Calf Pain, Foot Numbness And Swelling With Ambulation - Softball

Abstract

HISTORY A 14-year-old obese, otherwise healthy, female softball player with a 1.5 year history of intermittent right calf discomfort, swelling and “pins/needles” sensation of plantar foot, presented to clinic with incapacitating numbness and swelling of right foot. She also reported episodes of right toes “turning blue” during exercise, recalled no recent right lower extremity (RLE) injuries, and had been unable to participate in athletics for the past seven months. PHYSICAL EXAM Examination revealed palpable femoral and popliteal pulses, left >right and Doppler flow through the right posterior tibial (PT) >dorsalis pedis (DP) artery. On passive dorsiflexion of right foot, Doppler flow through DP and PT disappeared. There was mild edema over right lateral malleolus. Left LE had +2/4 pulses. Feet were of equal temperature with symmetric capillary and venous filling. Bilateral LE sensory and motor function was within normal limits and symmetric. Remainder of exam was unremarkable. DIFFERENTIAL DIAGNOSIS Popliteal artery aneurysm Popliteal cyst Deep venous thrombosis Compartment syndrome TESTS AND RESULTS Arterial/Venous Duplex Scan: RLE - Decreased velocity of right distal PT and DP with monophasic waveform and severe spectral broadening, probable high grade stenosis. LLE - Normal Computer Tomography Arteriogram: RLE - Slight narrowing of popliteal artery just cephalad to femoral condyles with irregularity in lumen and dilatation just below this point. Narrowing associated with one-centimeter diameter slip of muscle extending between popliteal vein and artery causing compression. Dilation could be impending aneurysm or source of emboli. LLE - Unremarkable FINAL/WORKING DIAGNOSIS Popliteal artery entrapment syndrome of RLE with 50% popliteal artery stenosis TREATMENT AND OUTCOMES Surgery involved posterior popliteal exposure. Aberrant muscle slip from medial head of gastrocnemius crossing over the popliteal artery was identified and transected. Intraoperative arteriogram identified stenosis at this site and the artery was opened revealing fibrous plague on intimal surface of lumen, irregularity at entrapped portion, and a normal trifurcation. Saphenous vein patch-angioplasty was performed to repair the artery. Doppler flow and palpable Right PT pulse restored Post-operative course was uneventful Six month follow-up included strong right palpable PT pulse, normal exercise treadmill test and RLE Doppler studies. Occasional bouts of right calf tenderness that resolved with rest, no swelling. Patient participated in a full season of softball following rehabilitation therapy.