MLTJ Muscles, Ligaments and Tendons Journal CIC Edizioni Internazionali 2014 April-June; 4(2): 141–148. ISSN: 2240-4554
Published online 2014 July 14.

Popliteal entrapment syndrome. A systematic review of the literature and case presentation

Kemal Gokkus,1 Ergin Sagtas,2 Tamer Bakalim,3 Ertugrul Taskaya,3 and Ahmet Turan Aydin4

1 Department Orthopaedics, Ozel Antalya Memorial Hospital, Turkey
2 Radiology section, Ozel Antalya Memorial Hospital, Turkey
3 Cardiovascular Surgery Section, Ozel Antalya Memorial Hospital, Turkey
4 Orthopaedics and Traumatology, Ozel Antalya Memorial Hospital, Turkey

Corresponding author: Kemal Gokkus, Department Orthopaedics, Ozel Antalya Memorial Hospital, Zafer mah yildirim beyazit caddesi, 91 07326 Antalya, Turkey, E-mail: kgokkus@yahoo.com

Summary

Popliteal artery entrapment syndrome (PAES) is rare in young adults. Claudication of the young patient, which is often overlooked, is a very rare symptom for orthopedic surgeons. In elder patients, the physician might expect atherosclerotic claudication, however in young patients, popliteal artery entrapment syndrome (PAES) should be considered as a possibility in the cases of claudication. Here, an unusual presentation of an uncommon disease that is not widely known by orthopedic surgeons is reported.

Keywords: tendons, circulation, lower limb surgery, muscles, contact sports, popliteal artery

Introduction

Popliteal entrapment’s anatomical basis was first described by Anderson Stuart in 18791. In 1965, the term “PAES” was coined by Love and Whelan2. Popliteal artery entrapment means popliteal artery compression caused by an abnormal anatomical relationship between the vessel and nearby musculotendinous structures or surrounding muscle hypertrophy. This can cause functional impairment3 or arterial compression which might lead to chronic vascular microtraumas of arterial wall with possible intramural hematoma or thrombus, distal embolization, aneurysm, dissections and thrombosis with acute distal ischemia in later term4. PAES can be explained as the entrapment syndrome of popliteal artery, which is characterized by artery compression secondary to an abnormal relationship of popliteal artery to adjacent muscle and tendons. This is thought to be caused by abnormal embryologic development.

Embryological development of popliteal fossa suggests there is a “competition for more space” between primitive neurovascular bundles and migrating muscle groups58.

Most common anomalies include incomplete or delayed migration of the medial head of gastrocnemius muscle (MHGM).

The abnormal lateral position of MHGM might cause popliteal artery displacement2,4,911.

Contraction of a big and powerful muscle in such a limited space, which is bordered by strong fascias and solid bone, results in forced compression of adjacent neurovascular bundle.

Compression and entrapment process may result in repetitive trauma and early atherosclerosis, leading to a decrease in flow of popliteal artery or even occlusion8,1215.

The differential diagnosis for patients with exercise induced lower leg pain includes chronic exertional compartment syndrome16. Unresolved muscle strain (This classically occurs at the musculotendinous junction of the medial head of gastrocnemius. It is common in middle-aged athletes in racquet sports and is often called ‘tennis leg’. On examination, local tenderness over the medial head of gastrocnemius –or which ever muscle is involved– is characteristic)17. Medial tibia stress syndrome, fibular and tibial stress fractures, fascial defects, nerve entrapment syndrome, vascular claudication (artherosclerotic or popliteal artery entrapment syndrome) and lumbar disc herniation17 (Tab. 1).

Table 1.Table 1.
The Table shows differential diagnosis for patients with exercise induced lower leg pain.

With this case presentation, we wanted to emphasize a possibility of popliteal entrapment syndrome in a young man during differential diagnosis of chronic lower extremity pain in young individuals or young athletes. The aim of this study is to remind the orthopedic surgeons about the rare and unusual properties popliteal entrapment syndrome.

Case report

A 22-year-old (R.K) professional wrestler came to our clinic with progressive pain, cramps and paresthesia in his right calf after walking 200 m. The pain had been ongoing for 6 months. The patient was diagnosed with peripheral arterial occlusion, not specified as a popliteal entrapment syndrome, and was followed up with medical treatment for 6 months (oral silostazol, Tab. 2 times in a day), mainly because the first colleague did not suspect popliteal artery entrapment syndrome.

