Bilateral Exertional Calf Pain - Page #4
 

Working Diagnosis:
Functional popliteal artery entrapment syndrome

Treatment:
Underwent bilateral functional popliteal artery release, which involves releasing a constricted popliteal fossa outlet created by soleus muscles. Intra-operatively, patient was also found to have an enlarged popliteus muscle.

Outcome:
He is now 1 year post-op from bilateral functional popliteal artery entrapment release, has returned to full activity and is completely asymptomatic.

Author's Comments:
Physical exam, PDI ultrasound and ABI were consistent with popliteal artery entrapment syndrome. However, MRI/MRA demonstrated no anatomic variation in the gastrocnemius muscles and no vascular entrapment with provocation. Given this the final diagnosis was functional popliteal artery entrapment syndrome. In symptomatic patients what is the role of non-invasive testing such as PDI US and ABI in the diagnosis of FPAES?

Editor's Comments:
This case highlights a fairly unusual cause of exertional calf pain. Recent literature suggests dual-source CT angiography and ultrasound as non-invasive studies useful in establishing this diagnosis. Further, classification systems exist which may be helpful in discerning those patients that need decompression vs decompression with bypass vs angioplasty.

Sun X, et al. Dual source CT angiography in popliteal artery entrapment syndrome. J Med Imag and Rad Onc 57(2013): 156-160.

Causey MW, et al. Ultrasound is a critical adjunct in the diagnosis and treatment of popliteal entrapment syndrome. J Vasc Surg 57(2013): 1695-97.

Whelan TJ, Haimmovici H. Vascular surgery: principles and techniques. 2nd ed. New York: McGraw-Hill,
1984; pp 557-567.

Rich NM, Collins GJ, McDonald PT, et al. Popliteal vascular entrapment. Its increasing interest. Arch Surg
1979; 114: 1377-84.

References:
1. Oschman Z, Metherell E. Popliteal artery entrapment syndrome misdiagnosed as chronic exertional compartment syndrome in a young athlete: Role of dynamic ultrasound. S Arf J SM 2012; 24: 65-66.
2. Edwards PH et al. A Practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med 2005; 33:1241-1249.
3. Turnipseed W. Functional popliteal artery entrapment syndrome. A Poorly understood and often misdiagnosed diagnosis that is frequently mistreated. Journal of Vascular Surgery 2009; 49:1189-1195
4. Goh B, Tay KH, Tan SG. Diagnosis and Surgical Management of Popliteal Artery Entrapment Syndrome. ANZ J Surg 2005; 75:869-873.
5. Rignault DP et al. The functional popliteal entrapment syndrome. Int Angio. 1985; 4:341-3.
6. Delany TA, Gonsalez LL. Occlusion of popliteal artery due to muscle entrapment. Surgery 1971; 69:97-101.
7. Roche Nagle G et al. Vascular claudication in a young patient: popliteal entrapment syndrome. Hong Kong Med J 2009;15:388-390.
8. Hershman EB, Tauliopolaus S. Lower leg pain diagnoses and treatment of compartment syndromes and other pain syndromes of the leg. Sports med 1999;27(3):193-204.
9. Akkersdijk WL et al. Colour Duplex Ultrasonographic Imaging and Provocation of Popliteal Artery Compression. Eur J Vasc Endovasc Surg 1995; 10: 342-435.
10. Sun X, et al. Dual source CT angiography in popliteal artery entrapment syndrome. J Med Imag and Rad Onc 57(2013): 156-160.

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