Symptoms of Popliteal Artery Entrapment Syndrome (PAES)
PAES characteristically presents with calf claudication, paresthesia, and swelling during exercise in young, athletic individuals without atherosclerotic risk factors. 1
Primary Clinical Presentation
The hallmark symptom triad includes:
- Calf claudication (pain, cramping, or fatigue in the calf muscles during exercise) 1, 2
- Paresthesias (tingling or numbness sensations) 1
- Swelling during physical activity 1
These symptoms occur specifically during plantar flexion activities and are relieved by rest, typically within 10 minutes. 1, 2
Key Distinguishing Features
Patient Demographics:
- Occurs predominantly in young adults (mean age 30.5 years, range 17-52 years) without traditional atherosclerotic risk factors 3
- Affects males in 83% of cases 3
- Commonly presents in athletes, particularly runners (43%), soccer players (26%), and rugby players 3
Symptom Characteristics:
- Intermittent claudication affecting the feet and calves specifically after exercise 2, 4
- Pain is unilateral or bilateral (74% of patients have bilateral involvement) 3
- Symptoms are exercise-induced and relieved by rest 2, 5
- The pain occurs during activities involving plantar flexion, not ankle extension 1
Physical Examination Findings
Provocative maneuvers reveal:
- Decreased or absent ankle pulses during plantar flexion maneuvers 1
- Normal pulses at rest in early disease 2
- In advanced cases with thrombosis: pallor, loss of arterial pulses below the knee, and acute limb pain 5
Associated Conditions
Chronic Exertional Compartment Syndrome (CECS):
- Present in 86% of PAES patients when intra-compartmental pressure measurements are performed 3
- This high association rate means patients may experience additional symptoms of compartment syndrome including tightness and pressure sensation in the calf 3
Timing and Progression
Diagnostic delay is common:
- Median time from symptom onset to diagnosis is 34 months (range 3-180 months) 3
- This delay occurs because symptoms overlap with other conditions like exertional compartment syndrome 6
Advanced Disease Manifestations
If left untreated, PAES progresses to:
- Popliteal artery thrombosis with sudden severe pain, pallor, and loss of pulses 5
- Arterial stenosis or occlusion 2, 5
- Distal arterial thromboembolism 2, 5
- Arterial aneurysm formation 5, 6
- Critical limb ischemia in severe cases 6
Clinical Pitfalls
Common diagnostic errors include:
- Misdiagnosis as exertional compartment syndrome alone (despite 86% having both conditions) 6, 3
- Failure to consider PAES in young patients with calf claudication who lack atherosclerotic risk factors 4, 6
- Overlooking the diagnosis in patients under 50 years old presenting with lower extremity claudication 4, 6
The diagnosis should be suspected in any patient under 50 with calf claudication, particularly if they are athletic and lack traditional cardiovascular risk factors. 4, 6