Working Diagnosis:
Bilateral Popliteal Artery Entrapment Syndrome

Treatment:
She underwent evaluation for chronic exertional compartment syndrome (CECS). Although initial compartment pressure testing showed only mild elevations, persistent symptoms prompted repeat testing and ultimately led to bilateral four-compartment fasciotomies.
She underwent a left popliteal artery entrapment release with left popliteus resection and resection of the medial gastrocnemius head. The release of the right popliteal artery entrapment happened 2 months later. She started physical therapy and rehabilitation after both procedures.

Outcome:
She was dropped from her ROTC program but has been able to walk longer distances without issue.

Left Popliteal artery release went well, no complications. Case Photo #7

Right Popliteal artery release went well Case Photo #8 but three weeks post-operatively she developed nonpurulent cellulitis Case Photo #9 that was treated with Keflex. Case Photo #10

She has developed pain around her Achilles' tendons bilaterally that is currently being treated with over-the-counter medication and physical therapy with diagnostic ultrasound results demonstrating her Achilles' are not injured.

Her postoperative course was complicated by hematoma formation, wound dehiscence, rejection of internal sutures, and delayed closure that required a total of four surgical procedures with no infections documented. Following postoperative improvement, she was released to unrestricted activity.

Author's Comments:
Routine follow-up occurs with dynamic duplex ultrasound in 2-3 months. At 2 months, 33% are at full return with 50% partial return, unfortunately, no standardized return-to-play protocol exists. 78-82% of athletes return to sport at 14-16 months and 92.5% have no residual compression. Prognostic factors that improve outcomes: concurrent fasciotomy, male sex, and not requiring arterial reconstruction. Symptom recurrence is 11-17% at one year postoperatively. Popliteal artery entrapment syndrome (PAES) is a frequently missed diagnosis in young athletes that have exertional leg pain with an average time to diagnose of 34 months after initial presentation and bilateral involvement in 74-84% of cases. It also has distinguishing vascular features consisting of leg coolness in the posterior lower leg during exercise, plantar paresthesias, and diminished posterior tibial or dorsalis pedis pulses with ankle plantarflexion or dorsiflexion. The most reliable screening test is exercise ankle-brachial indices (ABI) as static imaging carries high false-negative rates. This leads to the gold standard of imaging for PAES of dynamic angiography with forced plantarflexion, such as in this particular case. Lastly, early intervention is essential in preventing arterial thrombosis and irreversible ischemia as delay in care may lead to complex arterial reconstruction.

Editor's Comments:
This case highlighted the challenge of diagnosing popliteal artery entrapment syndrome in a young athlete with chronic exertional leg pain, particularly when initial exercise ABI and duplex studies were unrevealing. Provocative angiography ultimately demonstrated dynamic bilateral popliteal artery occlusion with plantarflexion, and surgical decompression with popliteus and medial gastrocnemius resection, followed by rehabilitation, resulted in improved walking tolerance and functional recovery.

References:
1. Midterm Outcomes From a 20-Year Experience Treating Functional Popliteal Artery Entrapment Syndrome in Athletes. Journal of Vascular Surgery. 2025. Cabot JH, Yang L, Shalita C, et al.

2. Surgical Management of Functional Popliteal Entrapment Syndrome in Athletes. Journal of Vascular Surgery. 2019. Lavingia KS, Dua A, Rothenberg KA, Fredericson M, Lee JT.

3. Presentation, Diagnosis, and Management of Popliteal Artery Entrapment Syndrome: 11 Years of Experience With 61 Legs. Scandinavian Journal of Medicine and Science in Sports. 2018. Corneloup L, Labanère C, Chevalier L, et al.

4. Popliteal Artery Entrapment Syndrome: A Diagnostic and Treatment Enigma for Orthopaedic Surgeons. The Journal of the American Academy of Orthopaedic Surgeons. 2021. Miller TL, Backs R, Vaccaro PS.

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