Updated: 6/1/2021

Popliteal Artery Entrapment Syndrome

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  • summary
    • Popliteal artery entrapment syndrome is a condition characterized by constriction of the popliteal artery by adjacent muscles, tendons or fibrous tissue.  
    • Diagnosis can be suspected clinically with diminished pulses with active foot plantar flexion or passive foot dorsiflexion and confirmed with a lower extremity arteriogram.
    • Treatment is generally conservative for mild symptoms with vascular surgery indicated for patients with refractory symptoms.
  • Epidemiology
    • Demographics
      • male predominance (about 4:1)
      • patient age typically 25-40 years old
  • Etiology
    • Mechanism
      • typically due to underlying anatomic abnormality
    • Pathophysiology
      • decreased blood flow distal to the popliteal fossa leading to signs and symptoms consistent with compartment syndrome
  • Classification and Anatomy
      • Modified Whelan Classification
      • Type I
      • Medial head of the gastrocnemius is normal but the popliteal artery runs in an aberrant course
      • Type II
      • Medial head of the gastrocnemius is located laterally, no deviation of popliteal artery
      • Type III
      • There is an abnormal muscle bundle from the medial head of the gastrocnemius that surrounds and constricts the popliteal artery
      • Type IV
      • Popliteal artery is entrapped by the popliteus muscle
      • Type V
      • Popliteal vein is entrapped with the popliteal artery in any of the above scenarios
  • Presentation
    • Symptoms
      • swelling
        • patients often report limb swelling as primary complaint
      • paresthesias
        • foot numbness and paresthesias also common
        • tingling sensation of toes following vigorous exercise
      • cramping
        • calf cramping following even light exercise as the condition worsens
      • limbs can occasionally be asymptomatic
    • Physical exam
      • diminished pulses with active foot plantar flexion or passive foot dorsiflexion
      • coolness of posterior calf and paresthesias may also be present
      • can easily be confused with posterior compartment syndrome
  • Imaging
    • Radiographs
      • usually normal
    • Doppler ultrasound
      • less invasive than arteriogram
      • useful during physical exam to detect changes in pulse when active plantar flexion or passive dorsiflexion is performed
    • Arteriogram
      • used to confirm diagnosis
      • close to 100% sensitivity
      • will show stenosis, obliteration and post-stenotic dilation
    • MRI/MRA and CT/CTA
      • studies ongoing to evaluate usefulness for detection of popliteal artery entrapment
  • Treatment
    • Nonoperative
      • activity modification and observation
        • indications
          • mild symptoms with rigorous exercise only
    • Operative
      • vascular bypass with saphenous vein vs endarterectomy
        • indications
          • if damage to the popliteal artery or vein
          • most patients eventually require surgery
        • technique
          • can perform posterior or medial approach to popliteal fossa
            • posterior approach provides improved exposure
            • medial approach used more when bypass is indicated
          • structures released depend on the type of entrapment
  • Complications
    • Surgical failure
      • 30% rate of return of entrapment
      • can result in need for amputation
    • Wound infection
      • <5%
    • DVT
      • around 10%
  • Prognosis
    • 70-100% of patients are reported to be asymptomatic after surgery

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Questions (1)

(OBQ06.235) A 25-year-old marathon runner presents with pain, coolness, and tingling in her lower leg and foot which are exacerbated with walking, but relieved once she starts running for a few minutes. Compartment pressures are normal at rest and with exercise. Her physical exam is significant for pain with passive dorsiflexion and plantar flexion of the ankle. These symptoms are most consistent with which of the following conditions?

QID: 246

Lumbar radiculopathy



Piriformis syndrome



Exertional compartment syndrome



Popliteal artery entrapment syndrome



Tibial stress fracture



L 2 D

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Evidence (8)
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