Exertional Leg Pain in A 54 Year-old Male Runner

HISTORY: A 54-year-old male runner presented for evaluation of left calf pain that began while running a half marathon. He was able to complete the race, and took about 6 weeks off of running. Upon return to running, about 0.5 miles into the run, he would experience a calf “tightness” that was 6/10 at worst and 1/10 at best and radiated down the lateral leg to the foot with associated paresthesias. Pain worsened with running and walking long distances and it improved rapidly with rest. He denied any fever, chills, recent weight loss, pain at night, swelling, focal weakness or similar pain prior to his injury. He previously tried rest, Tylenol, nonsteroidal anti-inflammatories, taping, bracing and stretching with minimal relief. PHYSICAL EXAMINATION: Exam was unremarkable. Lumbar spine and lower leg range of motion was full and pain-free. There was no tenderness to palpation in the lower leg. Strength and sensation were intact. Straight leg raise was negative. Gait was non-antalgic. DIFFERENTIAL DIAGNOSIS: 1) Sural nerve entrapment; 2) Chronic exertional compartment syndrome; 3) Popliteal artery entrapment syndrome; 4) Peripheral arterial disease; 5) Radiculopathy TEST AND RESULTS: Left leg compartment pressure testing was negative. Diagnostic ultrasound-guided left sural nerve block failed to resolve symptoms. Left lower extremity MRI without contrast using an isometric resisted dorsiflexion/plantar flexion protocol was negative for narrowing of the popliteal vessels, stress fracture, and chronic exertional compartment syndrome. Lower extremity arterial ankle brachial index demonstrated mild left arterial occlusive disease located at the level of the left superficial femoral artery that was confirmed on CT angiography. FINAL WORKING DIAGNOSIS: Peripheral arterial disease with associated intermittent claudication due to left superficial femoral artery occlusion at the level of the adductor canal. TREATMENT AND OUTCOMES: The patient underwent angioplasty with stent placement resulting in successful recanalization of the occluded left superficial femoral artery. He was started on clopidogrel for one month post-operatively and continued on a daily 81 mg aspirin. He returned to running pain-free two days after the procedure and had no reoccurrence of symptoms.