Popliteal Artery Entrapment or Chronic Exertional Compartment Syndrome?

Table 2

Key features distinguishing common sources of leg pain in the athlete.

	Chronic exertional compartment syndrome	Medial tibial stress syndrome	Tibial stress fracture	Soleal sling syndrome	Popliteal artery entrapment syndrome
Primary site of pathology or structure(s) affected	Fascial compartments [19]: Anterior (45%); Deep posterior (40%); Lateral (10%); Superficial posterior (5%)	Distal posteromedial 1/3 of tibial shaft [8, 20, 21]	Proximal tibial metaphysis or diaphysis [8, 20, 21]; Mid-diaphysis more common in runners [8]	Tibial nerve as it passes through origin of soleus [8, 22]	Anatomic: aberrant anatomy of proximal gastrocnemius, popliteal artery, or both [1, 8]; Functional: hypertrophied proximal gastrocnemius compresses artery during exercise [2, 8]
Key identifying symptom(s)	Diffuse painful cramping, burning, “fullness” in leg [8, 20]; Paresthesias with exertion [8, 20]	Recurrent localized, dull, bony ache [8]	Insidious onset localized leg pain; Classically improving mid exercise and then returning at end of exercise [8]	Pain or paresthesias in nerve distribution worse with exertion	Exertional calf pain, cramping, tensing, and claudication symptoms; Paresthesias in sole of the foot (tibial nerve) [5]
Key identifiers from patient history	Recurrent with exertion; Running and jumping type activities [8, 20, 23]; Bilateral (85 to 95% of cases) [19]	Often late in sports season or periods of increased training intensity [8]	History of eating disorder, female athlete triad, repetitive high-impact activities (marching, running, jumping) [8]	Pain with activity, worse with continued activity [8]	Predominantly males under thirty years old [8]; High-intensity exercise with significant PF and DF at the ankle
Key finding(s) of physical exam	Compartment tenderness and tensing in immediate postexercise period [8]; Pain with passive stretch of affected muscles in immediate postexercise period [8, 23]	Palpable bony tenderness over medial border of distal tibia [8, 19, 20]	Localized, bony tenderness to palpation over fracture site [8]; Vibratory pain from tuning fork [8]	Pain out of proportion with palpation over posterior midline of distal popliteal fossa [24]; Positive Tinel sign at site of nerve compression [8]; Isolated FHL weakness [24]	Weaker distal pulses compared to uninvolved side, or attenuation of pulses with foot positioned in DF or PF with knee extension [5–8]
Diagnostic modalities of choice	Intracompartmental pressure (ICP) measurements continuously during exercise [23] more reliable than pre- and postexercise [8]	Radiographs; triphasic bone scan if radiographs negative	Radiographs; triphasic bone scan if radiographs negative	Diagnostic nerve block [8]; EMG rule out confounding lumbar disc disease [25]; T2 MRI enhancement showing thickened soleus sling [26]	Provocative ABI with ankle PF or DF [5–7]; Dynamic CDUS; Dynamic MRI/MRA or CTA [8–11, 14]; Arteriography is gold standard [8]

Compartments: anterior: deep peroneal nerve. Deep posterior: tibial nerve. Superficial posterior: sural nerve. Lateral: superficial peroneal nerve. Female athlete triad: eating disorder, amenorrhea, and osteoporosis. FHL: flexor hallucis longus, PF: plantarflexion, DF: dorsiflexion, and ABI: ankle-brachial index.