Table 2.Table 2.
The Table shows the list of selected articles about popliteal entrapment syndrome in the recent literature.

Physical examination revealed pain, palor, tingling and marked tenderness with prominent feeling of fullness in his right calf. All the lower extremity muscles, especially crural muscles were hypertrophic when compared to normal. The peripheral pulses of dorsalis pedis and posterior tibial artery were not palpable even during rest and after the exercises and palor of the cruris was evident after exercises. The perimeter of the right calf is 1.5 cm less than his left side. Doppler ultrasonography revealed increased popliteal artery flow that was consistent with stenosis and MRI and CT angiography revealed a segmental stenosis, post stenotic aneurysm and thrombus of popliteal artery (Fig. 1a,b) which leads embolism to the small crural arteries (Fig. 2a).

Figure 1a.Figure 1a.
Pre operative - MRI angiography: the arrows show stenotic segment clearly. Notice the decreased blood flow at distal cruris.
Figure 1b.Figure 1b.
Arrow 1: popliteal artery stenotic segment; Arrow 2: post stenotic aneurysm and thrombus.
Figure 2a.Figure 2a.
Ct angiography: 1,2,3,4 numerics show abundant collateral arteries, right popliteal artery is normal. Ω, α, β represent distal occlusions due to micro embolism. The arrow shows stenotic segment.

On MRI, an abnormal tendinous insertion originating from medial head of gastrocnemius was detected. After a neglected period of 6 months with conservative treatment at other clinics, the patient finally came to our clinic. Based on these clinical and radiological findings, the source of claudication was thought to be popliteal artery stenosis and with the aid of MRI imagining, abnormal tendinous insertion which originates from gastrocnemius medial head was found (Fig. 3a), confirming the diagnosis of popliteal entrapment syndrome.

Figure 3a.Figure 3a.
Arrow a shows abnormal musculotendinous insertion of the medial gastrocnemius head.

Surgical intervention (surgical decompression of the popliteal artery and embolectomy with prophylactic four compartment fasciotomies) is considered. Under general anesthesia, patient was set in prone position. The classical S shaped incision is used to cross the flexion crease. The fascia overlying the popliteal fossa is incised, exposing the neurovascular bundle. The abnormal musculotendinous insertion originating from the gastrocnemius medial head was detected between the artery and vein. Following that, myotomy and decompression were performed by orthopaedic surgeons (Fig. 3b). After this procedure, the cardiovascular surgeons performed arteriotomy and embolectomy. The arteriotomy closed with separated sutures. Following that the patient was set in supine position and the four compartment fasciotomies were performed.

Figure 3b.Figure 3b.
Omega represents abnormal muscular part of the insertion, originating from medial head of gastrocnemius; Asterisk represents the abnormal fibrous sheat that lies under the abnormal musculotendinous insertion. Notice the post stenotic aneurysm. Alpha represents (more ...)

Our patient was a professional young wrestler. Following the surgical intervention, pain resolved and patient returned his professional wrestling after two months. No weakness was detected at plantar flexion and no discomfort about the functions of the gastrosoleus group was reported at follow up.

After surgery, vascular claudication resolved rapidly and patient was able to return his professional wrestling career in two months.

We were able to obtain post-operative (4 months after surgery) MRI angiography results of the patient, showing the stenotic segment and occlusion of the distal segments were resolved but one branch of trifucatio remained still occluded. However, the occlusion was compensated by peripheral collateral circulation (Fig. 2,b), as a result of decompression, embolectomy and fasciatomy.

Figure 2b.Figure 2b.
Post operative angiography; Arrow a shows foot print of previous stenotic segment that totally resolved. Arrow c shows one branch of the trificutaio still occlused but collateral circulation established (Arrow d); Arrow b shows unaffected side.

Discussion

Abnormal embryologic development leads to various anomalous relations in the popliteal fossa that are responsible for entrapment15,18,19.

