VASCULAR ISSUES Question 1- Could this be vascular? Yes/No

Supporting evidence ■ There is little, if anything to support a ‘trapped nerve’ or NMS hypothesis ■ The pain pattern is non-dermatomal ■ The condition is not responding to conventional NMS methods ■ The condition is clearly effort/heart rate related ■ The symptoms are reproduced during exercise conditions ■ The subjective descriptions of ‘tired’, ‘fullness’ and shoe tightness are commonly reported ischaemic symptoms

■ He reports a family history of cardio-vascular disease on the male side ■ The vascular system has not so far been proposed, nor ruled out as a hypothesis.

Negating evidence ■ The patient is ‘too young’ to suffer ischaemic pain – faulty clinical reason- ing – many young athletes have been shown to suffer flow limitation problems

■ The patient reports being able to ‘run all day’ at lower levels of effort - faulty clin- ical reasoning – symptoms of mild to moderate flow limitation are often only revealed at high end effort/HR.

Action point 2 You decide to explore the vascular option via objective testing in your clinic which has some gym equipment including a treadmill. You take the lower limb pulses at rest. They are all normal (figure 1).

Findings ■ On the right the pulses are present, strong and bounding ■ On the left it is quite difficult to find the pulse and when you do, it is much weaker than the other side.

■ When you retake the foot pulses after the patient has recovered and his heart rate returns to normal, they feel the same on each side.

Action point 3 You consent the patient and ask him to run at the same pace that would reproduce his symptoms after which you return him to the couch and re take the foot pulses again.

QUESTION If they are normal, should they be stronger or weaker post exercise?

Figure 1: Pulse palpation at the lower limb is commonly normal at rest but may be weaker or absent at the periphery after exercise testing (ie. maximal ergometer or treadmill test) in patients with flow limitation problems.

Question 2 – What is happening here? Answer – By simple pulse palpation testing, you have just discovered that the patient is suffering from an arterial vas- cular flow problem! The athlete is suffering either a flow lim- itation due to kinking or a ‘narrowed pipe’. It is not occluded or blocked because he can make lower level efforts quite happily, but when the lower limbs demand more flow ie. going up hill or sprinting, the affected artery cannot cope with the demand and the ath- lete suffers ischemic pain. This is revealed by a repeated pulse examination after the patient has reproduced their symptoms via relevant exercise methods ie. cycling, run- ning, hopping. The only thing you are not sure of at this stage is exactly where the flow limitation or narrowing is.

Question 3 – Is this enough to con- firm the problem Y/N Answer – No, the athlete needs to go on for further testing to include a further treadmill test followed by an Ankle to Brachial Pressure Index (ABPI) measurement. This is where blood pressures are taken at the ankle and arm and a simple calculation made to determine the index. If the outcome

is positive i.e. below 0.66 (2) then further tests may include Duplex ultra sound imaging of the vessels and perhaps angiog- raphy or Magnetic Resonance Arteriogram (MRA) – this will determine the exact site of the affected vessel.

Question 4– Where do I refer the patient to?

Answer – A well crafted letter to the GP or local sports medicine centre will usually do the trick, though it is worthwhile detailing your examina- tion findings, both subjective and objective (bul- let points often make the findings clearer) and perhaps adding an external iliac artery (EIA ) or flow limitation reference (3) as the knowledge is relatively specialised.

Question 5 – So what are the options for the patient if they confirm a narrowed artery? Answer – This very much depends on the spe- cialist and the level of competition of the ath-

lete. Current thinking suggest that hobby athletes should con- tinue their sport (ideally at a lower level) but monitor their symptoms and if things are getting worse they may have to seek further advice.

14 sportEX medicine 2008;35(Jan):13-17