Functional Popliteal Artery Entrapment Research Articles

Exercise transcutaneous oximetry in functional popliteal artery entrapment syndrome diagnosis.

Functional poplitealartery entrapment syndrome is a subtype of poplitealartery entrapment syndrome (PAES) without vascular disease or musculotendinous anomaly behind the knee. Symptoms are induced by popliteal artery extrinsic compression, leading to calf pain during lower limbs exercise. Non-invasive tests are still required to improve the diagnostic management of functional PAES. Exercise transcutaneous oxygen pressure (Ex-tcpO2) is of interest to provide objective arguments for the presence of regional blood flow impairment. The aim of the study was to analyze whether Ex-tcpO2 could serve as a non-invasive technique for detecting ischemia resulting from PAES. Patients with suspected PAES were recruited between 2017 and 2020. The diagnosis was confirmed or rejected, according to the surgical decision based on our diagnosis management involving a multidisciplinary team. Each patient underwent Ex-tcpO2 with specific maneuvers. The decrease from rest of oxygen pressure (DROP) index served for the interpretation of exercise results. Sixty-five legs with suspected PAES were recruited. Diagnosis was confirmed in 34 (52.3%) and rejected in 32 (47.7%). The average DROP values found in confirmed and rejected group at left leg were -21.6 ± 15.4mmHg and -10.9 ± 11.1mmHg, respectively (p for Mann-Whitney 0.004), and -15.8 ± 11mmHg and -11.1 ± 7.5mmHg, respectively, at right leg (p = 0.088). Ex-tcpO2 sensitivity and specificity were 52.9% and 78.1%, respectively. Ex-tcpO2 is an original non-invasive investigation for patients with claudication of doubtful arterial origin. The sensitivity and specificity are 52.9% and 78.1% in functional PAES diagnosis using 15mmHg as threshold to detect ischemia during tiptoeing elevations.

Long-term evaluation of surgery for functional popliteal artery entrapment syndrome

Long-term evaluation of surgery for functional popliteal artery entrapment syndrome

Long-Term Functional Outcomes After Surgery of Functional Popliteal Artery Entrapment Syndrome

Functional popliteal artery entrapment syndrome (fPAES) is a subtype of PAES without anatomic abnormalities entrapment of the popliteal artery. One of the management of symptomatic fPAES is surgical exploration of the popliteal region with popliteal artery release with lysis of fibrous bands. There is a lack of data regarding the long term functional results of this surgery, most of the studies focusing on vascular patency in anatomical PAES. The aim of this study was to assess the efficacy of surgery in functional PAES, focusing on long term physical activity return after surgery with the Tegner activity scale. All patients that underwent surgery for fPAES from January 1st 2010 to December 31th 2020 were searched. After ethical approved, all patients were called to evaluate physical activity since surgery. The Tegner activity scale is a numerical scale with each value (0 to 10) representing specific activity. The aim was to evaluate everyday activity limitations and participation restriction after surgery. The results for each patient were recorded: « before symptoms », « before surgery » and « after surgery ». Over the study period, 33 patients were included with 61 symptomatic legs. The mean time between surgery and phone call was 38.6± 21.9 months. The median score of the Tegner activity scale "before symptoms" was 7 (4-7), the median score "before surgery" was 3 (2-3) and the median score at the time of the phone call, "after surgery" was 5 (3-7). P-value was <0.0001 by comparing results "before surgery" and "after surgery". Results demonstrated that the sport activity and intensity level is significantly higher after surgery even if patients did not reach their initial sport activity level.

Intravascular ultrasound imaging for diagnosis and characterization of the popliteal compression syndrome.

