DIFFERENTIAL DIAGNOSIS

ALTERED HAEMODYNAMICS VASCULAR ISSUES IN SPORT

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Common iliac artery External iliac artery

low on the list of differential diagnoses when assessing young athletes, diagnosis may be missed or delayed. Historically long delays in diagnosis have been reported, often leading to prema- ture retirement from top level sport (3). Case reports relate to poor recognition of these conditions by medical practitioners and manual therapists alike (4). This article attempts to address this issue and discusses the presentations and diagnostic methods relating to lower limb arterial insufficiency in athletes.

Femoral artery

The following conditions are relatively rare (although French and Dutch physicians collectively report over 1,000 cases of EIAE in athletes since the late 80s) and infrequently encountered. However knowledge of their existence is important to prevent pro- longed misdiagnosis and inappropriate management. Simple clin- ical tests described in this article may aid recognition and differ- ential diagnosis in suspected cases.

Figure 2: The normal anatomy of the popliteal fossa

Popliteal artery

Reports of arterial flow issues affecting the aorto-femoro- popliteal (AFP) axis in athletes include: ● Popliteal artery entrapment ● Adductor canal syndrome ● External iliac artery endofibrosis ● Common iliac artery endofibrosis ● Aortic coarctation/stenosis.

Figure 1: Arteries of the lower limb By Alan Taylor, MSc, MCSP and Roger Kerry, MMACP, MCSP

Introduction Sport at all levels places special demands on the performer. Aerobic activity, common to most competitive sport, demands adequate blood flow and oxygen delivery to meet the demands of active muscles. Until recently exercise-induced leg pain (EILP) in sport was thought to be largely due to compartment syndrome or occasionally popliteal artery entrapment.

The last 15 years has seen an increase in the awareness of med- ical practitioners to the existence of vascular problems in young athletes. In 1985 French physicians (1) reported the first case of external iliac artery endofibrosis (EIAE). The condition was at the time thought to be a rare form of fibrotic arterial stenosis princi- pally affecting high mileage cyclists (2). Since then arterial flow issues at various anatomical sites have been discovered in young marathon runners, fell runners, weight lifters, speed skaters, triathletes, throwing athletes and many others. These discoveries have revolutionised the approach of practitioners investigating exercise-induced limb pain.

Vascular conditions commonly present or masquerade as neuro- musculo-skeletal (NMS) conditions. As vascular insufficiency is

Differential diagnosis 1. Popliteal artery entrapment syndrome (PAES) Definition: Progressive stenosis of the popliteal artery due to mechanical trauma from abnormal anatomical variants in the popliteal fossa. Various anomalies are reported relating to the medial head of gastrocnemious and or popliteus. For example instead of running inbetween the two heads of gastrocnemious as is usually the case (Fig.2), the popliteal artery may bypass the popliteal fossa and run down the medial aspect of the medial head of gastrocnemius. Presentation: PAES is considered to be under reported. It is becoming a significant cause of bi/unilateral calf or tendo- achilles (TA) EILP in young athletes (5). The condition may be associated with perceived weakness and paraesthesia in the calf or foot at times of effort. Discomfort is usually elicited by specif- ic levels of exercise ie. runners may report pain only when sprint- ing or running on slopes/hills. Symptoms are often eased quickly and simply by reducing the intensity of the activity. In more advanced cases the athlete may need to stop exercising to gain relief. If the limb remains in the gravity dependant position the pain usually disappears within seconds, elevation has the oppo- site effect. Assessment: Examination at rest is usually normal. Pulse palpation after exercise may be diminished at the posterior tibial and dorsalis pedis sites. This may be affected by provocative manoeuvres such as full active plantarflexion or passive dorsiflexion with the knee held in hyperextension. If the condition has progressed to aneurysm, a pulsatile mass may be palpable in the popliteal fossa.

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