unfortunately. I am a self-employed (and work from home) mom of 2 responsible for all the driving to school, appointments, activities, etc, so I have to be able to plan ahead. I’m curious about all of the things to consider - not being able to drive, how long the hospital stay is, etc, etc...

I hope your recovery has gone very well!!

Sara

Bump

Looking for feedback from younger athletes. I’m in my early 30’s and need surgery for PAES

Bump this wrote:

Bump

Looking for feedback from younger athletes. I’m in my early 30’s and need surgery for PAES

Try reaching out to Andrew Colley at ZAP. I heard an interview with him where he talked about having surgery for it.

Ask Andrew wrote:

Bump this wrote:

Bump

Looking for feedback from younger athletes. I’m in my early 30’s and need surgery for PAES

Try reaching out to Andrew Colley at ZAP. I heard an interview with him where he talked about having surgery for it.