Functional popliteal artery entrapment syndrome (fPAES) is a rare form of nonatherosclerotic claudication most often seen in young athletic patients. Diagnosis remains challenging, with various imaging modalities showing equivocal or subtle findings that may be missed. We sought to critically examine and quantitate the utility of intravascular ultrasound (IVUS) imaging, a common diagnostic tool for vascular compression syndromes, in diagnosis and characterization of fPAES. Patients presenting to a single tertiary care center between 2019 and 2022 with symptoms of PAES but without an anatomic etiology or equivocal workup were selected. Angiogram and IVUS with maneuvers were performed on affected extremities at rest, active plantarflexion/dorsiflexion, and plantarflexion/dorsiflexion against resistance. IVUS examination was recorded using a pull-back technique from the tibial vessels to the superficial femoral artery. The degree, length, and anatomic location of compression using the two imaging modalities were compared. Angiogram and IVUS with maneuvers were performed on 17 lower extremities (9 left, 8 right) in 15 patients (88% female; mean age, 21.2years). Evidence of arterial compression on angiography was noted in 88.2% (n= 15) of limbs (66.7% complete contrast cessation and 20% popliteal artery tapering); 13.3% (n= 2) only demonstrated sluggish flow as possible evidence of compression. Arterial compression was seen on IVUS imaging in 15 of 17 limbs, and all completely compressed around the IVUS catheter. The IVUS-measured mean length of compression was 10.5cm± 4.2 (median, 11cm; range, 4-23cm). Compression involved only the popliteal vessels in 86.7% (n= 13); one patient had both popliteal and tibioperoneal trunk compression, whereas another had tibioperoneal trunk and peroneal artery compression. Popliteal vein compression was 100%. The contrast cessation point on angiography and the proximal point of compression on IVUS imaging differed in 80% of cases (P< .05). The distal extent of compression was unable to be determined by angiogram findings but was clearly delineated by IVUS imaging in all cases. IVUS imaging is a more sensitive diagnostic and descriptive imaging modality compared with angiogram in patients with possible fPAES. IVUS and angiogram findings are greatly discordant; moreover, IVUS imaging can provide detailed information such as the precise extent and anatomic location of the arterial compression, which may be useful in aiding surgical planning. IVUS imaging should be considered the gold standard for diagnosing and characterizing fPAES before intervention planning.

Optimizing the diagnostic approach of functional popliteal artery entrapment syndrome: Presented at the Forty-fifth Midwestern Vascular Surgical Society annual meeting, Chicago, Illinois, September 9-11, 2021. Presented at the Wisconsin Surgical Society annual meeting, Kohler, Wisconsin, November 6-9, 2021.

Optimizing the diagnostic approach of functional popliteal artery entrapment syndrome: Presented at the Forty-fifth Midwestern Vascular Surgical Society annual meeting, Chicago, Illinois, September 9-11, 2021. Presented at the Wisconsin Surgical Society annual meeting, Kohler, Wisconsin, November 6-9, 2021.

Toxine Botulique de type A et médecine du sport: ­revue de littérature et applications pratiques

In sports medicine, Botulinum Toxin type A (BoNT-A) can sometimes be used as an alternative for some of the most common pathologies of the musculoskeletal system. The objective of this narrative review is to identify the main current indications for BoNT-A in common sports pathologies, the technical conditions for its use, the doses used, and the main beneficial or adverse effects expected, in order to allow a practical approach for the clinician. The injections are performed by a Physical and Rehabilitation Medicine or Sports Medicine specialist, and requires an operator trained in EMG and/or ultrasound muscle detection. The main indications are epicondylalgia, plantar fasciitis, chronic exertional compartment syndrome (CECS), the functional popliteal artery entrapment syndrome (FPAES) and patellofemoral syndrome. The main effect sought being muscle-relaxant, undesirable transient paresis may occur, requiring some precautions regarding the dose used and a search for the optimal period in the sports calendar in order to minimize this risk. Despite the multiplication of recent studies on the subject, the current level of evidence remains low and limits the use of BoNT-A to cases of failure or contraindication to first- or second-line treatments, and is performed without any guarantee of financial coverage.

Concurrent Diagnosis of Functional Popliteal Artery Entrapment Syndrome and Chronic Exertional Compartment Syndrome in Athletes.

Concurrent Diagnosis of Functional Popliteal Artery Entrapment Syndrome and Chronic Exertional Compartment Syndrome in Athletes.

Optimizing the diagnostic approach of functional popliteal artery entrapment syndrome

ObjectiveFunctional popliteal artery entrapment syndrome (fPAES) is an underdiagnosed and undertreated etiology of atypical claudication. Symptoms of fPAES include deep posterior muscle cramping and pain with exercise and, unlike anatomic PAES, there are seldom vascular complications. Common noninvasive diagnostic modalities include ankle-brachial index, arterial duplex Doppler ultrasound (DUS) examination, and cross-sectional imaging such as magnetic resonance angiography (MRA). Entrapment can be difficult to reproduce during diagnostic testing, requiring provocative maneuvers. Because we believed different provocative maneuvers provide different diagnostic efficacy, we sought to optimize our diagnostic approach to fPAES. MethodsWe performed a retrospective review of patients before and after optimizing our noninvasive imaging protocol comparing patients with fPAES versus other atypical claudicants with chronic compartment syndrome. ResultsArterial DUS examination and exercise ankle-brachial index were important components of our protocol with a significant decrease in systolic posterior tibial blood pressure of –14 mm Hg after exercise, whereas nonentrapment release patients had an overall increase of 8 mm Hg (P = .006). Arterial DUS examination of the distal PA with forced plantarflexion demonstrated a trend toward an increase in the measured velocity ratio, especially in the middle and distal PA. MRA with stressed plantar flexion findings were positive in 6 of 11 patients with fPAES, with false negatives likely owing to patients’ inability to maintain a provocative position for the duration of the MRA. ConclusionsDiagnosing fPAES is challenging owing to a lack of standardized diagnostic testing and provocative maneuvers. Different maneuvers demonstrated varying diagnostic yields for fPAES. Exercise ABIs were the most reliable vascular laboratory test to detect changes attributable to fPAES and to distinguish it from chronic compartment syndrome. Segmental PA DUS examination seems to be promising as a means of detecting PA impingement. Stress positional MRA effectively demonstrates anatomic PAES, but has a false-negative rate for fPAES.

