Working Diagnosis:
Functional popliteal artery entrapment syndrome

Treatment:
The patient elected left popliteal artery entrapment release and debulking of the medial head of the gastrocnemius muscle.

Outcome:
The patient did well post-operatively. He initially had difficulty plantarflexing but started physical therapy and was progressing well. However, due to the ongoing COVID-19 pandemic, he was lost to follow-up.

Author's Comments:
The incidence of chronic exertional compartment syndrome in people with chronic exercise-related lower leg pain ranges from 14-27%. This case highlights a trend noted among sports medicine providers that many cases of chronic exertional compartment syndrome are not straightforward and may be attributed to another diagnosis or may be multifactorial. While this patient did have elevated compartment pressures consistent with chronic exertional compartment syndrome, he continued to experience exertional leg pain despite bilateral fasciotomies. It would be reasonable to explore other etiologies of his symptoms, particularly popliteal artery entrapment syndrome (PAES) as PAES and chronic exertional compartment syndrome have overlapping symptoms and similar active patient populations.

Editor's Comments:
Functional popliteal artery entrapment syndrome (PAES) tends to occur in younger, active patients and affects males more than females. It is the result of abnormal anatomy in the popliteal fossa of the knee which causes an entrapment of the artery as it courses behind the knee. With activity, this can result in claudication with function impairments as well as chronic vascular complications. Other symptoms include distal paresthesias, foot swelling blanching, pallor, and cool feet. Surgical intervention is needed in cases that are severe and persistent. Botulinum toxin A injection is a conservative treatment option, but more research is currently needed. Duplex ultrasound is a method now being utilized in the diagnosis as it can be done dynamically, placing the patient in provocative maneuvers. Additionally, ankle-brachial indices and plain CT or MR and with added angiography can prove useful for diagnosis.

References:
1. Turnipseed WD. Functional popliteal artery entrapment syndrome: A poorly understood and often missed diagnosis that is frequently mistreated. J Vasc Surg. 2009 May;49(5):1189-95.

2. Shahi N, Arosemena M, Kwon J, Abai B, Salvatore D, DiMuzio P. Functional Popliteal Artery Entrapment Syndrome: A Review of Diagnosis and Management. Ann Vasc Surg. 2019 Aug;59:259-267. doi: 10.1016/j.avsg.2018.12.105.

3. Schubert AG. Exertional compartment syndrome: review of the literature and proposed rehabilitation guidelines following surgical release. Int J Sports Phys Ther. 2011 Jun;6(2):126-41.

4. Turnipseed WD. Clinical review of patients treated for atypical claudication: a 28-year experience. J Vasc Surg. 2004 Jul;40(1):79-85.

5. Lovelock T, Claydon M, Dean A. Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management. Int J Sports Med. 2021;42(13):1159-1166.

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