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Concurrent Chronic Exertional Compartment Syndrome And Popliteal Artery Entrapment Syndrome
Tiffany Bellomo, MD, Connie Hsu, MD, Pavan Bolla, MBBS, Dana Kotler, MD, Abhisekh Mohapatra, MD.
Massachusetts General Hospital, Boston, MA, USA.
DEMOGRAPHICS: The patient is a 21-year-old female with no past medical history who presented with 2 years of progressively worsening bilateral calf pain.
HISTORY: The pain intensified to a severe 10 out of 10 burning sensation in both calves after less than 10 minutes of running with associated weakness during ankle dorsiflexion, plantarflexion, and eversion. She denied experiencing paresthesias, other joint pain, chronic fatigue, or systemic infection symptoms. She had no previous surgeries, did not smoke, and did not use illicit drugs. Physical examination was largely normal, except for calf pain during toe walking and passive ankle movements. Pulses in the dorsalis pedis and posterior tibial arteries were palpable. X-rays were negative for fractures. Treadmill testing showed elevated compartment pressures up to 60 mmHg, supporting a diagnosis of Chronic Exertional Compartment Syndrome (CECS). A point-of-care ultrasound revealed a patent popliteal artery in the neutral position that was compressed after plantar flexion. Dynamic MRA showed excess hypertrophied gastrocnemius muscle in the intercondylar notch bilaterally causing compression of the popliteal arteries and veins during plantarflexion. A diagnostic angiogram confirmed dynamic compression of the right popliteal artery during plantarflexion bilaterally, establishing a diagnosis of popliteal artery entrapment syndrome (PAES) (Figure 1).
PLAN: With the suspicion that popliteal vein entrapment was the underlying etiology for chronic compartment pressure increase, a popliteal artery and vein entrapment release was performed. A posterior lazy S incision was made in the right popliteal fossa. The dissection was carried down to the gastrocnemius muscle, which was severely hypertrophied. Given the popliteal artery was in the normal anatomic position, PAES type VI was diagnosed, and the medial head of the gastrocnemius muscle was resected. Post-surgery, provocative maneuvers no longer compressed the popliteal artery. At a one-month follow-up, the patient reported improvement in right calf pain and is undergoing rehabilitation.
DISCUSSION: This case highlights a rare instance where a young female athlete was diagnosed with both CECS and type VI PAES and experienced symptom relief with popliteal artery entrapment release alone. Underlying PAES should be investigated by dynamic imaging even with a clear diagnosis of CECS.
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