Working Diagnosis:
Popliteal artery entrapment syndrome

Treatment:
The patient underwent left popliteal artery entrapment release with vascular surgery. Postoperative angiogram showed resolution of previously noted occlusion with resisted plantarflexion.

Outcome:
At one month post-op, she noted slight left calf pain after prolonged walking but less than prior to surgery. She continued her physical therapy home exercise program and gradually increased her walking. At 2.5 months post-op, she was released to return to soccer without restrictions. She will consider having the right popliteal artery entrapment released in the future.

Author's Comments:
The most common presentation of popliteal artery entrapment syndrome is claudication-type pain at the distal leg with exercise and paresthesias in the tibial nerve distribution. Symptoms go away soon after activity is stopped. It is most common in young men with a male:female ratio of 15:1.
There are six types of popliteal artery entrapment syndrome. Type V involves primary venous entrapment, type VI is associated with other variants, and type F involves no anatomic abnormality. This case was considered a type F.

Editor's Comments:
The F in type F popliteal artery entrapment syndrome refers to the functional component of the entrapment and absence of anatomic abnormality. It was initially described in 1985 as a separate entity from anatomic popliteal artery entrapment syndrome. Clinicians must maintain a high index of suspicion for popliteal artery entrapment syndrome in the active patient presenting with lower extremity claudication that rapidly improves with rest. It is commonly confused with chronic exertional compartment syndrome, tibial stress fracture, soleal sling syndrome, and medial tibial stress syndrome. One hallmark that distinguishes it from chronic exertional compartment syndrome is a more rapid cessation of symptoms after stopping exercise in patients with popliteal artery entrapment syndrome. Magnetic resonance angiogram, duplex ultrasound, and ankle/brachial indices all have evidence of efficacy in diagnosing popliteal artery entrapment syndrome. However, it is imperative that testing is performed with provocation, either by having the patient actively plantarflex the ankle, rapid heel raises, or hopping on one foot until symptoms are reproduced.

References:
Pandya YK, Lowenkamp MN, Chapman SC. Functional popliteal artery entrapment syndrome: A review of diagnostic and management approaches. Vasc Med. 2019 Oct;24(5):455-460.

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