Persistent Bilateral Leg Pain In A Lacrosse Player - Page #4
 

Working Diagnosis:
Functional Popliteal artery entrapment syndrome

Treatment:
Surgery was planned to treat popliteal functional gastrocnemius entrapment. A 4-5cm calf incision was made in the upper medial calf and the investing fascia was incised to enter the popliteal space. The popliteal artery and popliteal vein were identified; the fascial attachments of the gastrocnemius and soleus muscle to the medial tibia were incised using electrocautery. This completely opened the very dense and strong fascia that was obviously constricting the popliteal artery. Additionally, the anterior soleus fascia was identified and an excision was made of a portion from the tibial attachment lateral to the fibula. The procedure was performed bilaterally and the wound was closed in layers with 3-0 Vicryl and the skin was closed with subcuticular 4-0 Monocryl suture.

Outcome:
Post-surgery the patient returned to play in 4 weeks with countinued physical therapy. She did not exhibit previous symptoms of bilateral leg numbness and pain. The patient's medial scars over the mid third of the gastrocnemius healed well and the patient had good popliteal and posterior tibial pulses and normal gastrocnemius tone.

Author's Comments:
This case illustrated the non-classic form of popliteal syndrome with functional compression of the popliteal artery by the gastrocnemius muscle and fascia. The surgical treatment of releasing the gastrocnemius fascia and anterior soleus fascia proved to be a suitable solution. The infrequency of popliteal artery entrapment syndrome and the surgical treatment made this case notable.

The symptoms of popliteal artery entrapment syndrome include pain, cramping, and weakness of calf muscles when exercising and relieved with rest. The symptoms are similar to compartment syndrome which is caused by increased pressure within an anatomical compartment that results in insufficient blood supply to the tissue within the space.

Classic popliteal artery entrapment is caused by congenital alterations of the popliteal artery course and compression is due to abnormal anatomical relationship between the vessel and nearby musculotendinous structures.

The patient was previously treated for compartment syndrome with a fasciotomy because of symptoms and confirmed increased pressure within the lateral and anterior compartments of the lower leg bilaterally. Treatment via a fasciotomy did not relieve pain and numbness of calf muscles upon return to play. Further investigation of the popliteal artery was pursued.

Popliteal artery entrapment syndrome in young athletic patients presents as a challenging diagnosis as the classic signs are not specific on physical exam.

The use of Doppler ultrasound and MRI imaging remain essential in the diagnosis of popliteal artery compression.

Surgery releasing the gastrocnemius and soleus muscles and fascial attachments of the tibia
thus relieving the pressure on the popliteal artery in the mainstay.

Successful surgery enabled the patient to return to competitive play without complications or
reoccurrences of previous ischemic symptoms in the lower legs and resulted in normal 2+ bilateral pulses.

Editor's Comments:
The author did an excellent job describing the popliteal artery occlusion and in this case, the non-classic, functional compression of the artery by the muscle and fascia. While the patient was initially treated for compartment syndrome the surgery did not relieve the symptoms and the practioner pursued further testing. Making sure to keep popliteal artery entrapment in the differential for a patient with exertional leg pain and high compartment pressure is important and could possibly have led to more investigations prior to the ineffective fasciotomy.

References:
Joy SM, Raudales R. Popliteal Artery Entrapment Syndrome. Curr Sports Med Rep. 2015 Sep-Oct;14(5):364-7.

Hameed M, Coupland A, Davies AH. Popliteal artery entrapment syndrome: an approach to diagnosis and management. Br J Sports Med. 2018 Aug;52(16):1073-1074.

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