ALTERED HAEMODYNAMICS Condition PAES

Pain Behaviour localisation

Calf, foot Description Clinical sign

Exercise induced pain Exercise induced Reduction or loss clears quickly - <1 pain, cramps, minute

numbness paraesthesia

Adductor canal Calf, foot A/A or may present A/A (early) syndrome

as acute condition Cold foot (advanced) EIAE Thigh

of pulses with sustained active PF or passive DF

Reduction of pulses following repeated active PF/DF

Exercise induced - Exercise induced Bruit at EIA. maximal efforts.

Clears quickly - <1 Cramps, fullness, pulses after minute

‘loss of force’, Reduced numbness

Aortic

coarctation/ including fatigue - clears stenosis

buttock

Compartment Calf syndrome

Bi-lateral (±95%)

gradually after effort fatigue Exercise induced

Lower limb Lower limb ache or Bi-lat leg ache, Reduced cramps,

maximal exercise

peripheral pulses. Aortic bruit

clears slowly >1 min. pain, tightness compartment Ankle weakness Paraesthesia

Table 1: Differential diagnosis of vascular issues in the lower limb

presence of a blood flow problem in 85% of cases. Duplex ultra- sound flow studies after exercise, MRA or standard arteriogram will usually reveal the site of the lesion. Arteriogram has been known to provide false negatives in mild cases due to the asymmetry of the endofibrotic lesions. Management: Is largely dependent on the level of the affected athlete and the extent of the lesion. Professional or Olympic stan- dard athletes will often demand surgery despite the fact that there are no long-term follow-up results. Surgery involves endofi- brosectomy (removal and shortening of the damaged section of vessel) with saphenous vein patching or grafting. Extra vascular release has been advocated for minor lesions, again without long term follow up (3). Post surgery a strict rehabilitation regime is followed after an initial rest period. A number of professional cyclists have returned to World-class competition following surgery. Sports participants at lower levels are advised against surgery due to the lack of long-term follow-up and relative risk/benefit of the procedure.

4. Aortic coarctation Definition: Rare congenital abnormality of the aorta leading to stenosis and diminished blood flow to the lower limbs. Presentation: If the condition is missed in early childhood, it may present around the age of 20 and may be manifest during effort related activities in sport. It has been reported in a 17 year old Australian rules football player (8). The sufferer complained of chronic (bilateral) leg fatigue and difficulty ‘keeping up’ during training. Symptoms became apparent as the demands of the sport increased. The athlete may describe ‘heaviness’ in the legs, inter- mittent pain or cramping in the thighs or calfs (non-dermatomal) and poor performance. Team players report having to switch to less mobile roles involving less running. The sufferer may present for sports medicine assessment complaining of sports related fatigue. Assessment: The condition is very rare and as such is usually revealed after exclusion of other causes. It may be suspected if

auscultation of the aorta reveals a loud bruit. Systemic blood pressure may be elevated however, infrarenal coarctation does not always cause hypertension. The condition may be confirmed by ultrasound examination. Doppler flow studies will usually reveal the stenosis and alteration of blood velocity at the site of the lesion. Further confirmation may be sought via arteriogram, mag- netic resonance angiogram (MRA) or computerised tomographic angiogram (CTA). Management: Depends largely on the exact site of the abnormal- ity, symptoms and the presence of systemic hypertension. If aneurysm is present as a complication of the condition and the athlete is involved in impact sport there is a higher risk of rup- ture. Surgery involving synthetic grafting of the aorta in the case of the Australian football player produced a return to sport together with a marked improvement in overall fitness and abili- ty to run.

Clinical assessment Musculoskeletal examination may be entirely normal. The tempta- tion at this stage to make the symptoms fit a known clinical pat- tern is high. It is also common to trial treatments for perceived ‘nerve entrapments’ or ‘muscle imbalance’. A number of non inva- sive clinical tests may be used to assist the clinician to differenti- ate between common neuromusculoskeletal conditions and vascu- lar syndromes and prevent delays in appropriate management.

Pulse palpation Simple pulse palpation at the groin, popliteal fossa, and foot will only reveal abnormalities at rest in advanced cases, but is an important starting point in the search for vascular insufficiency. Clinicians who use pulse palpation regularly will be aware that it is a technique which requires a large degree of practise and skill. It should also be noted that the dorsalis pedis pulse is congeni- tally absent in 10% of patients. In EILP of a transient nature a simple exercise test to reproduce the symptoms may be followed by repeat pulse palpation. The rationale here is that arterial insuf-

SportEX 11

Exercise-induced Distended tense Normal pulses

after exercise

Duplex flow study.

Arteriogram MRA Compartment

pressures pre/post exercise

Rare None

Running, athletics

ABPI max.test Key investigation

with active PF or passive DF

Arteriogram MRA

Reported in skiers,

Duplex ultrasound skating, MRA

runners Cycling, running

Sport specificity

Doppler/Duplex Running ultrasound

Athletics