The most widely accepted classification system, proposed by Love and Whelan2 and modified by Rich et al.12 divides popliteal vascular entrapment syndrome into six types. Type 1 is an aberrant medial arterial course around a normal medial head of gastrocnemius muscle. In Type 2, the abnormal medial head of the gastrocnemius inserts laterally on the distal femur and medially displaces the popliteal artery. In Type 3, the popliteal artery is in its normal position, but an aberrant accessory slip fom the medial head of the gastrocnemius muscle wraps around the popliteal artery and entraps it. In Type 4, the popliteal artery is entrapped by a fibrous band or the popliteus muscle. Type 5 is any form of the first four types that involves the popliteal vein. Type 6, the functional type, has been described in people with symptoms in whom a normally positioned popliteal artery is entrapped by a normally positioned but hypertrophied gastrocnemius muscle. In our case, the patient was classified as a “Type 3” (Fig. 3b).

The differential diagnosis for patients with exercise induced lower leg pain includes chronic exertional compartment syndrome, medial tibia stress syndrome, fibular and tibial stress fractures, fascial defects, nerve entrapment syndrome, vascular claudication (artherosclerotic or popliteal artery entrapment syndrome) and lumbar disc herniation16, 17.

In our case, physical examination and radiologic imagining studies were all clear, proving popliteal entrapment syndrome. As the surgical intervention certainly showed popliteal artery, we also decided to make a prophylactic fasciatomy in order to prevent the lower limb from compartment syndrome, which can happen following vascular surgery10, 20.

The presence of vascular injury more often results in the development of extremity compartment syndrome (ECS) and has been shown to be highly predictive of the need to perform fasciotomy to reduce the risk of limb loss or death21,22.

There is an abundance of evidence that treatment of an existing ECS requires urgent and complete fasciotomy and that a delay in treatment results in significant morbidity 2226.

The chronic exertional compartment syndrome might be a second possible diagnosis but since we made the decision about the prophylactic four compartment fasciatomy, we did not think this alternative diagnosis might cause us trouble.

In the literature there were a few articles about popliteal artery syndrome that affects young sports participants. We scanned 390 articles in literature (pubmed from 1965 to 2013). In this scan we mostly selected articles about the young individuals (5 articles), extremely interesting and didactic cases (5 articles), pediatric cases (8 articles), Sport professionals (10 articles: female olympic taekwondo player, 34 year old athletic trainer, basketball, Football and Roller Hockey Players, elite rower, competitive bike rider, young athletes), functional entrapment syndromes (2 articles)3, 6, 9, 11,2755.

In this point of spectral focus our article might be described as unique about being focused on a professional wrestler.

Also our case will be the first case which popliteal entrapment syndrome in a young wrestler who was treated with both fasciatomy and decompression of popliteal artery with embolectomy. In our case, the post stenotic aneurysm and thrombus which leads to embolism at crural arteries can easily be seen. These late changes can be attributed to the delayed diagnosis.

Wrestling (Turkish: güreş) is considered as an “ancestral sport” in Turkey, represented foremost by the annual Kırkpınar tournament in oil wrestling 56.

Our patient was the young participant of the Kırkpınar oil wrestling tournament.

Usually an open fasciotomy for an athlete need to be choice very carefully, we have only one case who treated with embolectomy and prophylactic fasciatomy at this manner (prophylactic fasciatomy to prevent the lower limb from compartment syndrome which can occure after vascular surgery in an athlete). So we need more cases to make a scientific evidence. This was the limitation of our paper.

In conclusion, a physician (Emergency medicine doctors, Orthopedic surgeons, Family doctors, General surgeons, Vascular surgeons) should evaluate unilateral lower extremity pain with his/her existent knowledge, but popliteal entrapment syndrome is a very rare condition and is not widely known by orthopedic surgeons. Popliteal entrapment syndrome has the potential to cause significant morbidity. With this case presentation, we wanted to emphasize a possibility of popliteal entrapment syndrome during differential diagnosis in vascular claudication and chronic pain of the lower extremity. The aim of the surgical intervention is to restore the abnormal relationship between the artery and medial head of gastrocnemius and decompress four compartments in leg.

Acknowledgments

The authors would like to thank Antalya Memorial Hospital chief of medicine Dr. Sevim Suekinci for providing the necessary settings for the study and to our English editor Taylan Alpaslan for his work.

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