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Popliteal artery entrapment syndrome

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Popliteal artery entrapment syndrome
Normal course of the popliteal artery at the back of the knee

The popliteal artery entrapment syndrome (PAES) is an uncommon pathology that occurs when the popliteal artery is compressed by the surrounding popliteal fossa myofascial structures. This results in claudication and chronic leg ischemia. This condition mainly occurs in young athletes compared with those elderly affected with peripheral artery disease and associated with atherosclerosis. Patients with PAES mainly present with intermittent feet and calf pain associated with exercises and relieved with rest. PAES can be diagnosed with a combination of medical history, physical examination, and advanced imaging such as duplex ultrasound, computer tomography, or magnetic resonance angiography. Management can range from non-intervention to opening surgical decompression with a generally good prognosis. Complications of PAES can include stenotic artery degeneration, complete popliteal artery occlusion, distal arterial thromboembolism, or even formation of an aneurysm.

History

The syndrome was first described in 1879 by Anderson Stuart, a medical student, in a 64-year-old male.[1] Hamming and Vink in 1959 first described the management of the popliteal artery syndrome in a 12-year-old patient. The patient was treated with myotomy of the medial head of the gastrocnemius muscle and concomitant endarterectomy of the popliteal artery. They later reported four more cases and claimed that the incidence of this pathology in patients younger than 30 years old with claudication was 40%. Servello was the first to draw attention to diminished distal pulses observed with forced plantar- or dorsiflexion in patients with this syndrome.[2] Bouhoutsos and Daskalakis in 1981 reported 45 cases of this syndrome in a population of 20,000 Greek soldiers.[3] Over the last few decades, the increasing frequency with which popliteal artery entrapment is reported, strongly suggests a greater awareness of the syndrome.[4]

Epidemiology

In the general population, popliteal artery entrapment syndrome (PAES) has an estimated prevalence of 0.16%.[5] It is most commonly found in young, physically active males.[6] In fact, sixty percent of all cases of this syndrome occur in athletically active males under the age of 30.[7] The predilection of this syndrome presents in a male to female ratio of 15:1.[5] This discrepancy in prevalence may be partially attributed to the findings that males are generally found to be more physically active than females or because a large portion of the data accumulated for PAES is from military hospitals that treat mostly male populations.[7] The prevalence of PAES varies through different populations; it increases in those who participate in running, soccer, football, basketball, or rugby.[8] During embryonic development, the medial head of gastrocnemius migrates medially and superiorly. This migration can cause structural abnormalities, such as irregular positioning of the popliteal artery, and can account for the rare instances of entrapment caused by the popliteus muscle.[7] Less than 3% of all people are born with this anatomical defect that progresses into PAES, and of those who are born with the anatomical defect, the majority never develop symptoms.[8] Bilateral presentation of PAES is found in approximately 30% of cases.[9]

Pathophysiology and Classification

PAES can be classified as either congenital or functional.[10] Analysis of human embryological development has shown that the popliteal artery and the medial head of the gastrocnemius muscle arise at approximately the same time. Because of that, abnormal development of the position of the muscles in relation with the nearby vessels can result in potential vascular compromise.[10] The varying types of PAES can be classified based on aberrant migration and resultant attachments of the medial head of the gastrocnemius muscle. Type VI PAES (functional PAES) describes a subtype which is due to repeated microtrauma resulting in the destruction of the internal elastic lamina and damage to the smooth muscles resulting in fibrosis and scar formation.

Type I: the popliteal artery courses more medially around a normally positioned medial head of the gastrocnemius muscle.[10]

Type II: the medial head of the gastrocnemius muscle attaches more laterally to the femur.[10]

Type III: Aberrant additional tendon of the gastrocnemius muscle encircles a normally positioned popliteal artery.[10]

Type IV: the popliteal artery is compressed by the popliteus muscle or a fibrous brand.[10]

Type V: The compression of both the popliteal artery and vein by any of the above causes.[10]

Type VI: The normally positioned popliteal artery is entrapped by the gastrocnemius muscle hypertrophy.[10]

Additionally, a more practical classification system is introduced by Heidelberg et al.[11] This system classifies PAES into three main types:

Type 1: The problem lies in the abnormal position of the popliteal artery.[11]

Type 2: The problem lies in the abnormal insertion of the medial head of the gastrocnemius muscle.[11]

Type 3: Both types 1 and 2 are presented.[11]

Medical History and Physical Examination

Patients with PAES are typically healthy young male without previous history of cardiovascular risk factors such as smoking, hypertension, hypercholesterolemia, or diabetes.[12] Typically, patients present with intermittent claudication that is worsened with exercise and relieved with rest.[10] Associated symptoms include numbness, discoloration, pallor, and coolness in the affected lower extremity.[12] Physical examination of suspected PAES may be hypertrophy of the calf muscles, as well as diminished, unequal, or absent pulses in the lower extremity upon plantarflexion or dorsiflexion.[13]