Piecing Together the Puzzle of Functional Popliteal Artery Entrapment Syndrome: A Diagnosis Requiring Multiple Modalities in Conjunction With Clinical Judgment

Functional popliteal artery entrapment syndrome (fPAES) is an underevaluated and undertreated etiology of atypical claudication that is challenging to diagnose. We analyzed 2 years of patients who underwent evaluation with our standardized protocol for the evaluation of fPAES. This protocol incorporates multiple diagnostic modalities including exercise ankle-brachial index (ABI), Doppler ultrasound (DUS) examination with plantarflexion, and magnetic resonance angiography (MRA) with provocative maneuvers including plantarflexion.

Dry Needling of the Medial Gastrocnemius as Novel Treatment for Type-VI Functional Popliteal Artery Entrapment Syndrome

Popliteal artery entrapment syndrome is rare, commonly overlooked, and characterized by the compression of the popliteal artery via the surrounding myofascial structures. Presented is a 28-year-old active-duty male service member with unilateral exertional left lower extremity pain, paresthesia, and discoloration. Popliteal musculoskeletal and Doppler ultrasound showed normal anatomy with functional compression of the popliteal artery by the medial head of the gastrocnemius. This is the first case in current literature to report ultrasound-guided dry needling to the medial head of the gastrocnemius as novel treatment for functional popliteal artery entrapment syndrome.

Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management.

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.

Patient-Reported Outcomes of Surgical Management of Functional Popliteal Artery Entrapment Syndrome

Patient-Reported Outcomes of Surgical Management of Functional Popliteal Artery Entrapment Syndrome

Identification Of Functional Popliteal Artery Entrapment Syndrome In Athletes Who Have Failed Compartment Release

Level of evidence: IV OBJECTIVE: To evaluate the work up and outcomes of athletes with exertional leg pain, specifically the co-existence of functional popliteal artery entrapment syndrome (FPAES) and chronic exertional compartment syndrome (CECS), in athletes who were unable to return to sport or have significant symptomatic improvement after lower leg compartment fasciotomy. Design: Retrospective case series Setting: Outpatient musculoskeletal sports clinic, outpatient vascular surgery clinic Participants: 36 patients aged 15-67 (average age 26.9) diagnosed with functional popliteal artery entrapment syndrome using CT-angiogram with provocative maneuvers or MRI-angiogram with provocative maneuvers. In our cohort, a moderate number of athletes (11/36 athletes, 19/59 affected limbs) were referred for evaluation by vascular surgery after already having undergone lower leg fasciotomies for chronic exertional compartment syndrome. Interventions: Partial debulking of anterolateral quadrant of the medial head of the gastrocnemius muscle with or without fasciotomy Main Outcome Measures:Return to sport/previous activities RESULTS: Mean follow up was 52.3 ± 22.2 months. 78% (28/36) of the patients were able to fully return to their previous athletic competitive levels. All patients were able to resume their athletic sport at a recreational level. The patients participated in a myriad of sports and athletic activities: 14 runners, 9 soccer players, 3 unspecified, 2 lacrosse, 2 basketball, 1 triathlete, 1 jumper, 1 diver, 1 water polo, 1 rugby, 1 skier. At 6-month follow-up, there were 13% of affected limbs that had recurrent symptoms, at 12 months, only 5% had recurrent symptoms and at three years, no patients had symptoms present. CONCLUSIONS:Many of these patients were unable to return to participate in high levels at their respective sport even after initial fasciotomy for CECS, suggesting that FPAES was unidentified, overlooked, or possibly developed after fasciotomy. FPAES can be a co-existing diagnosis that warrants screening during the evaluation of CECS. Provocative CT-A and MRI-A protocols can help guide the diagnosis as well as location of muscle debulking to alleviate the functional entrapment that occurs in these athletes with exercise. It is important to consider and screen for this diagnosis to allow for proper treatment and return to sport.

