Claudication in Athletes

The American College of Cardiology Annual Meeting this year in New Orleans was excellent. Here is the summary of a case/lecture on claudication in athletes.

Bryon Wells, MD from Emory University gave a great lecture at ACC on “Claudication in Athletes” on Monday, March 6, 2023. He was discussing a female marathoner with leg pain, who had actually had femoral venous stents place for “pelvic congestion syndrome”. Here are his salient points:

· Claudication evaluations in athletes should measure ankle-brachial indexes or perform vascular imaging after/during their usual exercise or during plantar flexion / extension.

· Endofibrosis of the external iliac artery is seen in high-volume cyclists — probably because of pelvic hyper flexion in their bent-over, riding position.

· It is repaired with angioplasty or open surgical patch widening of the artery.

· Try to avoid stenting if they intend to return to the sport because of possible injury to the stent.

· Popliteal artery entrapment syndrome is usually due to hypertrophy of the medial head of the gastrocnemius, which compresses the popliteal artery during exertion.

· It occurs in athletes secondary to the increase in the gastrocnemius muscle size with training. So, it usually occurs in runners or soccer players, etc.

· It should be diagnosed and fixed because it is progressive and can lead to thrombotic occlusion and/or embolism.

· About 1–3% of the population has some gastrocnemius compression of the popliteal artery, but symptomatic disease is much more prevalent in athletes because of the muscle hypertrophy.

· Cystic adventitial disease refers to cystic masses that can develop in the adventitia of the popliteal artery and lead to compression. They need to be surgically or percutaneously drained, but often reoccur.

· Adductor canal syndrome is claudication that occurs in runners and skiers because of an abnormal muscle band that compresses the femoral artery in the inner part of the thigh. It can cause acute occlusion and ischemia. Again, the increase in skeletal muscle mass with exercise appears to contribute to the pathology.

· These truly vascular conditions need to be differentiated from non-vascular conditions including:

· Exercise-induced compartment syndrome — This presents as lateral — posterior calf pain in runners.

· The muscle swells during exercise from fluid moving into the interstitial spaces. The surrounding fascia’s can limit expansion and the increased intramuscular pressure decreases muscle blood flow to cause ischemia and pain. (My comment: Remember Arnold Schwarzenegger’s “I will pump you up”. This fluid influx is why body builders exercise before competition, to swell the muscle.)

· Treatment is detraining to decrease the muscle size or fasciotomy. (My comment: Mary Decker Slaney, the great American female middle distance runner from the 1980’s, had bilateral fasciotomies for this.)

· The critical pressure is >30 mm Hg recorded by intramuscular measurements during pain-producing exercise. .

· Spinal stenosis can present as pseudo-claudication. True claudication is highly reproducible at an almost fixed distance and resolves rapidly with exercise cessation. Pseudo-claudication from spinal stenosis is highly variable in onset and slow and variable in time to relief.

· Stress fractures also can cause claudication like symptoms.