HOW TO RECOGNISE VASCULAR FLOW PROBLEMS IN ATHLETES – A CLINICAL REASONING EXERCISE
INTRODUCTION Vascular flow problems in elite athletes are now a well recognised clinical entity (1). It is well documented that a small number of athletes suffer arterial and venous syndromes which appear to have a direct link to their sporting activities. These cases are rare (though up to 1 in 5 elite cyclists has been reported (4)) and often mimic neuromusculo-skeletal conditions (NMS), making them challenging to diagnose and triage accurately. This article is designed to assist sports practitioners to identify and triage appropriately athletes who are suffering vascular problems.
Most athletes will describe the ‘pain’ of effort and injury, but sometimes the dividing line can appear blurred as the athlete strug- gles to define the difference between the two. It is the task of the clinician to analyse and make sense of the reports of pain and dysfunction which may affect performance at the top level. Advanced clinical reasoning skills are essential to ensure the athlete makes it back to top performance in the minimal time frame. Case studies are used as a clinical exercise to work through logically.
By Alan J Taylor and Roger Kerry
CASE 1 – A 39 YEAR OLD MALE FELL RUNNER Background ■ He works as a sales rep and spends 4-6 hours a day driving.
■ He complains of a 3 year history of insid- ious onset exercise induced (non der- matomal) left thigh and calf pain together with a “tingly /numb feeling in his foot”. This occurs when raising his efforts during running, for example to climb slopes.
■ His general health is reported as good. ■ He has no pain at rest. ■ He has no similar pain on the right side. ■ He has no pain when running on the flat or down hill.
■ The condition is gradually worsening. ■ He has been told that he has a ‘trapped nerve’ by various manual therapists and
sports practitioners who have seen him during the 3 year period.
■ MRI scan – lumbar spine reveals mild disc space narrowing with no apparent neural impingement.
■ His orthopaedic consultant and previous physiotherapist have suggested his problem may be linked to the ‘biome- chanics’ of his running style ie. leaning forwards to run up slopes.
■ He has received manipulative therapy for his spine to correct various ‘abnormali- ties’ relating to his sacro-iliac joints and ‘leg length inequalities’.
■ He has received insoles for his shoes for apparent over-pronation.
■ He has received treatment for ‘muscle imbalance’ and advice on altering his posture and continues with a ‘hyper extension programme’ which makes his
Action point 1 YOU decide to explore the case further through deeper questioning, revealing the following:
■ The pain only occurs at high end effort and he can reproduce it on the flat if he “sprints” to get his heart rate up.
■ When the pain occurs, his leg feels “full” and tired and goes a bit “wobbly”.
■ If he eases off to allow his heart rate to drop his pain disappears – he does NOT have to stop.
■ He also reports that his shoe feels tight. So much so that he often stops to loosen it (to no effect).
■ The affected leg seems to take longer to recover from the effort of harder hill running.
■ The pain seems to be kicking in at lower levels of effort
■ Further exploration of family history reveals CV (cardiovascular) disease on the male side of the family – which the patient had not previously reported as he did not think it relevant to his NMS condition).
Considerations ■ The pain pattern is clearly exercise induced
■ There is a relationship to effort/HR ■ Previous NMS treatment has been inef- fective
■ The condition is worsening ■ There is a family history of vascular disease.
■ He takes regular massage which makes the leg feel better.
■ Acupuncture has also been useful in reducing the pain but like ALL of the other treatment he has sought ‘has not solved the problem’.
■ He reports no relevant past medical history or family history ■ He takes no medication.
Questions ■ What are your thoughts at this stage? ■ Can you/should you offer a treatment that the other therapists have perhaps not offered and if so, what is your rationale?
■ Should you take a different approach? If so, what is your approach and your rationale?