A Novel Approach to the Treatment of Popliteal Artery Entrapment Syndrome in College Athletes

Functional popliteal artery entrapment syndrome (FPAES) is a rare disorder that results from hypertrophy and overuse injury of calf muscles, which in turn compress neurovascular structures in the popliteal fossa. A majority of FPAES cases involve young athletes, who present with symptoms during exercise. Most commonly, FPAES is surgically treated with muscle debulking by use of a posterior S-shaped incision. Here we present our case series of college athletes undergoing FPAES repair by a novel medial incision approach.

Functional popliteal artery entrapment syndrome: A review of diagnostic and management approaches.

Functional popliteal artery entrapment syndrome (FPAES) presents a challenge for clinicians in the field today. The relative rarity of the disease coupled with its affliction primarily in young, athletic individuals makes it a difficult condition to diagnose. Treatment modalities have been limited to surgical intervention, with more novel methods being developed over the last several years. We present a case report and review the diagnostic and management approaches for FPAES, shedding light on proposed future interventions.

Concurrent Exertional Compartment Syndrome and Functional Popliteal Artery Entrapment Syndrome: A Case Report

Exertional leg pain is a common and disabling condition in athletes with challenging diagnosis and management. We report the case of a 29-year-old rugby player with a history and clinical examination consistent with chronic exertional compartment syndrome (CECS). Compartment pressure measurement was supportive of the diagnosis. However, magnetic resonance angiography (MRA) with provocative maneuvers showed functional popliteal artery entrapment syndrome (PAES). For the treatment of CECS, bilateral fasciotomy of the anterolateral compartments permitted return to full sport participation in 8 weeks. A follow-up MR angiogram at 12 months showed resolution of the popliteal entrapment leading us to hypothesize a possible relationship between CECS and functional PAES.

FUNCTIONAL POPLITEAL ARTERY ENTRAPMENT SYNDROME: INVESTIGATION WITH DYNAMIC AND DOPPLER ULTRASOUND

A. Background Functional popliteal artery entrapment syndrome (fPAES), a cause of exertional leg pain, has a clinical presentation and clinical findings that are often indistinguishable from those of other leg pain causes (1). This condition may also coexist and overlap in symptomatology with other leg pain causes, further complicating the diagnosis (2). Although fPAES is usually considered a rare cause of leg pain (3), the true incidence of this condition is unknown, and fPAES is likely underdiagnosed and underreported (4). A missed diagnosis may result in disease progression and the use of unnecessary invasive procedures (3), and untreated fPAES may lead to popliteal artery damage, embolization, and limb ischemia (5). Although a diagnostic method using a combination of dynamic ultrasound and MR imaging/MR angiography has been described for fPAES (5), to our knowledge, no investigational studies have been performed to assess the dynamic ultrasound findings in this entity. This study sought to evaluate the usefulness of dynamic plantar flexion and dorsiflexion of the calf and the effect on the popliteal artery Doppler waveform in patients with clinically suspected fPAES and no structural abnormality. B. Methods We performed a retrospective review of ultrasound studies in patients who presented with clinically suspected PAES over a 3-year period. The ultrasound studies consisted of an anatomic survey of the popliteal. Dynamic nonresistant dorsiflexion and plantar flexion evaluations of the popliteal artery plus spectral Doppler evaluations of the popliteal artery obtained in neutral, plantar flexion, and dorsiflexion positions were performed before and after patients exercised. Patients with anatomic abnormalities were excluded. The following parameters were assessed: The proportion of symptomatic knees versus asymptomatic knees in which plantar flexion and/or dorsiflexion of the foot resulted in popliteal artery compression. The peak systolic velocity (PSV) of the popliteal artery in all positions for knees with and knees without dynamic popliteal artery compression. The absolute value change in PSV of the popliteal artery from neutral to plantar flexion and from neutral to dorsiflexion in the pre- and postexercise state for knees with and knees without dynamic popliteal artery compression. ROC analysis for clustered data was used to assess the ability of PSV to distinguish between knees with and knees without arterial compression. C. Results A total of 88 knees (77 symptomatic, 11 asymptomatic) in 45 patients were included in the study. Dynamic arterial compression was observed in 38% (29/77) of symptomatic knees. No compression seen in asymptomatic knees. Both pre-exercise and postexercise knees with arterial compression had significantly higher absolute changes in PSV from neutral to plantar flexion versus knees without arterial compression (Table). There was a smaller significant change in PSV from neutral to dorsiflexion in the pre-exercise state. There was no significant change in PSV in the postexercise state from neutral to dorsiflexion or with respect to PSV values at any position between knees with and knees without arterial compression. D. Conclusions/Significance In patients with clinically suspected PAES without anatomic abnormality, dynamic ultrasound demonstrated compression of the popliteal artery in 38% of knees. No dynamic arterial compression was seen in asymptomatic knees. There was a significant elevation in PSV from neutral to plantar flexion in pre- and postexercise states and from pre-exercise neutral to dorsiflexion positions in knees with arterial compression versus knees without arterial compression. Tables [Table: see text] References Joy SM, Raudales R. Popliteal artery entrapment syndrome. Curr Sports Med Rep. 2015;14(5):364-367. Hislop M, Kennedy D, Cramp B, Dhupelia S. Functional popliteal artery entrapment syndrome: poorly understood and frequently missed? A review of clinical features, appropriate investigations, and treatment options. J Sports Med (Hindawi Publ Corp). 2014;2014:105953. Gaunder C, McKinney B, Rivera J. Popliteal artery entrapment or chronic exertional compartment syndrome? Case Rep Med. 2017;2017:6981047 Hislop M, Brideaux A, Dhupelia S. Functional popliteal artery entrapment syndrome: use of ultrasound guided Botox injection as a non-surgical treatment option. Skeletal Radiol. 2017;46(9):1241-1248. Williams C, Kennedy D, Bastian-Jordan M, Hislop M, Cramp B, Dhupelia S. A new diagnostic approach to popliteal artery entrapment syndrome. J Med Radiat Sci. 2015;62(3):226-229.

