We report the case of an Olympic female taekwondo player who, at the age of sixteen, developed progressive pain in the gastrocnemius muscle. She presented with atypical lower extremity claudication with continuous race for 5-10 minutes and hardening of the muscle that prevented her from pursuing the race. Physical examination revealed pulses present without any significant alteration. Ultrasound study did not show any change in muscular structure. Forced plantar flexion generated pain that improved with rest. Compartment pressure was measured according to the modified criteria of Pedowitz (Pedowitz et al., 1990). Abnormal compartment pressure (22 mmHg) was observed in the left leg in the superficial posterior compartment and anterior compartment at rest 5 minutes after exercise. In the right lower extremity, abnormal compartment pressure (26 mmHg) was observed at rest in the superficial posterior compartment, and in the anterolateral compartment (30 mmHg). These values were maintained after exercise (30 mmHg in the superficial posterior compartment, and 30 mmHg in the anterior compartment). Deep posterior compartment pressure was normal at rest, reaching 20 mmHg after exercise (Table 1). Fasciectomy of anterolateral and posterior compartments (superficial and deep) of both legs was performed. No postoperative complications were observed but symptoms did not completely disappear as discomfort persisted with long-term exercise. Magnetic resonance imaging (MRI) study showed no significant alterations. Measurement of compartment pressures was repeated six months after surgery, showing pathological values at rest and after effort in both deep posterior compartments (Table 1). A repeat fasciectomy of deep posterior compartment was performed, extended to muscle fascia (epimysium) and tibialis posterior muscle. The patient had a favourable evolution, returned to her full activity and won a national competition. Nevertheless, pain reappeared four months after surgery. We reviewed the compartment pressure values that appeared to be within normal limits. Doppler ultrasonography showed a reduction of arterial flow with forced plantar flexion with collapse of the popliteal artery and vein. Ankle brachial indices decreased from 1 to 0.6 bilaterally after five minutes exercise. Functional magnetic resonance angiography (fMRA) with forced plantar flexion showed bilateral arteriovenous collapse, more evident in the lower left limb. Detailed study of MRI results did not show any anatomic abnormality of muscle or ligament insertion, and the patient was diagnosed of FPAES (Figure 1a). Surgery of the left leg was performed via a posterior approach in the popliteal fossa according to the method of Trickey. The proximal third of the hypertrophied tendon of plantaris muscle compressing the vascular bundle was excised, leaving the muscle belly into place (Figure 1b and Figure 1c). The patient evolved favourably with complete resolution of symptoms and was able to resume high level sporting activity. Atypical claudication symptoms persisted in the contralateral non-operated leg (right) and, following the good results obtained with surgery in the left leg, the same procedure was used, hypertrophied plantaris muscle was identified and excised. The patient evolved favourably, maintaining high competition level and remained asymptomatic at one year follow-up. |