The differential in athletes causing exertional leg pain can result from various conditions, most commonly chronic exertional compartment syndrome (CECC), tendinitis, medial tibial stress syndrome (MTSS), stress fractures, popliteal artery entrapment syndrome, and nerve entrapment. Symptoms associated with these conditions often overlap, making a definitive diagnosis difficult. Appropriate diagnostic studies are needed to allow accurate diagnosis in order to develop appropriate treatment plans, avoid complications, and allow athletes to return to play.
A 17 year old male mid-distance runner with a significant past medical history of transposition of the great arteries, status-post surgical correction as an infant, presented with progressive right calf pain. He denied any weakness or associated swelling or firmness of the leg. He did not have any pain with walking, prolonged walking, or cross-training activities. On inspection, patient had mild atrophy of the right calf, but no swelling or palpable mass.
Resisted muscle testing was normal without pain, and neuro exam was normal bilaterally without foot drop. All provocative tests were negative. However, he exhibited decreased lower extremity pulses on the right compared to the left. Patient was exercised, which elevated his pain in the gastroc-soleus region. Pulses remained palpable bilaterally, but weaker on the right. There was palpable muscular tightness, but no compartmental swelling or firmness. After about 3 minutes, all complaints resolved. There was concern for arterial deficiency due to discordant pulses found on physical exam. An MR angiogram was obtained of this pelvis and lower extremities to evaluate his vasculature, which revealed complete occlusion of the distal aspect of the right external iliac artery, common femoral artery, and common femoral vein, with extensive collateralization.
The patient underwent successful arterial bypass with autologous vein graft. Now, 4 months post-operatively, he is able to run 40 miles a week without pain.
Chronic leg pain in weight-bearing athletes is a common clinical presentation that may be difficult to diagnose given that symptoms may be ambiguous. The characteristics of the pain and examination findings after exercise give strong clues to the diagnosis. This case is an example of why a thorough history and physical examination is crucial in establishing a definitive diagnosis. Vascular causes of exertional leg pain are relatively rare, but may be the answer in athletes refractory to treatment for the more common overuse syndromes of the lower extremities. Literature has shown endofibrotic disease, popliteal artery aneurysm, cystic adventitial disease, and peripheral arterial dissection to be causes of arterial entrapment, and deep vein thrombosis as a cause of extertional lower extremity pain. On the other hand, this case is unique given that the etiology of this patient's pain was arterial occlusion likely due to prior cardiac catheterization associated with his congenital heart disease.