VASCULAR ISSUES

Action point 2 You take the lower limb pulses at rest. They are all normal.

Action point 3 You now need to include the exercise component. You consent the patient and ask him to run or hop/jump ( remember the symptoms were manifest when he was on his toes) to a level that would reproduce his symptoms after which you return him to the couch and re-take the foot pulses again. They should be easy to find and bounding after effort, if they are normal.

Findings ■ Post exercise foot pulses are weak on both sides. ■ 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.

2a) 2b)

Figure 2: Pulse palpation findings may be confirmed by hand held Doppler U/S in (a) ankle active plantar flexion or (b) passive dorsi flexion.

■ However you note that when the patient stands on his toes his posterior tibial pulse disappears – this is confirmed by Doppler U/S examination in the clinic (figures 2a and 2b).

Question 2 – What is happening here? Answer – This time the athlete is suffering a ‘dynamic arterial entrapment’ which is only manifest during exercise. In other words he gets soft tissue impingement of his popliteal artery usually by the gastrocnemius head or a muscle slip/fascial band from plantaris (figures 3a and 3b). This occurs dynamically, in this case, when he is on his toes. At all other times the artery is patent.

This again is revealed by reproducing the syptoms via exercise and then repeating the pulse examination, or by

functional

testing ie. forced plantar flexion (in some cases passive dorsi- flexion has the same effect). NOTE; - as pulse ‘switch off’ is known to occur in a small percentage of normal individuals, it is only relevant if it fits with a relevant clinical picture and/or you can make a side to side comparison (unilateral cases).

Question 3– Is this enough to confirm the problem Y/N Answer – No, the athlete needs to go on for further testing as per Case 1 together with provocative PF/DF tests using Duplex U/S or angiography/MRA. This will determine the exact site of the affected vessel.

Question 4 – Where do I refer the patient to? Answer – Again a well crafted letter to the GP or local sports medicine centre will usually do the trick, though it is worth- while detailing your examination findings, both subjective and objective (bullet points often make the findings clearer) and perhaps adding a popliteal artery entrapment syndrome (PAES) reference (5) as the knowledge is relatively specialised.

Question 5– What happens then? This depends on the findings and particularly on the type of anatomical anomaly. If it is judged that the artery can be released surgically then that is the best option. If the artery is routed abnormally and impinged upon by the head of gastroc- nemius then the options are more risky i.e. by–pass surgery which is unlikely to be undertaken on a hobby athlete in the UK. However, it may be considered if the condition is advancing or in professional/elite performers if it is a limitation to performance (5).

3a 3b

Figure 3: Dynamic arterial compromise’ shown here at the popliteal artery (a)abnormal but patent route of the popliteal artery (b) shows complete cessation of flow when the gastrocnemius is activated during plantar flex- ion

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