Leg Pain in a Tennis Player

Abstract

HISTORY A 45-year-old male presented with a two-year history of a slowly progressive, cramping, “stuck” feeling in his left thigh when running or playing tennis. Prior investigations at symptom onset were unrevealing. With exertion, he described pain radiating down his thigh into the ball of his left foot. At presentation to our clinic, he had not played tennis for six months due to these symptoms. He could, however, walk slowly eight blocks, or stand for up to two hours, without symptoms. Prolonged sitting produced a “numb” sensation in his left lateral buttock that would often radiate from the left groin into the mid thigh area. No leg paresthesias or weakness described. No bowel or bladder changes reported. He did note discomfort (“funny feeling”) at night radiating into his left leg. PHYSICAL EXAMINATION Gait including heel and toe walking was normal. Reflexes (including Babinskis) were normal and symmetric. Strength testing L2 -S1 was normal. Sensation was normal in the arms and legs, other than a small area of reduced pin sensibility below his left inguinal herniorrhaphy scar. Lumbar range of motion with left lateral bending caused mild left lumbar pain but no leg referred pain. Hip maneuvers were negative. Seated straight leg raise and reversed straight leg raise were negative. No lumbar, gluteal, or sciatic notch tenderness was noted. Examination of pulses on right leg revealed strong right femoral and popliteal, and a weak right dorsalis pedis. Pulses were non-palpable in the left leg even to the femoral level. Capillary refill was satisfactory in the left foot. No abdominal masses or bruits were appreciated. DIFFERENTIAL DIAGNOSIS Intimal thickening/endofibrosis of the iliac artery Stenosis/kinking of iliac artery Adventitial cystic disease of the iliac artery Adductor canal outlet syndrome Chronic compartment syndrome of the posterior thigh Mass in the pelvis Buerger's disease Upper lumbar radiculopathy TEST AND RESULTS Left Hip x-ray: –Unremarkable. MRI of the lumbar spine without contrast: –Unremarkable. MRI of the pelvis and left thigh without contrast: –Unremarkable. Lower arterial Doppler studies: –Revealed at rest an ABI of 1 on the right and 0.7 on the left. Gadolinium-enhanced MRA of the pelvis and lower extremities: –High grade (90%) focal stenosis of the proximal left common iliac artery. FINAL/WORKING DIAGNOSIS High-grade focal stenosis at the origin of the left common iliac artery. TREATMENT AND OUTCOMES Angioplasty and stenting of the left common iliac artery was performed. The patient returned to playing tennis in 2 weeks, without any recurrence of prior symptoms. Advised to quit smoking. Control lipids.