Diagnosis

Differential diagnosis

Exercise induced lower leg pain includes chronic exertional compartment syndrome,[14] unresolved muscle strain (this classically occurs at the musculotendinous junction of the medial head of gastrocnemius), medial tibia stress syndrome, fibular and tibial stress fractures, fascial defects, nerve entrapment syndrome, vascular claudication (atherosclerotic or popliteal artery entrapment syndrome) and referred pain from lumbar disc herniation.[15]

References

  1. ^ Gokkus, Kemal; Sagtas, Ergin; Bakalim, Tamer; Taskaya, Ertugrul; Aydin, Ahmet Turan (2014-07-14). "Popliteal entrapment syndrome. A systematic review of the literature and case presentation". Muscles, Ligaments and Tendons Journal. 4 (2): 141–148. ISSN 2240-4554. PMC 4187583. PMID 25332925.
  2. ^ Servello, Manfredi (1962-11-01). "Clinical Syndrome of Anomalous Position of the Popliteal Artery". Circulation. 26 (5): 885–890. doi:10.1161/01.CIR.26.5.885.
  3. ^ Bouhoutsos, J; Daskalakis, E (July 1981). "Muscular abnormalities affecting the popliteal vessels".
  4. ^ Stager, Andrew; Clement, Douglas (1999-07-01). "Popliteal Artery Entrapment Syndrome". Sports Medicine. 28 (1): 61–70. doi:10.2165/00007256-199928010-00006. ISSN 1179-2035.
  5. ^ a b "Popliteal Artery Occlusive Disease: Background, Problem, Epidemiology". 2016-04-10. {{cite journal}}: Cite journal requires |journal= (help)
  6. ^ Sharma, Aditya (2014). "Conditions Presenting with Symptoms of Peripheral Arterial Disease". Seminars in Interventional Radiology. 31 (4): 281–291. doi:10.1055/s-0034-1393963. PMC 4232436. PMID 25435652.
  7. ^ a b c Stager, Andrew; Clement, Douglas (2012-09-23). "Popliteal Artery Entrapment Syndrome". Sports Medicine. 28 (1): 61–70. doi:10.2165/00007256-199928010-00006. ISSN 0112-1642. PMID 10461713. S2CID 26958095.
  8. ^ a b "Popliteal Artery Entrapment Syndrome (PAES) | Cleveland Clinic". Cleveland Clinic. Retrieved 2016-12-19.
  9. ^ Drigny, Joffrey; Reboursière, Emmanuel; Desvergée, Antoine; Ruet, Alexis; Hulet, Christophe (2019-06). "Concurrent Exertional Compartment Syndrome and Functional Popliteal Artery Entrapment Syndrome: A Case Report". PM&R. 11 (6): 669–672. doi:10.1002/pmrj.12081. ISSN 1934-1482. {{cite journal}}: Check date values in: |date= (help)
  10. ^ a b c d e f g h i Júnior, Francisco Cialdine Frota Carneiro; Carrijo, Eduardo Nazareno dos Anjos; Araújo, Samuel Tomaz; Nakano, Luis Carlos Uta; de Amorim, Jorge Eduardo; Cacione, Daniel Guimarães (2018-01-09). "Popliteal Artery Entrapment Syndrome: A Case Report and Review of the Literature". The American Journal of Case Reports. 19: 29–34. doi:10.12659/AJCR.905170. ISSN 1941-5923. PMC 5769514. PMID 29311538.
  11. ^ a b c d Papaioannou, S; Tsitouridis, K; Giataganas, G; Rodokalakis, G; Kyriakou, V; Papastergiou, Ch; Arvaniti, M; Tsitouridis, I (2009). "Evaluation of popliteal arteries with CT angiography in popliteal artery entrapment syndrome". Hippokratia. 13 (1): 32–37. ISSN 1108-4189. PMC 2633250. PMID 19240818.
  12. ^ a b Davis, Donald D.; Shaw, Palma M. (2022), "Popliteal Artery Entrapment Syndrome", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 28722994, retrieved 2022-12-04
  13. ^ "ClinicalKey". www.clinicalkey.com. Retrieved 2022-12-04.
  14. ^ Bong MR, Polatsch DB, Jazrawi LM et al. Chronic exertional compartment syndrome: diagnosis and management.Bull Hosp Jt Dis. 2005;62(3-4):77-84.
  15. ^ Locke S. Exercise related chronic lower leg pain. Aust Fam Physician 1999; 28:569–573.
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