Popliteal Entrapment

Popliteal artery entrapment syndrome (PAES) is a rare developmental defect in which the gastrocnemius muscle, popliteus muscle or tendons neighbouring the popliteal fossa are abnormally formed and can cause extrinsic compression of the popliteal artery when the lower limb is maintained in certain positions. Currently five anatomical variants of popliteal entrapment have been identified and are summarised in Table 1 (Wright et al, 2004). However, over-development of the gastrocnemius muscle can produce similar entrapment of the popliteal artery, and is often observed in professional athletes or in those with professions that require physical activity.

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Patients with PAES commonly present with intermittent calf claudication or parasthesia and symptoms are normally exacerbated upon exercise. Since the patient demographic of those suffering from PAES is typically young athletic individuals, the symptoms are often likely to be attributable to musculoskeletal disorders rather than vascular disease. However, differential diagnoses can include a number of lower limb disorders such as peripheral vascular disease, cystic adventitial disease, arterio-venous fistulae, compartment syndrome, muscle rupture, neuropathy and venous.

If left undiagnosed, prolonged exposure to PAES can result in micro-trauma to the popliteal artery, and can ultimately lead to localised stenoses, aneurysms or complete occlusion. See figure 1.

If PAES is suspected, current recommendations stipulate that stress positional assessment using spectral Doppler ultrasound and waveform analysis, when combined with Ankle Brachial Pressure Index measurements, can provide a rapid, non-invasive method for accurate diagnosis. However, results should be confirmed with further tests since Levien and Veller (1999) establish that approximately 50% of individuals experience popliteal entrapment in extreme plantar flexion and dorsiflexion positions.

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Figure 1: Occlusion of the left popliteal artery identified through duplex ultrasound colour-flow imaging identified in patient with suspected PAES. Mid-section of vessel appears occluded with echolucent material.

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Figure 2: Distal popliteal artery moving towards proximal tibial peroneal trunk appears occluded with echolucent material. No flow identified on duplex ultrasound colour-flow imaging.

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