Functional popliteal artery entrapment syndrome (FPAES) treatment with incobotulinumtoxinA: 3 successful clinical cases

Functional popliteal artery entrapment syndrome (FPAES) treatment with incobotulinumtoxinA: 3 successful clinical cases

Botulinum toxin: A new treatment for functional popliteal artery entrapment syndrome? Five patients relieved more than one year

Functional popliteal artery entrapment syndrome (FPAES) is an uncommon cause of exercise-induced leg pain. Artery compression is mostly due to hypertrophic gastrocnemius muscles (GCM) without any anatomic abnormality. Surgical arteriolysis of popliteal artery is often proposed, sometimes with myotomy. But long-term efficacy of surgery is unknown. As botulinum toxin A (BoNT-A) injections can induce localised and partial muscular atrophy and hypotonia, we supposed that BoNT-A injections in GCM could relieve pain associated with FPAES. We describe five patients with a FPAES treated with BoNT-A and followed more than one year. Diagnostic was confirmed by provocative tests in plantar or dorsal flexion of the ankle on vascular imagery (doppler ultrasonography, computed tomography or magnetic resonance angiography). Other causes of leg pain were excluded, such as chronic exertional compartment syndrome with compartment pressure after exercise. BoNT-A was injected under electromyograph guidance in the proximal third of both heads of GCM (two sites/head), with 25 to 37.5 U of Incobotulinum toxin A or 100 to 160 US of Abobotulinum toxin A. Exercise-induced leg pain completely disappeared after treatement for all patients and they resumed their normal level of sports or physical professional activities. One patient was treated twice, eight months after the first injections, since he relapsed. There were no muscular weakness but the patient treated with the highest dose had transient asthenia and mictional disorders. Four patients are currently still asymptomatic, with a follow up between 14 and 28 months. One patient relapsed late after 50 months. BoNT-A injections could be used as a new conservative therapeutic strategy in FPAES and could reduce functional compression by improving artery-GCM impingement. This study is the first to demonstrate that BoNT-A could induce long-lasting resolution of symptoms, more than one year as previoulsy described (Hislop, 2017). It is well tolerated if the dose is well choosed.

The relationship between training load and Injury rates in adolescent males participating in hurling during a 12-month calendar year

Botulinum Toxin-A (BoNT-A) is an effective intervention for Functional Popliteal Artery Entrapment Syndrome (FPAES) however, concerns with this intervention include reductions in strength and performance.This case presents an elite male athlete with FPAES who underwent BoNT-A injection and the results of testing before and after injection. The athlete experienced a decrease in strength and performance at one week post-injection however, he returned to baseline levels within four weeks. When comparing sprint distance during games, before and after injection, the athlete had an increase in his sprint distance per game post-injection. Finally on ultrasound he had visible medial gastrocnemius denervation atrophy with a decrease in arterial flow velocity at four weeks post-injection.BoNT-A may be an effective minimally invasive treatment option for FPAES however, athletes may experience a transient decrease in function following BoNT-A injection and consequently caution must be taken with regard to treatment timing.